1
|
Piret J, Boivin G. Management of Cytomegalovirus Infections in the Era of the Novel Antiviral Players, Letermovir and Maribavir. Infect Dis Rep 2024; 16:65-82. [PMID: 38247977 PMCID: PMC10801527 DOI: 10.3390/idr16010005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/08/2024] [Accepted: 01/12/2024] [Indexed: 01/23/2024] Open
Abstract
Cytomegalovirus (CMV) infections may increase morbidity and mortality in immunocompromised patients. Until recently, standard antiviral drugs against CMV were limited to viral DNA polymerase inhibitors (val)ganciclovir, foscarnet and cidofovir with a risk for cross-resistance. These drugs may also cause serious side effects. This narrative review provides an update on new antiviral agents that were approved for the prevention and treatment of CMV infections in transplant recipients. Letermovir was approved in 2017 for CMV prophylaxis in CMV-seropositive adults who received an allogeneic hematopoietic stem cell transplant. Maribavir followed four years later, with an indication in the treatment of adult and pediatric transplant patients with refractory/resistant CMV disease. The target of letermovir is the CMV terminase complex (constituted of pUL56, pUL89 and pUL51 subunits). Letermovir prevents the cleavage of viral DNA and its packaging into capsids. Maribavir is a pUL97 kinase inhibitor, which interferes with the assembly of capsids and the egress of virions from the nucleus. Both drugs have activity against most CMV strains resistant to standard drugs and exhibit favorable safety profiles. However, high-level resistance mutations may arise more rapidly in the UL56 gene under letermovir than low-grade resistance mutations. Some mutations emerging in the UL97 gene under maribavir can be cross-resistant with ganciclovir. Thus, letermovir and maribavir now extend the drug arsenal available for the management of CMV infections and their respective niches are currently defined.
Collapse
Affiliation(s)
| | - Guy Boivin
- Centre de Recherche en Infectiologie, CHU de Québec-Université Laval, Quebec City, QC G1V 4G2, Canada;
| |
Collapse
|
2
|
Chae S, Kim HS, Cho SY, Nho D, Lee R, Lee DG, Kim M, Kim Y. Genetic Variants Associated with Drug Resistance of Cytomegalovirus in Hematopoietic Cell Transplantation Recipients. Viruses 2023; 15:1286. [PMID: 37376586 DOI: 10.3390/v15061286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 05/25/2023] [Accepted: 05/27/2023] [Indexed: 06/29/2023] Open
Abstract
Cytomegalovirus (CMV) infection is a serious complication in hematopoietic cell transplantation (HCT) recipients. Drug-resistant strains make it more challenging to treat CMV infection. This study aimed to identify variants associated with CMV drug resistance in HCT recipients and assess their clinical significance. A total of 123 patients with refractory CMV DNAemia out of 2271 HCT patients at the Catholic Hematology Hospital between April 2016 and November 2021 were analyzed, which accounted for 8.6% of the 1428 patients who received pre-emptive therapy. Real-time PCR was used to monitor CMV infection. Direct sequencing was performed to identify drug-resistant variants in UL97 and UL54. Resistance variants were found in 10 (8.1%) patients, and variants of uncertain significance (VUS) were found in 48 (39.0%) patients. Patients with resistance variants had a significantly higher peak CMV viral load than those without (p = 0.015). Patients with any variants had a higher risk of severe graft-versus-host disease and lower one-year survival rates than those without (p = 0.003 and p = 0.044, respectively). Interestingly, the presence of variants reduced the rate of CMV clearance, particularly in patients who did not modify their initial antiviral regimen. However, it had no apparent impact on individuals whose antiviral regimens were changed due to refractoriness. This study highlights the importance of identifying genetic variants associated with CMV drug resistance in HCT recipients for providing appropriate antiviral treatment and predicting patient outcomes.
