Cytomegalovirus infections in heart and heart and lung transplant recipients

High incidence of clinically significant cytomegalovirus infection in CMV D+/R+ lung transplant recipients receiving 3 months of antiviral prophylaxis

BACKGROUND

Universal antiviral prophylaxis is the preferred preventive strategy for lung transplant recipients (LTRs) at risk of CMV infection. We compared the risk of CMV infection between CMV D+/R + and D-/R + LTRs after 3 months of prophylaxis.

METHODS

This was a retrospective review of CMV R + LTRs transplanted between 2005 and 2013. Patients dying before completing 3 months, or receiving >180 days of prophylaxis were excluded. The primary outcome was proportion of LTRs who developed CMV infection and clinically significant CMV infection defined as CMV infection leading to preemptive therapy or CMV disease.

RESULTS

We analyzed 90 D+/R + and 72 D-/R + with a median follow up of 730 days. CMV infection and disease was more common in D+/R + compared to D-/R+ (CMV infection 66% vs 40%; P = 0.001; CMV disease 13% vs 4% P = 0.045). Fifty-nine patients developed at least one episode of clinically significant CMV infection (41/90 [46%] D+/R + and 18/72 [25%] D-/R + P=0.007) with recurrence occurring in 29 LTRs (49% of patients with previous CMV infection), of which 22 (76%) were CMV D+/R+. Thirty percent had side effects related to CMV therapy.

CONCLUSION

Three months prophylaxis in D+/R + LTRs was associated with high rates of clinically significant CMV infection and recurrences.

Association of measles virus with rheumatoid arthritis

OBJECTIVE

Rheumatoid arthritis (RA) is a chronic inflammatory polyarthritis; while the cause is unknown, it has been speculated that an infectious agent could be the trigger for the disease. Numerous attempts at isolating an agent have been unsuccessful. Our purpose was to identify a virus from diseased tissue from a patient with RA.

METHODS

Diseased tissue taken at the time of knee replacement surgery from a patient with RA was inoculated into several cell lines and observed for cytopathic effect. Cells from the tissue were also grown as explants and were examined for viruses. Synovial fluid drawn 4 years prior to the surgery and frozen at -70 degrees C was also inoculated into cell lines. Following the development of a cytopathic effect and identification of the agent, sera from 50 patients with rheumatoid factor (RF)-negative RA were examined for IgM antibodies to the agent.

RESULTS

After many inoculations and numerous subpassages, measles virus was identified in 6 cell lines inoculated with either the minced tissue or synovial fluid. Six cell lines co-cultivated with one or more of 9 explants also showed the presence of measles virus. Measles virus was confirmed by immunofluorescence and by neutralization. Eleven of 50 (22%) sera samples from patients with RF-negative RA had IgM antibodies to measles virus recombinant nucleoprotein.

CONCLUSION

There is an association between measles virus and RA.

Manifestations of human cytomegalovirus infection: proposed mechanisms of acute and chronic disease

Infections with human cytomegalovirus (HCMV) are a major cause of morbidity and mortality in humans with acquired or developmental deficits in innate and adaptive immunity. In the normal immunocompetent host, symptoms rarely accompany acute infections, although prolonged virus shedding is frequent. Virus persistence is established in all infected individuals and appears to be maintained by both a chronic productive infections as well as latency with restricted viral gene expression. The contributions of the each of these mechanisms to the persistence of this virus in the individual is unknown but frequent virus shedding into the saliva and genitourinary tract likely accounts for the near universal incidence of infection in most populations in the world. The pathogenesis of disease associated with acute HCMV infection is most readily attributable to lytic virus replication and end organ damage either secondary to virus replication and cell death or from host immunological responses that target virus-infected cells. Antiviral agents limit the severity of disease associated with acute HCMV infections, suggesting a requirement for virus replication in clinical syndromes associated with acute infection. End organ disease secondary to unchecked virus replication can be observed in infants infected in utero, allograft recipients receiving potent immunosuppressive agents, and patients with HIV infections that exhibit a loss of adaptive immune function. In contrast, diseases associated with chronic or persistent infections appear in normal individuals and in the allografts of the transplant recipient. The manifestations of these infections appear related to chronic inflammation, but it is unclear if poorly controlled virus replication is necessary for the different phenotypic expressions of disease that are reported in these patients. Although the relationship between HCMV infection and chronic allograft rejection is well known, the mechanisms that account for the role of this virus in graft loss are not well understood. However, the capacity of this virus to persist in the midst of intense inflammation suggests that its persistence could serve as a trigger for the induction of host-vs-graft responses or alternatively host responses to HCMV could contribute to the inflammatory milieu characteristic of chronic allograft rejection.

The human cytomegalovirus

Human cytomegalovirus (HCMV), a betaherpesvirus, represents the major infectious cause of birth defects, as well as an important pathogen for immunocompromised individuals. The viral nucleocapsid containing a linear double-stranded DNA of 230 kb is surrounded by a proteinaceous tegument, which is itself enclosed by a loosely applied lipid bilayer. Expression of the HCMV genome is controlled by a cascade of transcriptional events that leads to the synthesis of three categories of viral proteins designated as immediate-early, early, and late. Clinical manifestations can be seen following primary infection, reinfection, or reactivation. About 10% of infants are infected by the age of 6 months following transmission from their mothers via the placenta, during delivery, or by breastfeeding. HCMV is a significant post-allograft pathogen and contributes to graft loss independently from graft rejection. Histopathologic examination of necropsy tissues demonstrates that the virus enters via the epithelium of the upper alimentary, respiratory, or genitourinary tracts. Hematogenous spreading is typically followed by infection of ductal epithelial cells. Infections are kept under control by the immune system. However, total HCMV clearance is rarely achieved, and the viral genome remains at selected sites in a latent state. Virological and molecular detection of HCMV, as well as serological demonstration of a specific immune response, are used for diagnosis. Treatment of HCMV infections is difficult because there are few options. The presently available drugs produced a significant clinical improvement, but suffer from poor oral bioavailability, low potency, development of resistance in clinical practice, and dose-limiting toxicities.

Synergy of type I interferon-A6 and interferon-B naked DNA immunotherapy for cytomegalovirus infection

Delivery of type I IFN transgenes by naked DNA immunization can protect against cytomegalovirus infection and myocarditis. Here, we investigate IFN transgene expression, antiviral efficacy, and immunomodulation of myocarditis using various treatment regimes in a mouse CMV model. In vivo expression of the IFN transgene was observed in the sera for 35 days post-DNA inoculation. Prophylactic IFN-A6 and IFN-B DNA treatment for 14 days prior to murine cytomegalovirus (MCMV) infection was more efficacious in significantly reducing viral titres, than 2 days prior to or 2 days post-virus infection. Similarly, IFN-A6 DNA treatment commencing 14 days prior to virus infection was superior in suppressing both acute and chronic myocarditis. Furthermore, reduction of autoantibody titres was more pronounced when IFN was administered 14 days prior to viral infection. Combinational IFN gene therapy was assessed for synergy between IFN subtypes. Combination treatment with either IFN-A6/A9 or IFN-A6/B greatly reduced spleen viral titres while IFN-A6/B and IFN-A9/B reduced virus replication in the liver. Only IFN-A6/A9 and IFN-A9/B reduced acute viral myocarditis, whereas IFNA6/B treatment was most efficacious for autoimmune chronic myocarditis. Finally, treatment with IFN-A6 DNA 2 weeks post-MCMV infection proved effective at inhibiting the development of chronic autoimmune myocarditis. These findings suggest that immunomodulation of both antiviral and autoimmune responses by IFN DNA immunization may be an avenue for improved viral immunotherapy.

Risk factors for cytomegalovirus reactivation after CD6+ T-cell-depleted allogeneic bone marrow transplantation

BACKGROUND

Cytomegalovirus (CMV) infection is a significant cause of morbidity and mortality after allogeneic hematopoietic stem cell transplantation (HSCT). Recipients of T-cell-depleted (TCD) transplants may be more susceptible to CMV infection as a result of the reduction in transferred T cell immunity. We sought to determine the effect of prior donor and patient CMV exposure on the incidence of CMV infection after TCD allogeneic HSCT.

METHODS

We retrospectively examined CMV antigen testing results in all patients who had undergone CD6+ TCD related and unrelated donor allogeneic HSCT at our institution from 1996 to 1999. All 124 patients who had documented donor and recipient CMV serologies pretransplant and had undergone CMV antigen testing before day +100 posttransplant were included in the analysis.

RESULTS

Forty-one percent of seropositive recipients and 1% of seronegative recipients developed evidence of CMV reactivation (odds ratio 54.1, 95% confidence interval [CI] 6.9-424.1, P<0.001). Prior donor CMV exposure did not place seronegative recipients at increased risk of CMV conversion. Multivariable analysis indicated that prior donor CMV exposure significantly reduced the risk of CMV reactivation in seropositive recipients by 81% (odds ratio 0.19, 95% CI 0.04-0.91, P=0.04). Grades II to IV acute graft-versus-host disease (GVHD) was associated with CMV conversion (P=0.04) when seropositive recipients underwent HSCT from CMV-negative donors, but not when the donor was CMV-seropositive (P=0.54).

CONCLUSIONS

The CMV serology status of the recipient, rather than the donor, was the primary determinant of risk for CMV conversion after TCD allogeneic HSCT. Despite CD6+ T-cell depletion, immunity against CMV seemed to be transferred with the donor graft and protected seropositive HSCT recipients from CMV reactivation.

Type I interferon gene therapy protects against cytomegalovirus-induced myocarditis

Type I interferons (IFNs) are produced early in response to viral infection and modulate adaptive immunity. Previously we demonstrated localized protection against murine cytomegalovirus (MCMV) infection in IFN DNA-inoculated mice. Here we examine the effect of seven IFN subtypes (IFNA1, A2, A4, A5, A6, A9 and B), administered by DNA inoculation, on systemic MCMV infection and myocarditis. IFN transgene expression altered the pathogenesis of MCMV infection with regard to virus titre and myocarditis. IFNA6 treatment reduced MCMV replication whilst IFNA5 and A2 enhanced virus replication. IFNA6, A9, and B treatment inhibited acute myocarditis. A T helper type 1-like, antibody and cytokine, response correlated with decreased virus titre and myocarditis. In addition, IFNA6 was able to reduce chronic cardiac inflammation. This research into the effectiveness of seven type I IFNs, using DNA gene therapy, highlights the need for correct subtype usage in the treatment of disease. We demonstrate effective subtypes for treatment in both the acute and chronic phases of MCMV infection and the resultant development of myocarditis.