Collapse
Affiliation(s)
- Seungwan Chae
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- Catholic Genetic Laboratory Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Hoon Seok Kim
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- Catholic Genetic Laboratory Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Sung-Yeon Cho
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- Catholic Hematology Hospital, Seoul St. Mary's Hospital, Seoul 06591, Republic of Korea
| | - Dukhee Nho
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- Catholic Hematology Hospital, Seoul St. Mary's Hospital, Seoul 06591, Republic of Korea
| | - Raeseok Lee
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- Catholic Hematology Hospital, Seoul St. Mary's Hospital, Seoul 06591, Republic of Korea
| | - Dong-Gun Lee
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- Catholic Hematology Hospital, Seoul St. Mary's Hospital, Seoul 06591, Republic of Korea
| | - Myungshin Kim
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- Catholic Genetic Laboratory Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Yonggoo Kim
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- Catholic Genetic Laboratory Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| |
Collapse
|
3
|
Park KR, Kim YE, Shamim A, Gong S, Choi SH, Kim KK, Kim YJ, Ahn JH. Analysis of Novel Drug-Resistant Human Cytomegalovirus DNA Polymerase Mutations Reveals the Role of a DNA-Binding Loop in Phosphonoformic Acid Resistance. Front Microbiol 2022; 13:771978. [PMID: 35185843 PMCID: PMC8851065 DOI: 10.3389/fmicb.2022.771978] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 01/13/2022] [Indexed: 12/19/2022] Open
Abstract
The appearance of drug-resistant mutations in UL54 DNA polymerase and UL97 kinase genes is problematic for the treatment of human cytomegalovirus (HCMV) diseases. During treatment of HCMV infection in a pediatric hematopoietic cell transplant recipient, H600L and T700A mutations and E576G mutation were independently found in the UL54 gene. Foscarnet (FOS; phosphonoformic acid) resistance by T700A mutation is reported. Here, we investigated the role of novel mutations in drug resistance by producing recombinant viruses and a model polymerase structure. The H600L mutant virus showed an increase in resistance to ganciclovir (GCV) by 11-fold and to FOS and cidofovir (CDV) by 5-fold, compared to the wild type, while the E756G mutant virus showed an increase in resistance to FOS by 9-fold and modestly to CDV by 2-fold. With the FOS-resistant T700A mutation, only H600L produced increased FOS resistance up to 37-fold, indicating an additive effect of these mutations on FOS resistance. To gain insight into drug resistance mechanisms, a model structure for UL54 polymerase was constructed using the yeast DNA polymerase as a template. In this model, HCMV DNA polymerase contains a long palm loop domain of which H600 and T700 are located on each end and T700 interacts with the FOS binding pocket. Our results demonstrate that H600L and E756G mutations in UL54 polymerase are novel drug-resistant mutations and that the acquisition of both H600L and T700A mutations in the DNA-binding loop confers increased resistance to FOS treatment, providing novel insights for the mechanism acquiring foscarnet resistance.
Collapse
Affiliation(s)
- Kye Ryeong Park
- Department of Microbiology, Sungkyunkwan University School of Medicine, Suwon, South Korea
| | - Young-Eui Kim
- Department of Microbiology, Sungkyunkwan University School of Medicine, Suwon, South Korea
| | - Amen Shamim
- Department of Precision Medicine, Institute for Antimicrobial Resistance Research and Therapeutics, Sungkyunkwan University School of Medicine, Suwon, South Korea.,Department of Computer Science, University of Agriculture, Faisalabad, Pakistan
| | - Shuang Gong
- Department of Microbiology, Sungkyunkwan University School of Medicine, Suwon, South Korea
| | - Soo-Han Choi
- Department of Pediatrics, Pusan National University Hospital, Busan, South Korea
| | - Kyeong Kyu Kim
- Department of Precision Medicine, Institute for Antimicrobial Resistance Research and Therapeutics, Sungkyunkwan University School of Medicine, Suwon, South Korea.,Samsung Biomedical Research Institute, Samsung Medical Center, Seoul, South Korea
| | - Yae-Jean Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jin-Hyun Ahn
- Department of Microbiology, Sungkyunkwan University School of Medicine, Suwon, South Korea.,Samsung Biomedical Research Institute, Samsung Medical Center, Seoul, South Korea
| |
Collapse
|
4
|
Abstract
Human herpesviruses are large double-stranded DNA viruses belonging to the Herpesviridae family. The main characteristics of these viruses are their ability to establish a lifelong latency into the host with a potential to reactivate periodically. Primary infections and reactivations with herpesviruses are responsible for a large spectrum of diseases and may result in severe complications in immunocompromised patients. The viral DNA polymerase is a key enzyme in the replicative cycle of herpesviruses, and the target of most antiviral agents (i.e., nucleoside, nucleotide and pyrophosphate analogs). However, long-term prophylaxis and treatment with these antivirals may lead to the emergence of drug-resistant isolates harboring mutations in genes encoding viral enzymes that phosphorylate drugs (nucleoside analogs) and/or DNA polymerases, with potential cross-resistance between the different analogs. Drug resistance mutations mainly arise in conserved regions of the polymerase and exonuclease functional domains of these enzymes. In the polymerase domain, mutations associated with resistance to nucleoside/nucleotide analogs may directly or indirectly affect drug binding or incorporation into the primer strand, or increase the rate of extension of DNA to overcome chain termination. In the exonuclease domain, mutations conferring resistance to nucleoside/nucleotide analogs may reduce the rate of excision of incorporated drug, or continue DNA elongation after drug incorporation without excision. Mutations associated with resistance to pyrophosphate analogs may alter drug binding or the conformational changes of the polymerase domain required for an efficient activity of the enzyme. Novel herpesvirus inhibitors with a potent antiviral activity against drug-resistant isolates are thus needed urgently.
Collapse
Affiliation(s)
| | - Guy Boivin
- CHU de Québec-Université Laval, Quebec City, QC, Canada.
| |
Collapse
|
5
|
Ghassabian H, Falchi F, Timmoneri M, Mercorelli B, Loregian A, Palù G, Alvisi G. Divide et impera: An In Silico Screening Targeting HCMV ppUL44 Processivity Factor Homodimerization Identifies Small Molecules Inhibiting Viral Replication. Viruses 2021; 13:v13050941. [PMID: 34065234 PMCID: PMC8160850 DOI: 10.3390/v13050941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 05/18/2021] [Accepted: 05/18/2021] [Indexed: 12/19/2022] Open
Abstract
Human cytomegalovirus (HCMV) is a leading cause of severe diseases in immunocompromised individuals, including AIDS patients and transplant recipients, and in congenitally infected newborns. The utility of available drugs is limited by poor bioavailability, toxicity, and emergence of resistant strains. Therefore, it is crucial to identify new targets for therapeutic intervention. Among the latter, viral protein–protein interactions are becoming increasingly attractive. Since dimerization of HCMV DNA polymerase processivity factor ppUL44 plays an essential role in the viral life cycle, being required for oriLyt-dependent DNA replication, it can be considered a potential therapeutic target. We therefore performed an in silico screening and selected 18 small molecules (SMs) potentially interfering with ppUL44 homodimerization. Antiviral assays using recombinant HCMV TB4-UL83-YFP in the presence of the selected SMs led to the identification of four active compounds. The most active one, B3, also efficiently inhibited HCMV AD169 strain in plaque reduction assays and impaired replication of an AD169-GFP reporter virus and its ganciclovir-resistant counterpart to a similar extent. As assessed by Western blotting experiments, B3 specifically reduced viral gene expression starting from 48 h post infection, consistent with the inhibition of viral DNA synthesis measured by qPCR starting from 72 h post infection. Therefore, our data suggest that inhibition of ppUL44 dimerization could represent a new class of HCMV inhibitors, complementary to those targeting the DNA polymerase catalytic subunit or the viral terminase complex.
Collapse
Affiliation(s)
- Hanieh Ghassabian
- Department of Molecular Medicine, University of Padova, 35121 Padova, Italy; (H.G.); (M.T.); (B.M.); (A.L.); (G.P.)
| | | | - Martina Timmoneri
- Department of Molecular Medicine, University of Padova, 35121 Padova, Italy; (H.G.); (M.T.); (B.M.); (A.L.); (G.P.)
| | - Beatrice Mercorelli
- Department of Molecular Medicine, University of Padova, 35121 Padova, Italy; (H.G.); (M.T.); (B.M.); (A.L.); (G.P.)
| | - Arianna Loregian
- Department of Molecular Medicine, University of Padova, 35121 Padova, Italy; (H.G.); (M.T.); (B.M.); (A.L.); (G.P.)
| | - Giorgio Palù
- Department of Molecular Medicine, University of Padova, 35121 Padova, Italy; (H.G.); (M.T.); (B.M.); (A.L.); (G.P.)
| | - Gualtiero Alvisi
- Department of Molecular Medicine, University of Padova, 35121 Padova, Italy; (H.G.); (M.T.); (B.M.); (A.L.); (G.P.)
- Correspondence:
| |
Collapse
|
6
|
Yu U, Wang X, Zhang X, Wang C, Yang C, Zhou X, Li Y, Huang X, Wen J, Wen F, Liu S. Cytomegalovirus Infection and the Implications of Drug-Resistant Mutations in Pediatric Allogeneic Hematopoietic Stem Cell Transplant Recipients: A Retrospective Study from a Tertiary Hospital in China. Infect Dis Ther 2021; 10:1309-1322. [PMID: 33966176 PMCID: PMC8322184 DOI: 10.1007/s40121-021-00452-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2021] [Indexed: 10/28/2022] Open
Abstract
INTRODUCTION Drug-resistant cytomegalovirus (CMV) infection remains a challenge in the management of pediatric recipients of hematopoietic stem cell transplantation (HSCT). In this study, we retrospectively reviewed the clinical data on pediatric recipients of HSCT and identified known and unknown drug-resistant CMV variants. METHODS A total of 221 children underwent allogeneic HSCT between October 2017 and November 2019 at Shenzhen Children's Hospital; of these, 35 patients were suspected of having drug-resistant CMV infections and were tested for drug-resistant mutations in the UL97 and UL54 genes by Sanger sequencing. RESULTS Mutations in UL97 or UL54, or in both, were detected in 11 patients. Most of these mutations have not been previously reported. The UL97 mutation (A582V) was detected in only one patient who also harbored two UL54 mutations (T760X and R876W). One patient with both the G604S and T691A mutations in the UL54 gene died of CMV pneumonia. We investigated the risk factors associated with the development of drug-resistant CMV infection. Patients in whom both the donor and recipient had positive CMV serostatuses were less likely to have drug-resistant mutations (Fisher's exact test, p < 0.05). CONCLUSION Newly and previously detected CMV mutations in UL97 and UL54 may be associated with the development of drug-resistant CMV infection. The detection of these mutations may provide guidance for the management of post-transplant CMV infections.