The risk of transfusion-acquired CMV infection in seronegative solid-organ transplant recipients receiving non-WBC-reduced blood components not screened for CMV antibody (1984 to 1996): experience at a single Canadian center

BACKGROUND

The use of CMV-safe cellular blood components has been recommended for CMV-sero- negative recipients of CMV seronegative (R-D-) solid- organ transplants.

STUDY DESIGN AND METHODS

The incidence of CMV infection in 281 CMV-seronegative patients receiving renal, heart, heart-lung, lung, and liver transplants at our center between January 1984 and October 1996 was studied. The blood components that these patients received were neither WBC reduced nor screened for CMV antibody.

RESULTS

One hundred thirty-one of 154 (85.1%) patients receiving organs from CMV-seropositive donors (R-D+) developed CMV infection compared with three cases of presumptive transfusion-acquired (TA) CMV infection in 127 R-D- recipients (2.4%) (relative risk, 36.0; 95% CI, 11.8-110.4). The organ-specific incidence of TA CMV infection in R-D- patients was as follows: renal, 0 of 57 (0%); heart, 0 of 29 (0%); heart-lung and/or lung, 1 of 6 (16.7%); and liver, 2 of 20 (10%). There was no significant difference in the transfusion requirements of CMV-infected and -uninfected R-D- patients. False-positive results were often (40%) observed when posttransfusion serum samples were used for determination of the organ donor CMV serostatus.

CONCLUSION

The low risk of TA CMV infection observed in transplant patients who received standard blood components in our study should be considered when evaluating the efficacy of programs that provide CMV-safe blood components for this population.

Cytological monitoring of peripheral blood, bronchoalveolar lavage fluid, and transbronchial biopsy specimens during acute rejection and cytomegalovirus infection in lung and heart--lung allograft recipients

STUDY OBJECTIVES

Acute rejection and cytomegalovirus (CMV) infection are important complications after lung and heart--lung transplantation. We sought to investigate whether acute rejection and CMV infection demonstrated as CMV antigenemia had an effect on the cell profiles of peripheral blood (PB), bronchoalveolar lavage fluid (BAL-F), or TBB histology.

PATIENTS AND DESIGN

In this prospective study, composition of cells in PB, BAL-F, and TBB samples from 20 lung or heart-lung transplantation patients were analyzed during episodes of acute rejection or CMV antigenemia. Rejection was graded according to the International Society for Heart and Lung Transplantation criteria. As controls, samples with no evidence of rejection or infection were used. To evaluate the effect of time on cellular findings, samples were divided into three groups according to time after transplantation: 1--30, 31--180, and more than 180 d after transplantation.

RESULTS

Acute rejection was associated with mild blood basophilia (p<0.05; specificity 94%, sensitivity 42%). In BAL-F during rejection, the number of basophils (p<0.05), eosinophils (p<0.05), and lymphocytes (p<0.05; specificity 77%, sensitivity 64%) was increased compared to controls during the post-operative month 1. Later-occurring rejections were associated with increased amounts of neutrophils in BAL-F (p<0.05; specificity 82%, sensitivity 74%). In TBB histology, acute rejections were associated with perivascular and/or peribronchial infiltration of lymphocytes (p<0.001) and plasma cells (p<0.05) compared to controls. In our patients receiving gancyclovir prophylaxis, CMV antigenemia did not significantly alter the cell profiles in PB and BAL-F nor the inflammatory cell picture in TBB histology.

CONCLUSION

TBB histology remains the 'gold standard' for diagnosing rejection in lung and heart-lung transplantation patients, as the inflammatory cell findings in TBB specimens are highly specific for rejection. The cellular changes associated with rejection, mild PB basophilia and increased proportions of lymphocytes in early- and neutrophils in later-occurring rejection, observed in BAL-F cannot be considered specific for rejection, but may warrant clinical suspicion of rejection.

Preemptive therapy versus universal prophylaxis with ganciclovir for cytomegalovirus in solid organ transplant recipients

Whether preemptive therapy or universal prophylaxis with ganciclovir is the optimal approach against cytomegalovirus (CMV) remains unresolved. Controversy abounds with respect to the efficacy of preemptive therapy, the reliability of preemptive therapy tools, the logistical difficulties in conducting surveillance monitoring for CMV, the cost of prophylaxis, the effect of prophylaxis on indirect sequelae of CMV and epidemiology of CMV, and the potential for emergence of ganciclovir-resistant CMV. Although neither approach is wholly adequate, a discussion of the relative merits and limitations of the 2 approaches may guide the selection of a rational approach toward prevention of CMV infection in organ transplant recipients.

Comparison of the efficacy and cost effectiveness of pre-emptive therapy as directed by CMV antigenemia and prophylaxis with ganciclovir in lung transplant recipients

BACKGROUND

CMV disease remains a major complication of lung transplantation and attempts to prevent it have met with marginal success. In a previous study we documented that universal prophylaxis did not prevent CMV disease but merely delayed it, and was very costly.

METHODS

We compared the efficacy and cost of pre-emptive therapy with ganciclovir, guided by CMV antigenemia, to that of historic controls that received universal prophylaxis with ganciclovir. CMV antigenemia assay was done routinely and pre-emptive therapy was initiated if greater than 25 CMV positive cells per 100,000 polymorphonuclear cells were found.

RESULTS

Nineteen patients were enrolled; 6 of of whom received 12 courses of pre-emptive therapy. The incidence of CMV disease was 26% compared to 38% for the historical controls (p = 0.51). None of the patients that received pre-emptive therapy developed CMV disease following that therapy. Antigenemia failed to predict disease in 5 patients that developed it, and thus it is unknown if pre-emptive therapy could have prevented it. There was no mortality in either the study patients or historic controls directly related to CMV. The net savings with pre-emptive therapy was $2569 per patient.

CONCLUSIONS

We conclude that pre-emptive therapy with ganciclovir is as safe and effective as universal prophylaxis in preventing CMV disease in lung transplant recipients, and is less expensive. The appropriate surveillance technique and timing remain to be determine to optimize the efficacy of pre-emptive therapy.

Low-dose oral use of interferon inhibits virally induced myocarditis

Cytomegalovirus (CMV) infection has been associated with the development of myocarditis in humans. Our established mouse model for CMV myocarditis allows detailed investigation of the immunopathogenic mechanisms and therapies for cardiovascular disease. The type I interferons (IFN-alpha/beta) are part of the innate immune response to CMV infections. Previously, we have reported that daily treatment with low doses of murine IFN-alpha/beta administered by the oral-mucosal route significantly reduces early virus replication of murine CMV in the spleen and liver of infected mice. The oral-mucosal route provides an alternate delivery system to the current modes of IFN administration and is associated with fewer side effects. Since prophylactic treatment with type 1 IFNs may result in both antiviral and immunomodulatory effects that may lessen the development of disease, we wished to study the effect of IFN-alpha/beta on the development of myocarditis. Low-dose oral use of type I IFN (10 IU/day for 7 days prior to virus infection) did not abrogate myocarditis but suppressed the inflammatory response in both the acute and chronic phase of the disease. Furthermore, low-dose oral use of IFN was as effective at inhibiting myocarditis as a single injection of a high dose of IFN (20,000 IU) on the day of virus infection. These findings indicate the need for evaluation of low-dose use of oral IFN in the development of improved clinical therapies for the treatment of cardiovascular disease.

Bronchoalveolar lavage in lung transplantation. State of the art

Fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) has become a crucial tool in the management of lung transplant recipients. Detection of pulmonary infectious pathogens by culture, cytology, and histology of BAL, protected brush specimens, and transbronchial biopsies (TBB) is highly effective. Morphologic and phenotypological analyses of BAL cells may be suggestive for certain complications after lung transplantation. For interpretation of BAL findings, the natural course of BAL cell morphology and phenotypology after lung transplantation must be considered. During the first 3 months after pulmonary transplantation, elevated total cell count in BAL and neutrophilic alveolitis are common, representing the cellular response to graft injury and interaction of immunocompetent cells of donor and recipient origin. With increasing time after transplantation the CD4/CD8 ratio decreases due to lowered percentages of CD4 cells in BAL. During bacterial pneumonias, the cellular profile of BAL is characterized by a marked granulocytic alveolitis. Lymphocytic alveolitis with a decreased CD4/CD8 ratio is suggestive of acute rejection, but is also found in viral pneumonias and obliterative bronchiolitis. In the case of a combined lymphocytosis and neutrophilia without any evidence of infection, obliterative bronchiolitis should be considered. Functional analyses of BAL cells can give additional information about the immunologic status of the graft, even before histologic changes become evident but have not been established in routine transplant monitoring. However, functional studies suggest an important role of activated, alloreactive and donor-specific T lymphocytes in the pathogenesis of acute and chronic lung rejection. Investigations of soluble components in BAL have given further insight into the immunologic processes after lung transplantation. In this overview, the characteristics of BAL after lung transplantation will be summarized, and its relevance for the detection of pulmonary complications will be discussed.

Quantitation of human cytomegalovirus DNA in peripheral blood leukocytes of heart transplant recipients: relationship with pp65 antigenemia and with antiviral therapy