Collapse
Affiliation(s)
- Uet Yu
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Xiaodong Wang
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Xiaoling Zhang
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Chunjing Wang
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Chunlan Yang
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Xiaohui Zhou
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Yue Li
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Xiaochan Huang
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Jing Wen
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Feiqiu Wen
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Sixi Liu
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China.
| |
Collapse
|
7
|
Piret J, Boivin G. Antiviral Drugs Against Herpesviruses. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1322:1-30. [PMID: 34258735 DOI: 10.1007/978-981-16-0267-2_1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The discovery of the nucleoside analogue, acyclovir, represented a milestone in the management of infections caused by herpes simplex virus and varicella-zoster virus. Ganciclovir, another nucleoside analogue, was then used for the management of systemic and organ-specific human cytomegalovirus diseases. The pyrophosphate analogue, foscarnet, and the nucleotide analogue, cidofovir, have been approved subsequently and constitute the second-line antiviral drugs. However, the viral DNA polymerase is the ultimate target of all these antiviral agents with a possible emergence of cross-resistance between these drugs. Recently, letermovir that targets the viral terminase complex was approved for the prophylaxis of human cytomegalovirus infections in hematopoietic stem cell transplant recipients. Other viral targets such as the protein kinase and the helicase-primase complex are also evaluated for the development of novel potent inhibitors against herpesviruses.
Collapse
Affiliation(s)
| | - Guy Boivin
- CHU de Québec-Laval University, Quebec City, QC, Canada.
| |
Collapse
|
8
|
Van Leer Buter CC, de Voogd DWK, Blokzijl H, de Joode AAE, Berger SP, Verschuuren EAM, Niesters HGM. Antiviral-resistant cytomegalovirus infections in solid organ transplantation in the Netherlands. J Antimicrob Chemother 2020; 74:2370-2376. [PMID: 31093660 PMCID: PMC7183806 DOI: 10.1093/jac/dkz196] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 04/01/2019] [Accepted: 04/03/2019] [Indexed: 02/07/2023] Open
Abstract
Objectives Antiviral resistance in cytomegalovirus (CMV) may result from mutations in the molecular targets of antiviral agents. The aim of this study was to investigate both the prevalence of resistance-associated mutations and the factors associated with antiviral resistance in solid organ transplant (SOT) patients with repeated high CMV loads during antiviral treatment. Methods SOT patients were selected retrospectively, based on CMV loads of >30000 IU/mL at least twice in a period during which treatment was given. Patient samples were tested for antiviral resistance by Sanger sequencing the UL97 and UL54 genes of CMV, which code for the viral kinase and polymerase. Factors predisposing to and resulting from the development of antiviral resistance mutations were analysed. Results Multiple samples from 113 SOT patients were tested, showing resistance-associated mutations in 25 patients (22%). A further 20 (18%) patients showed mutations that were not known to be associated with antiviral resistance. Several factors were associated with development of resistance-associated mutations in UL97 as well as UL54, including human leucocyte antigen (HLA) mismatch, which occurred more frequently in the group of patients with resistance mutations. High-level resistance mutations were most frequently seen in UL97. Conclusions This study shows that by selecting patients solely on the basis of virological response to treatment, more patients with antiviral resistance mutations are identified. In this study we confirm findings by other groups that primary infections are associated with resistance development. Moreover, we show that HLA mismatch is associated with the development of antiviral resistance, which suggests a role for host immunity in the development of resistance.