OBJECTIVE: To retrospectively determine DNA levels in blood polymorphonuclear leukocytes (PMNLs) of 21 heart transplant patients who suffered from HCMV infection and who were monitored by the antigenemia assay (pp65 test) during follow-up, by use of a quantitative competitive polymerase chain reaction (PCR) assay for human cytomegalovirus (HCMV) DNA. METHODS: Quantitation of HCMV DNA by PCR was expressed as genome equivalents (GE) per 200 000 PMNLs. RESULTS: Ten patients experienced symptomatic HCMV infection (five primary infections and five reactivations) with mild symptoms and received ganciclovir treatment, whereas 11 asymptomatic HCMV infections were not treated. Therapy was discontinued when a 90% reduction of the pretreatment antigenic load was achieved in a symptomless patient. The mean HCMV DNA and antigenic loads were significantly higher in symptomatic than in asymptomatic patients: 4.6 x 105 plus minus 4.7 x 105 GE and 1.1 x 104 GE (p<0.0001) and 390 plus minus 350 versus 25 plus minus 12 pp65-positive PMNLs (p<0.0001), and in primary than in secondary infections (583 plus minus 403 pp65-positive PMNLs versus 85 plus minus 111, p=0.002 and 5.2 x 105 plus minus 5.2 x 105 GE instead of 1.5 x 105 plus minus 3.2 x 105 GE, p=0.02). A single course of 14--21 days of ganciclovir caused a marked decrease of HCMV DNA and antigenemia in eight of 10 patients in whom a 90% reduction of the antigenic load correlated with a 98% DNA reduction of the pretreatment levels. In two primary infections, a 90% antigenic reduction was achieved by 21 days of ganciclovir treatment, but those data only correlated with a DNA load reduction of 28% and 60% of the pretreatment levels. Fifteen and 12 days later, respectively, the two patients relapsed and underwent a second ganciclovir course, at the end of which a 90% reduction of the antigenic load correlated with a >98% DNA drop. GCV was discontinued and the patients recovered completely. In those two patients we retrospectively found persistent high DNA levels before the second ganciclovir course, whereas the antigenic load slowly increased after an apparent reduction. CONCLUSIONS: Our data suggest that: (1) DNA levels have the same trend as the pp65 antigen test---they are significantly higher in symptomatic and in primary HCMV-infected patients than in asymptomatic patients and those with secondary infection; (2) a 90% antigenic load reduction from the pre-treatment level may be a less reliable predictor of the efficacy of anti-HCMV therapy than DNA load, at least in primary infection, in which a much higher viral load and much more severe disease are present; and (3) a DNA load reduction of >98% of the pretreatment value is required for therapeutic success.

Prophylaxis post-transplant. The role of monitoring surveillance bronchoscopy and antimicrobials

One of the key areas of successful organ transplantation is the prompt recognition and treatment of problems that otherwise can progress rapidly, leading to morbidity and mortality. Surveillance and prophylaxis are essential in the field of transplant medicine.

Lung transplantation. Part II. Postoperative management and results

In part I of this 2-part article on lung transplantation (Western Journal of Medicine 1996; 165:355-363), we reviewed the current indications and operative techniques of the procedure. In part II, we describe the postoperative management and results of lung transplantation. We also discuss current controversies, such as the use of marginal donors, living-related transplants, marginal recipients, and single-versus double-lung transplantation for emphysema or pulmonary hypertension.

Cytomegalovirus as a cause of morbidity in heart transplantation. The experience of one center

The accumulated data from 78 heart transplant recipients surviving for more than one month postoperatively were reviewed; the median duration of follow up was 16 months. Cytomegalovirus (CMV) disease was seen most frequently in recipients of hearts from CMV-seropositive donors, irrespective of the recipient CMV antibody status. CMV-related illness was detected in 13 patients; of the six who developed pneumonitis, five were CMV-seropositive recipients with seropositive donors. CMV was not a common cause of hepatitis or gastrointestinal symptoms.

Comparative study of three PCR assays with antigenaemia and serology for the diagnosis of HCMV infection in thoracic transplant recipients

Three PCR assays were evaluated for the detection of human cytomegalovirus (HCMV) infection in heart and lung transplant recipients in comparison with HCMV antigenaemia and serology assay. Polymorphonuclear leucocyte (PMNL) samples taken at regular intervals after transplantation were tested for HCMV DNA using primer sets homologous to the glycoprotein B (gp58), major immediate early (IE1), and structural phosphoprotein (pp150) regions. The detection of HCMV infection at various times after transplantation showed all three primer sets to have a sensitivity of 100% and a specificity of 92.3% for the detection of HCMV infection although overall the gp58 primer set was found to be significantly more frequently associated with a positive PCR result than the IE1 (P = 0.0228) and pp150 (P = 0.0015) primer sets. The positive PCR result had a positive predictive value of 27.8% for HCMV disease. Detection of HCMV infection was first by the PCR assay, and significantly before the HCMV antigenaemia assay. Of nine patients who received antiviral therapy while PCR positive, only one patient cleared HCMV DNA from PMNLs during treatment but became positive again 17 days later. Quantitative PCR methodologies may improve the predictive value of PCR for HCMV disease and its value for monitoring antiviral therapy.

Comparison of polymerase chain reaction and pp65 antigen test for early detection of human cytomegalovirus in blood leukocytes of cardiac transplant recipients

OBJECTIVE: To establish whether polymerase chain reaction (PCR) for cytomegalovirus deoxyribonucleic acid (DNA) can provide clinical information for the management of the infection. METHODS: Leukocytes in 30 heart transplant recipients were monitored by pp65 antigen testing and PCR for 82 to 365 days after transplantation. RESULTS: Of the 30 patients, 26 developed cytomegalovirus infection, nine of whom were symptomatic. Altogether, 300 leukocyte samples were examined. The concordance between PCR and pp65 antigen test was 82.6%. In symptomatic patients after surgery, PCR detected cytomegalovirus infection after 38 plus minus 16 days and the pp65 antigen test, after 48 plus minus 15 days. Symptomatic infection correlated with a higher number of pp65-positive leukocytes than did asymptomatic infection: 310 plus minus 356 vs 24 plus minus 35 (p < 0.005)/200,000 examined, respectively. Clearance of virus was observed by PCR after 125 plus minus 73 days (range 29 to 225) in symptomatic, and after 82 plus minus 70 days (range 16 to 301) in asymptomatic, cases of infection. CONCLUSIONS: The positive predictive value of PCR for symptomatic infection was 34.6%. Our findings correlate with previous reports and show that the qualitative detection of cytomegalovirus DNA is not associated with overt disease whereas quantitation of pp65-positive leukocytes closely correlate with symptom onset. Insofar as the results are not quantitative, PCR is not a marker of clinically apparent infection. Careful monitoring of cytomegalovirus infection based on quantitative pp65 antigen assay can fulfill all clinical needs for early diagnosis and proper management of the infection

Questioning the clinical significance of upper gastrointestinal cytomegalovirus disease following heart transplantation

We performed a retrospective review of patients who underwent esophagogastroduodenoscopy after heart transplantation to determine the clinical setting in which upper gastrointestinal cytomegalovirus disease is identified. No gastrointestinal cytomegalovirus disease was found prior to transplant 51 and this period (from transplant 1 to 50) correspond to a time when significantly fewer esophagogastroduodenoscopies included biopsy. Patients in whom cytomegalovirus was identified were more likely to have been CMV seronegative and to have received a heart from a seropositive donor (60% vs 20%, P = 0.029). In addition, patients with cytomegalovirus used aspirin more commonly (90% vs 31%, P = 0.001), and underwent esophagogastroduodenoscopy earlier after transplantation (123d vs 652d, P = 0.029). We conclude that factors that increase the use of esophagogastroduodenoscopy and biopsy in the early transplant period increase the likelihood of identifying cytomegalovirus in gastrointestinal tissue. However, the clinical course and significance of cytomegalovirus identified in the upper gastrointestinal tract in heart transplant patients may be difficult to discern.

Transfusion-transmitted cytomegalovirus: the part-time pathogen

Viral infection is a well-known risk of blood product transfusion and much work has been devoted to the detection of such well-known pathogens as human immunodeficiency virus and hepatitis viruses in blood donors. Cytomegalovirus (CMV) is found in a much larger percentage of donor units than these other viruses but will cause disease in only a minority of recipients. Many pediatric patients (especially premature infants) are at risk for transfusion-transmitted CMV. This review describes work delineating the populations of patients most at risk for transfusion-transmitted CMV, describes methods for detecting CMV in blood donors, evaluates current methods for leuko-depletion of blood products, and provides recommendations for patients most likely to benefit from blood products with low risk of CMV transmission.

Fatal cytomegalovirus myocarditis in a seronegative ALL patient

Fatal cytomegalovirus (CMV) myocarditis occurred in a 2 year old boy with acute lymphoblastic leukemia (ALL) in remission. The patient showed mild hepatic dysfunction and a rapid progress of pancytopenia after complete remission had been achieved. At the fifth week of complete remission, he presented signs of heart failure such as tachycardia, S4 gallop on auscultation and decreased ejection fraction on echocardiography. However, no significant electrocardiographic changes were recognized. In addition to the cardiac dysfunction, the patient presented a marked tachypnea and dyspnea associated with hypoxemia. These were dramatically improved by methylprednisolone pulse therapy (30 mg/kg per day, for 3 days) and CMV high titer immunoglobulin (400 mg/kg per day, for 3 days). On the sixth day after signs of respiratory failure were improved, the patient suddenly presented a paroxysmal atrial tachycardia followed by a fatal ventricular fibrillation. Although we could detect neither a specific IgM antibody, a significant increase of IgG antibody, nor CMV genome by DNA hybridization techniques during the course of the illness, microscopic examination of necropsy specimens of the heart showed a marked disruption and disintegration of muscle bands associated with cytomegalic inclusion bodies. Polymerase chain reaction (PCR) yielded a 305 bp amplification product in the heart and lung tissues, supporting the view that myocarditis was caused by CMV.

Increased early mortality in women undergoing cardiac transplantation

BACKGROUND

To evaluate factors that explain sex differences affecting mortality after cardiac transplantation, a retrospective analysis of adult patients undergoing orthotopic cardiac transplantation was undertaken at the Columbia-Presbyterian Medical Center.

METHODS AND RESULTS

The study population consisted of 379 patients (75 women, 304 men) > or = 18 years of age who survived for > or = 48 hours after undergoing orthotopic cardiac transplantation between March 1985 and March 1992. The following were analyzed: incidence of death and treated rejection episodes, donor and recipient cytomegalovirus (CMV) matches, use of OKT3 induction therapy, and donor and recipient HLA mismatches. Women 49 +/- 12 years old and men 47 +/- 12 years old were characterized by differences in race and diagnosis. Women were more likely to be nonwhite (P < .01) and have idiopathic cardiomyopathy than were men (P < .01). A trend toward an increase in first-year rejection frequency was seen in women compared with men (P = .08). Overall actuarial survival was significantly reduced in women after transplantation (P < .05). At 36 months, female actuarial survival was 64 +/- 7% versus 76 +/- 3% for men (P < .05). The majority of patients in this study did not receive CMV prophylaxis. Univariate analysis revealed that only CMV(+) donor status and the use of OKT3 induction therapy affected survival in women. Multivariate analysis revealed a marked reduction in survival in female recipients of CMV(+) donors given OKT3 induction therapy. At 36 months, only 25% of women were still alive compared with 86% of women with neither risk factor (P < .001). Even without OKT3 induction there was markedly reduced survival in women with mismatched CMV status, ie, CMV(-) recipients of CMV(+) donors; 17% survival after 36 months versus 86% in women who were CMV(+) recipients (P < .05). Although at this institution during the study time period, CMV prophylaxis was not routinely employed and OKT3 induction was selectively used in higher-risk patients, conclusions regarding differences in outcome that are sex dependent are valid.