Collapse
Affiliation(s)
- Coretta C Van Leer Buter
- Department of Medical Microbiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Danielle W K de Voogd
- Department of Medical Microbiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Hans Blokzijl
- Department of Gastroenterology and Hepatology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Anoek A E de Joode
- Division of Nephrology, Department of Internal Medicine, University Medical Centre Groningen, Groningen, The Netherlands
| | - Stefan P Berger
- Division of Nephrology, Department of Internal Medicine, University Medical Centre Groningen, Groningen, The Netherlands
| | - Erik A M Verschuuren
- Department of Pulmonary Diseases, University Medical Centre Groningen, Groningen, The Netherlands
| | - Hubert G M Niesters
- Department of Medical Microbiology, University Medical Centre Groningen, Groningen, The Netherlands
| |
Collapse
|
9
|
Hasan MR, Sundaram MS, Sundararaju S, Tsui KM, Karim MY, Roscoe D, Imam O, Janahi MA, Thomas E, Dobson S, Tan R, Tang P, Lopez AP. Unusual accumulation of a wide array of antimicrobial resistance mechanisms in a patient with cytomegalovirus-associated hemophagocytic lymphohistiocytosis: a case report. BMC Infect Dis 2020; 20:237. [PMID: 32192451 PMCID: PMC7083060 DOI: 10.1186/s12879-020-04966-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 03/11/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Infections with multidrug-resistant organisms (MDRO) pose a serious threat to patients with dysregulated immunity such as in hemophagocytic lymphohistiocytosis (HLH), but such infections have rarely been comprehensively characterized. Here, we present a fatal case of HLH secondary to cytomegalovirus (CMV) infection complicated by both anti-viral drug resistance and sepsis from multiple MDROs including pandrug-resistant superbug bacteria. CASE PRESENTATION A previously healthy, six-year-old boy presented with a 45-day history of fever prior to a diagnosis of hemophagocytic lymphohistiocytosis and hemorrhagic colitis, both associated with CMV. On hospital admission, the patient was found to be colonized with multiple, multidrug-resistant (MDR) bacteria including vancomycin-resistant enterococci (VRE) and carbapenamase-producing organisms (CPO). He eventually developed respiratory, urine and bloodstream infections with highly drug-resistant, including pandrug-resistant bacteria, which could not be controlled by antibiotic treatment. Antiviral therapy also failed to contain his CMV infection and the patient succumbed to overwhelming bacterial and viral infection. Whole genome sequencing (WGS) of the MDR bacteria and metagenomic analysis of his blood sample revealed an unusual accumulation of a wide range of antimicrobial resistance mechanisms in a single patient, including antiviral resistance to ganciclovir, and resistance mechanisms to all currently available antibiotics. CONCLUSIONS The case highlights both the risk of acquiring MDR superbugs and the severity of these infections in HLH patients.
Collapse
Affiliation(s)
- Mohammad Rubayet Hasan
- Department of Pathology, Sidra Medicine, Level 2M, Office H2M-24093, PO BOX 26999, Doha, Qatar. .,Weill Cornell Medical College in Qatar, Doha, Qatar.
| | | | - Sathyavathi Sundararaju
- Department of Pathology, Sidra Medicine, Level 2M, Office H2M-24093, PO BOX 26999, Doha, Qatar
| | - Kin-Ming Tsui
- Department of Pathology, Sidra Medicine, Level 2M, Office H2M-24093, PO BOX 26999, Doha, Qatar
| | - Mohammed Yousuf Karim
- Department of Pathology, Sidra Medicine, Level 2M, Office H2M-24093, PO BOX 26999, Doha, Qatar.,Weill Cornell Medical College in Qatar, Doha, Qatar
| | - Diane Roscoe
- Department of Pathology, Sidra Medicine, Level 2M, Office H2M-24093, PO BOX 26999, Doha, Qatar
| | - Omar Imam
- Department of Pathology, Sidra Medicine, Level 2M, Office H2M-24093, PO BOX 26999, Doha, Qatar
| | - Mohammad A Janahi
- Department of Pathology, Sidra Medicine, Level 2M, Office H2M-24093, PO BOX 26999, Doha, Qatar.,Weill Cornell Medical College in Qatar, Doha, Qatar
| | - Eva Thomas
- Department of Pathology, Sidra Medicine, Level 2M, Office H2M-24093, PO BOX 26999, Doha, Qatar.,Weill Cornell Medical College in Qatar, Doha, Qatar
| | - Simon Dobson
- Department of Pathology, Sidra Medicine, Level 2M, Office H2M-24093, PO BOX 26999, Doha, Qatar.,Weill Cornell Medical College in Qatar, Doha, Qatar
| | - Rusung Tan
- Department of Pathology, Sidra Medicine, Level 2M, Office H2M-24093, PO BOX 26999, Doha, Qatar.,Weill Cornell Medical College in Qatar, Doha, Qatar
| | - Patrick Tang
- Department of Pathology, Sidra Medicine, Level 2M, Office H2M-24093, PO BOX 26999, Doha, Qatar.,Weill Cornell Medical College in Qatar, Doha, Qatar
| | - Andres Perez Lopez
- Department of Pathology, Sidra Medicine, Level 2M, Office H2M-24093, PO BOX 26999, Doha, Qatar.,Weill Cornell Medical College in Qatar, Doha, Qatar
| |
Collapse
|
10
|
Piret J, Boivin G. Clinical development of letermovir and maribavir: Overview of human cytomegalovirus drug resistance. Antiviral Res 2019; 163:91-105. [PMID: 30690043 DOI: 10.1016/j.antiviral.2019.01.011] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/17/2019] [Accepted: 01/18/2019] [Indexed: 01/28/2023]
Abstract
The prevention and treatment of human cytomegalovirus (HCMV) infections is based on the use of antiviral agents that currently target the viral DNA polymerase and that may cause serious side effects. The search for novel inhibitors against HCMV infection led to the discovery of new molecular targets, the viral terminase complex and the viral pUL97 kinase. The most advanced compounds consist of letermovir (LMV) and maribavir (MBV). LMV inhibits the cleavage of viral DNA and its packaging into capsids by targeting the HCMV terminase complex. LMV is safe and well tolerated and exhibits pharmacokinetic properties that allow once daily dosing. LMV showed efficacy in a phase III prophylaxis study in hematopoietic stem cell transplant (HSCT) recipients seropositive for HCMV. LMV was recently approved under the trade name Prevymis™ for prophylaxis of HCMV infection in adult seropositive recipients of an allogeneic HSCT. Amino acid substitutions conferring resistance to LMV selected in vitro map primarily to the pUL56 and rarely to the pUL89 and pUL51 subunits of the HCMV terminase complex. MBV is an inhibitor of the viral pUL97 kinase activity and interferes with the morphogenesis and nuclear egress of nascent viral particles. MBV is safe and well tolerated and has an excellent oral bioavailability. MBV was effective for the treatment of HCMV infections (including those that are refractory or drug-resistant) in transplant recipients in two phase II studies and is further evaluated in two phase III trials. Mutations conferring resistance to MBV map to the UL97 gene and can cause cross-resistance to ganciclovir. MBV-resistant mutations also emerged in the UL27 gene in vitro and could compensate for the inhibition of pUL97 kinase activity by MBV. Thus, LMV and probably MBV will broaden the armamentarium of antiviral drugs available for the prevention and treatment of HCMV infections.
Collapse
Affiliation(s)
- Jocelyne Piret
- Research Center in Infectious Diseases, CHU of Quebec and Laval University, Quebec City, QC, Canada
| | - Guy Boivin
- Research Center in Infectious Diseases, CHU of Quebec and Laval University, Quebec City, QC, Canada.
| |
Collapse
|
11
|
Hancer VS, Yarimcan FS, Buyukdogan M, Aki SZ, Oksuz B, Acar K, Acar M, Bulut P. A novel ganciclovir resistance mutation in the UL97 gene of the HHV-5 in an adult hematopoietic stem cell transplant recipient. Future Virol 2017. [DOI: 10.2217/fvl-2017-0085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Therapeutic management of cytomegalovirus (CMV) disease in hematopoietic stem cell transplantation patients can become a challenge because of the emergence of anti-CMV drug resistance. This case report presents a patient with clinical ganciclovir resistance due to a new mutation: histidine-to-asparagine change at residue 393 of UL97. This mutation, which is located in the nonfunctional region of the UL97 gene, is very unusual. Having more information about the mutations leading to drug resistance in CMV is important for both improved clinical management and development of new diagnostic tests and drugs.
Collapse
Affiliation(s)
- Veysel Sabri Hancer
- Department of Medical Genetics, Faculty of Medicine, Istinye University, Istanbul
| | - Filiz Saglam Yarimcan
- Department of Medical Microbiology, Faculty of Medicine, Istinye University, Istanbul
| | - Murat Buyukdogan
- Department of Medical Genetics, Faculty of Medicine, Istinye University, Istanbul
| | - Sahika Zeynep Aki
- Division of Hematology, Department of Internal Medicine, Bahcesehir University, Istanbul
| | - Burcu Oksuz
- Istinye University Genetic Diagnosis Center, Istanbul
| | - Kadir Acar
- Division of Hematology, Department of Internal Medicine, Altinbas University, Istanbul
| | - Muradiye Acar
- Istinye University Genetic Diagnosis Center, Istanbul
| | - Pelin Bulut
- Istinye University Genetic Diagnosis Center, Istanbul
| |
Collapse
|
12
|
Drug Susceptibility and Replicative Capacity of Multidrug-Resistant Recombinant Human Cytomegalovirus Harboring Mutations in UL56 and UL54 Genes. Antimicrob Agents Chemother 2017; 61:AAC.01044-17. [PMID: 28807919 DOI: 10.1128/aac.01044-17] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 08/05/2017] [Indexed: 11/20/2022] Open
Abstract
Letermovir is an investigational antiviral agent with a novel mechanism of action involving the viral terminase (pUL56). We evaluated the impact of the V236M mutation in the UL56 gene alone and in combination with the E756K mutation in the UL54 gene on drug susceptibility and viral replicative capacity of recombinant human cytomegalovirus. The double mutant exhibited at least borderline resistance to all antivirals tested (ganciclovir, foscarnet, cidofovir, brincidofovir, and letermovir) and replicated less efficiently than the wild-type virus in vitro.