CONCLUSIONS

(1) Women are at risk for reduced actuarial survival up to 3 years after cardiac transplantation. (2) Univariate analysis shows that women are selectively at risk for death when receiving hearts from CMV(+) donors and after receiving OKT3 induction therapy. (3) Multivariate analysis reveals that women are at even greater risk for death when receiving hearts from CMV(+) donors in conjunction with OKT3 induction therapy. (4) In the absence of OKT3 use, the greatest risk of death occurs in CMV(-) women transplanted with CMV(+) donor hearts. (5) When female to male survival curves are compared, factors that influenced survival in women did not appear to be problematic in men.

Association of cytomegalovirus infection with post-transplantation cardiac rejection as studied using the polymerase chain reaction

The relationship between cytomegalovirus (CMV) infection and cardiac allograft rejection is controversial, some authors reporting a significant association, others not, on the basis of the results of conventional virological diagnosis by culture or serology. This problem was reinvestigated in 88 patients using a semi-quantitative nest polymerase chain reaction (PCR) procedure for detecting CMV DNA in endomyocardial biopsy specimens. Significantly more positive biopsies were obtained from patients with moderate (grade 2; P = 0.02) or severe (grade 3a-4; P = 0.03) rejection than with no or mild (grade 0-1b) rejection, whereas there was no significant association between rejection and CMV as diagnosed by virus isolation from urine, throat or blood, or by the detection of CMV-IgM. PCR-positive biopsies originated most frequently from CMV-antibody positive recipients (R+) of hearts from seropositive donors (D+), in association with moderate or severe rejection rather than with mild or no rejection The detection of CMV in the heart thus seemed to be related more to R+D+ serological status than to severity of rejection, that is, to circumstances that favoured co-infection with strains of CMV from both donor and recipient. Studies on sequential biopsy specimens from selected patients also provided evidence that CMV infection and rejection were not always related events. The PCR was able to differentiate latent from active CMV infection; moreover, some seronegative individuals gave repeatedly positive biopsies, thereby supporting the work of others that some patients undergo CMV infection without mounting a detectable antibody response.(ABSTRACT TRUNCATED AT 250 WORDS)

HLA mismatching and cytomegalovirus infection as risk factors for transplant failure in cyclosporin-treated renal allograft recipients

In a study of the effects on renal allograft survival of HLA mismatching, mismatching for cytomegalovirus (CMV) antibody status, and post-transplant CMV infection, 148 cyclosporin-treated renal transplant recipients were given kidneys optimally matched for HLA-A, -B, and -DR antigens but not matched for CMV antibody status. Mismatching for HLA-B and -DR antigens was associated with a greater number of rejection episodes and a lower graft survival, but mismatching for CMV antibody status and posttransplant primary or recurrent CMV infection exerted no effect on graft survival. The role of matching of renal transplant recipients and donors for CMV antibody status in preference to HLA matching (proposed as a means of reducing the mortality associated with primary CMV infection) is discussed.

Detection of false seroconversions in cytomegalovirus seronegative platelet donors by serial complement fixation or IgG-specific radioimmunosorbent tests

A panel of 421 cytomegalovirus (CMV) seronegative-platelet donors was followed using complement-fixation (CFT) and IgG-specific radioimmunosorbent tests (RIST) to detect seroconversion. During 4623 person-months of observation 2452 serum specimens were tested, and the annual rate of seroreactivity detected by RIST was 56%. However, most of the positive RIST results were followed by negative results with later serum samples. CFT seroreactivity was a poor predictor of RIST seroreactivity. The high rate of transient seroreactivity detected by RIST may have reflected the lack of absolute specificity of the test. Alternatively, the results could illustrate the difficulty of determining whether an individual harbours latent CMV infection using antibody tests when some seronegative individuals appear to be latently infected. In the light of our observations recommendations for CMV antibody testing of blood donors are proposed.

Diagnosis of cytomegalovirus infection in heart transplant recipients

In a prospective study eight (47%) heart transplant recipients had recurrent cytomegalovirus (CMV) infection. Of these, five had received hearts from seropositive donors. Neither serology nor virus isolation from urine was reliably associated with clinical CMV infection, but a high CMV IgM index correlated with CMV infection.

Cytomegalovirus infection and disease after liver transplantation. An overview

Cytomegalovirus is the single most important pathogen in clinical transplantation. Although much progress has been made in our understanding of the molecular biology and epidemiology of CMV infection and in our ability to diagnosis and treat CMV disease, it remains a major cause of morbidity but is no longer a major cause of mortality after liver transplantation. Risk factors for CMV disease after liver transplantation include donor and recipient serologic status, the use of antilymphocyte therapy, and retransplantation. CMV disease occurs early after transplantation, and the most frequent site of disease is the hepatic allograft. We have treated 79 patients with intravenous ganciclovir, with ultimate control of disease achieved in 69 patients (87.3%). Preliminary results using intravenous immunoglobulin and oral acyclovir for CMV prophylaxis in high-risk patients have been encouraging. In addition to producing clinical syndromes. CMV may have direct immunologic effects and is a marker of the net state of immunosuppression.