Collapse
|
13
|
Differentiated Levels of Ganciclovir Resistance Conferred by Mutations at Codons 591 to 603 of the Cytomegalovirus UL97 Kinase Gene. J Clin Microbiol 2017; 55:2098-2104. [PMID: 28446569 DOI: 10.1128/jcm.00391-17] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 04/17/2017] [Indexed: 12/28/2022] Open
Abstract
Diagnostic mutations in the cytomegalovirus UL97 kinase gene are used to assess the level of associated ganciclovir resistance and therapeutic options. The best-known mutations at codons 460, 520, or 591 to 607 individually confer 5- to 10-fold-decreased ganciclovir susceptibility, except that a 3-fold decrease occurs in the case of the amino acid substitution C592G. Less common point and in-frame deletion mutations at codons 591 to 603 remain incompletely characterized. The ganciclovir susceptibilities of 17 mutants in this codon range were evaluated by use of the same recombinant phenotyping system and extensive assay replicates in two types of cell cultures. Amino acid substitutions K599E and T601M conferred no ganciclovir resistance, while A591V conferred 3.8-fold-decreased susceptibility. In-frame deletions of three or more codons conferred at least 8-fold-increased ganciclovir resistance, while the level of resistance conferred by one- or two-codon deletions varied from 4- to 10-fold, depending on their location. Measured levels of ganciclovir resistance were closely comparable when assays were performed in either fibroblasts or modified retinal epithelial cells. The significant revision of a few previously published resistance phenotypes and the new data strengthen the interpretation of genotypic testing for cytomegalovirus drug resistance.
Collapse
|
14
|
Campos AB, Ribeiro J, Pinho Vaz C, Campilho F, Branca R, Campos A, Baldaque I, Medeiros R, Boutolleau D, Sousa H. Genotypic resistance of cytomegalovirus to antivirals in hematopoietic stem cell transplant recipients from Portugal: A retrospective study. Antiviral Res 2017; 138:86-92. [DOI: 10.1016/j.antiviral.2016.10.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 10/24/2016] [Indexed: 01/22/2023]
|
15
|
Varela-Fascinetto G, Benchimol C, Reyes-Acevedo R, Genevray M, Bradley D, Ives J, Silva HT. Tolerability of up to 200 days of prophylaxis with valganciclovir oral solution and/or film-coated tablets in pediatric kidney transplant recipients at risk of cytomegalovirus disease. Pediatr Transplant 2017; 21. [PMID: 27753183 DOI: 10.1111/petr.12833] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/21/2016] [Indexed: 11/26/2022]
Abstract
This multicenter, open-label study evaluated the tolerability of extended prophylaxis with valganciclovir in pediatric kidney transplant recipients at risk of CMV disease. Fifty-six patients aged 4 months to 16 years received once-daily valganciclovir oral solution and/or tablets, dosed by BSA and renal function, for up to 200 days. The most common AEs on treatment were upper respiratory tract infection (33.9%), urinary tract infection (33.9%), diarrhea (32.1%), leukopenia (25.0%), neutropenia (23.2%), and headache (21.4%). There were fewer AEs during days 101-228 vs days 1-100. Twenty-seven patients (48.2%) had treatment-related AEs during valganciclovir treatment, most commonly leukopenia (21.4%), neutropenia (19.6%), anemia (7.1%), and tremor (5.4%). Treatment-related serious AEs were reported for nine patients (16.1%) and six withdrew due to AEs. Viremia was centrally confirmed in 10 patients; there was no confirmed CMV disease. One patient tested positive for a resistance mutation (UL97 L595F). Biopsy-proven acute rejection occurred in six patients (10.7%), but no graft loss or deaths occurred. In conclusion, up to 200 days of valganciclovir prophylaxis in pediatric kidney allograft recipients showed a safety profile consistent with that established in adult transplant patients.
Collapse
Affiliation(s)
- G Varela-Fascinetto
- Department of Transplantation, Hospital Infantil de México Federico Gómez, Mexico City, Mexico
| | - C Benchimol
- Department of Pediatrics, Mount Sinai Medical Center, New York, NY, USA
| | - R Reyes-Acevedo
- Department of Transplantation, Hospital de Especialidades Miguel Hidalgo, Aguascalientes, Mexico
| | - M Genevray
- PDS Safety Risk Management, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - D Bradley
- PD Clinical Science, Roche Products Ltd, Welwyn Garden City, UK
| | - J Ives
- PD Clinical Science, Roche Products Ltd, Welwyn Garden City, UK
| | - H T Silva
- Nephrology Division, Hospital do Rim, Universidade Federal de São Paulo, São Paulo, Brazil
| |
Collapse
|
16
|
Zarrouk K, Piret J, Boivin G. Herpesvirus DNA polymerases: Structures, functions and inhibitors. Virus Res 2017; 234:177-192. [PMID: 28153606 DOI: 10.1016/j.virusres.2017.01.019] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 01/10/2017] [Accepted: 01/22/2017] [Indexed: 11/25/2022]
Abstract
Human herpesviruses are large double-stranded DNA viruses belonging to the Herpesviridae family. These viruses have the ability to establish lifelong latency into the host and to periodically reactivate. Primary infections and reactivations of herpesviruses cause a large spectrum of diseases and may lead to severe complications in immunocompromised patients. The viral DNA polymerase is a key enzyme in the lytic phase of the infection by herpesviruses. This review focuses on the structures and functions of viral DNA polymerases of herpes simplex virus (HSV) and human cytomegalovirus (HCMV). DNA polymerases of HSV (UL30) and HCMV (UL54) belong to B family DNA polymerases with which they share seven regions of homology numbered I to VII as well as a δ-region C which is homologous to DNA polymerases δ. These DNA polymerases are multi-functional enzymes exhibiting polymerase, 3'-5' exonuclease proofreading and ribonuclease H activities. Furthermore, UL30 and UL54 DNA polymerases form a complex with UL42 and UL44 processivity factors, respectively. The mechanisms involved in their polymerisation activity have been elucidated based on structural analyses of the DNA polymerase of bacteriophage RB69 crystallized under different conformations, i.e. the enzyme alone or in complex with DNA and with both DNA and incoming nucleotide. All antiviral agents currently used for the prevention or treatment of HSV and HCMV infections target the viral DNA polymerases. However, long-term administration of these antivirals may lead to the emergence of drug-resistant isolates harboring mutations in genes encoding viral enzymes that phosphorylate drugs (i.e., nucleoside analogues) and/or DNA polymerases.