The incidence and consequences of cytomegalovirus transmission via blood transfusion to low birth weight, premature infants in north east Scotland

In a 2-year study involving 133 premature low birth weight (less than 1,500 g) infants, the impact of CMV infection via blood transfusion was assessed. 8.4% (7 out of 83) of transfused infants and 10% (7 out of 70) of those exposed to seropositive blood acquired CMV. In those less than 1,250 g the infection rate rose to 13.2% (7 out of 46). Seropositive infants were at a higher risk of acquiring CMV infection than seronegative ones. CMV infection did not give rise to specific immediate morbidity, and no deaths were attributed to CMV. The only source of nosocomial CMV infection was the transfused seropositive blood. Based on these findings, it was possible to formulate a CMV transfusion policy to premature infants in our region.

Neuropathologic findings after liver transplantation

Neuropathologic findings are described in 37 patients autopsied after one or more orthotopic liver transplants. Gross or microscopic lesions were observed in almost all patients, including anoxic-ischemic change, hemorrhages and/or infarcts, and opportunistic infections by fungi (most commonly Aspergillus) and rarely viruses (cytomegalovirus). Central pontine and extra-pontine myelinolysis was commonly observed, and appeared to result from severe multifactorial metabolic abnormalities in the perioperative period. Low-grade (microglial nodule) encephalitis without an obvious pathogen was often encountered. Common clinical neurologic abnormalities included encephalopathy, seizures (myoclonic, focal or generalized), obtundation and coma. These were found more commonly than focal findings, but clinical features in a given patient were not uniformly predictive of underlying neuropathologic change.

Discrepant results with a latex agglutination test in the assessment of cytomegalovirus antibody status of cardiac transplant donors

The cytomegalovirus (CMV) antibody status of 79 cardiac transplant recipients and their respective donors was determined by a latex-agglutination technique and by a CMV IgG ELISA technique on the same samples. Although good agreement between the two methods was found in recipient samples the latex method produced significantly more positive results in donor samples than did the ELISA test. Clinical and serological follow-up of the patients concerned over the first 6 months after transplantation suggested that the ELISA results were correctly predictive of donor transmitted primary CMV infection and that, therefore, the latex test was producing false positive readings. Further investigation is needed to discover the reason for these discrepancies. The use of donor samples taken at the time of organ retrieval may have prejudiced the latex test results. Until these problems are resolved it is suggested that the latex agglutination technique should not be the sole method adopted to assess donor CMV antibody status.

Screening of bone marrow and kidney transplant donors and recipients for cytomegalovirus antibody by commercial latex agglutination or competitive enzyme-linked immunosorbent assays

A commercial competitive enzyme-linked immunosorbent assay and a sensitive in-house radioimmunosorbent test detected cytomegalovirus (CMV) antibody in similar numbers of serum specimens (66 and 67 of 152, respectively) obtained from bone marrow and renal transplant donors and recipients. In contrast a commercial latex agglutination assay for CMV antibody apparently gave false positive results when testing serum specimens obtained from organ donors. The implications for CMV screening of organ transplant donors and recipients are discussed.

Management of cytomegalovirus antibody negative patients undergoing heart transplantation

In a series of 61 consecutive patients undergoing heart, heart and lung, and lung transplantation, 24 patients were known to be cytomegalovirus (CMV) antibody negative on the day of transplantation. Enzyme linked immunosorbent assays (ELISA) for CMV IgG were performed on donor samples on the day of operation. In 16 of the 24 susceptible patients the test was negative and the only preventive measure taken was the use of blood and blood products from CMV-antibody negative blood donors. None of these patients acquired primary infection with CMV. In another six patients the donor serum was found to contain CMV specific IgG, and in these patients, including one heart and lung transplant recipient, prophylaxis with CMV specific hyperimmune globulin was given. All six patients developed CMV IgM antibodies and in five there was an associated but clinically mild illness. None of these patients required treatment. In the remaining two patients ELISA tests on the donor sera gave equivocal results and hyperimmune globulin was withheld. Both patients developed primary CMV infection of greater severity than those given hyperimmune globulin and one required treatment. Reference tests confirmed that the donor sera contained CMV antibodies. Primary CMV infection in susceptible patients after heart transplantation can be avoided by the use of screened blood and blood products where the organ donor is seronegative to CMV and it can be improved by the use of prophylactic hyperimmune globulin where the donor is CMV antibody positive.

Neuropathology of heart transplantation

The neuropathology of 18 cardiac transplant recipients was reviewed with the clinical findings. Pathological changes were noted in the central nervous system (CNS) in 94% of the patients, the most frequent being cerebral vascular in origin (72%). Eight patients (44%) had multiple cerebral infarcts and morphologically, a large number of these antedated the transplantation. In addition 4 patients had acute focal ischemic changes which occurred after transplantation. Intracranial hemorrhage was noted in 5 patients (28%), including one case of fatal intracerebral hemorrhage following an acute hypertensive episode after the transplantation. While systemic infection was common (10 patients), there were only 5 cases of intracranial infection; including 3 cases of cytomegalovirus infection, one of candidiasis and one of aspergillosis. Post-transplant seizures, occurring in a third of the patients, were related to a variety of causative factors such as sepsis, intracranial hemorrhage, cerebral ischemia, metabolic encephalopathy and cyclosporin neurotoxicity. Of note in this series was the absence of CNS lymphoma or other systemic lymphoproliferative disorder.