Collapse
Affiliation(s)
- Karima Zarrouk
- Research Center in Infectious Diseases, CHU de Québec and Laval University, Quebec City, Quebec, Canada
| | - Jocelyne Piret
- Research Center in Infectious Diseases, CHU de Québec and Laval University, Quebec City, Quebec, Canada
| | - Guy Boivin
- Research Center in Infectious Diseases, CHU de Québec and Laval University, Quebec City, Quebec, Canada.
| |
Collapse
|
17
|
Bauters T, Bordon V, Florin L, Padalko E, Andrei G, Gillemot S, Fiten P, Opdenakker G, Snoeck R, Laureys G. Multidrug-resistant cytomegalovirus infection in a pediatric stem cell transplantation patient. Antiviral Res 2016; 132:149-53. [DOI: 10.1016/j.antiviral.2016.05.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 05/12/2016] [Accepted: 05/26/2016] [Indexed: 11/16/2022]
|
18
|
Abstract
PURPOSE OF REVIEW The purpose of this study is to provide updated information on diagnosis of cytomegalovirus (CMV) drug resistance, treatments for drug-resistant infection and potential uses of experimental antiviral compounds. RECENT FINDINGS For established CMV antivirals, uncommon viral UL97 kinase and UL54 DNA polymerase drug resistance mutations are sporadically described that expand an extensive existing database. Some novel mutations reported from treated patients have no drug-resistant phenotype and may be genotyping artefacts. Next-generation sequencing technology may enable earlier detection of emerging resistance mutations in treated patients. Management options for drug-resistant infection include optimization of host defenses, antiviral dose escalation, substitutions or combinations of standard or experimental antivirals. Maribavir and letermovir have antiviral targets distinct from the classic DNA polymerase. UL97 mutations elicited by ganciclovir and maribavir are different, although a single p-loop mutation can confer significant cross-resistance. High-grade resistance mutations in the UL56 terminase gene are readily selected in vitro under letermovir and await clinical correlation. SUMMARY Technical advancements can enhance the accurate and timely genotypic detection of drug resistance. Antivirals undergoing clinical trial offer the prospect of new viral targets and drug combinations, but unresolved issues exist with regard to their therapeutic potential for drug-resistant CMV and their genetic barriers to resistance.
Collapse
|
19
|
Campos AB, Ribeiro J, Boutolleau D, Sousa H. Human cytomegalovirus antiviral drug resistance in hematopoietic stem cell transplantation: current state of the art. Rev Med Virol 2016; 26:161-82. [DOI: 10.1002/rmv.1873] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 01/09/2016] [Accepted: 02/01/2016] [Indexed: 11/08/2022]
Affiliation(s)
- Ana Bela Campos
- Molecular Oncology and Viral Pathology Group (CI-IPOP); Porto Portugal
- Faculty of Medicine; University of Porto; Porto Portugal
| | - Joana Ribeiro
- Molecular Oncology and Viral Pathology Group (CI-IPOP); Porto Portugal
- Virology Service; Portuguese Oncology Institute of Porto; Porto Portugal
- Faculty of Medicine; University of Porto; Porto Portugal
| | - David Boutolleau
- Sorbonne Universités; UPMC Université Paris 06, CR7, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris); Paris France
- INSERM, U1135, CIMI-Paris; Paris France
- AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix; Service de Virologie; Paris France
| | - Hugo Sousa
- Molecular Oncology and Viral Pathology Group (CI-IPOP); Porto Portugal
- Virology Service; Portuguese Oncology Institute of Porto; Porto Portugal
| |
Collapse
|
20
|
Drouot E, Piret J, Boivin G. Artesunate demonstrates in vitro synergism with several antiviral agents against human cytomegalovirus. Antivir Ther 2016; 21:535-539. [DOI: 10.3851/imp3028] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2016] [Indexed: 10/22/2022]
|