Post-transplantation HTLV-1 myelopathy in three recipients from a single donor

Imaging Spectrum of HTLV-1–Related Neurologic Disease

Purpose of Review

Human T-cell lymphotropic virus type 1 (HTLV-1)–associated myelopathy (HAM) is a well-recognized neurologic complication of HTLV-1. Beyond HAM, several other neurologic manifestations are increasingly recognized, including acute myelopathy, encephalopathy, and myositis. The clinical and imaging features of these presentations are less well understood and potentially underdiagnosed. In this study, we summarize the imaging features of HTLV-1–related neurologic disease, providing both a pictorial review and pooled series of the less well-recognized presentations.

Recent Findings

35 cases of acute/subacute HAM and 12 cases of HTLV-1–related encephalopathy were found. In subacute HAM, cervical and upper thoracic longitudinally extensive tranverse myelitis was noted, while in HTLV-1–related encephalopathy, confluent lesions in the frontoparietal white matter and along the corticospinal tracts were the most prevalent finding.

Summary

There are varied clinical and imaging presentations of HTLV-1–related neurologic disease. Recognition of these features aids early diagnosis where therapy may have the greatest benefit.

Prevalence of Human T-Lymphotropic Virus Type 1 in Brain-Dead Organ Donors

Background: This study aimed to assess the prevalence of human T-lymphotropic virus type 1 (HTLV-1) among brain-dead organ donors at Masih Daneshvari Hospital in Tehran, Iran. Methods: By enzyme-linked immunosorbent assay (ELISA), 54 organ donors were screened for HTLV-1 virus in this descriptive cross-sectional study. Following that, Western blot confirmation was performed to confirm the HTLV-I infection. Results: Anti-HTLV-1 antibodies were detected in 2 (3.4%) cases out of 54 patients tested by ELISA. A western blot was performed in cases of positive results, but none of the subjects tested positive for HTLV-1 infection. Conclusions: The results of the present study indicated rare cases of HTLV-I infection in brain-dead organ donors. However, it is recommended that organ donors be investigated for the prevalence of this virus.

Antiretroviral Therapy in HTLV-1 Infection: An Updated Overview

The human T cell leukemic/lymphotropic virus type 1 (HTLV-1), discovered several years ago, is the causative agent for a rapid progressive haematological malignancy, adult T cell leukemia (ATL), for debilitating neurological diseases and for a number of inflammatory based diseases. Although the heterogeneous features of the diseases caused by HTLV-1, a common topic concerning related therapeutic treatments relies on the use of antiretrovirals. This review will compare the different approaches and opinions in this matter, giving a concise overview of preclinical as well as clinical studies covering all the aspects of antiretrovirals in HTLV-1 infection. Studies will be grouped on the basis of the class of antiretroviral, putting together both pre-clinical and clinical results and generally following a chronological order. Analysis of the existing literature highlights that a number of preclinical studies clearly demonstrate that different classes of antiretrovirals, already utilized as anti-HIV agents, are actually capable to efficiently contrast HTLV-1 infection. Nevertheless, the results of most of the clinical studies are generally discouraging on the same point. In conclusion, the design of new antiretrovirals more specifically focused on HTLV-1 targets, and/or the establishment of early treatments with antiretrovirals could hopefully change the perspectives of diseases caused by HTLV-1.

Rare and Emerging Viral Infections in the Transplant Population

Viral infections account for a large proportion of emerging infectious diseases, and the agents included in this group consist of recently identified viruses as well as previously identified viruses with an apparent increase in disease incidence. In transplant recipients, this group can include viruses with no recognized pathogenicity in immunocompetent patients and those that result in atypical or more severe disease presentations in the immunocompromised host. In this chapter, we begin by discussing viral diagnostics and techniques used for viral discovery, specifically as they apply to emerging and rare infections in this patient population. Focus then shifts to specific emerging and re-emerging viruses in the transplant population, including human T-cell leukemia virus 1, rabies, lymphocytic choriomeningitis virus, human bocavirus, parvovirus 4, measles, mumps, orf, and dengue. We have also included a brief discussion on emerging viruses and virus families with few or no reported cases in transplant recipients: monkeypox, nipah and hendra, chikungunya and other alphaviruses, hantavirus and the Bunyaviridae, and filoviruses. Finally, concerns regarding infectious disease complications in xenotransplantation and the reporting of rare viral infections are addressed. With the marked increase in the number of solid organ and hematopoietic stem cell transplants performed worldwide, we expect a corresponding rise in the reports of emerging viral infections in transplant hosts, both from known viruses and those yet to be identified.

The clinical impact of human T-lymphotrophic virus type 1 (HTLV-1) infection on the development of adult T-cell leukemia-lymphoma (ATL) or HTLV-1-associated myelopathy (HAM) / atypical HAM after allogeneic hematopoietic stem cell transplantation (allo-HSCT) and renal transplantation

Because there are limited clinical reports on the impact of human T-lymphotropic virus type 1 (HTLV-1) on organ transplantation, its effects on the development of adult T-cell leukemia-lymphoma (ATL), post-transplantation lymphoproliferative disorder (PTLD) and HTLV-1–associated myelopathy (HAM) or atypical HAM after organ transplantation remain unclear.

We retrospectively analyzed the impact of HTLV-1 in 54 allogeneic hematopoietic stem cell transplantation (allo-HSCT) cases and 31 renal transplantation cases between January 2006 and December 2016.

Among the 54 allo-HSCT cases, nine recipients with ATL tested positive for HTLV-1, and one was found to be an HTLV-1 carrier. All donors tested negative for HTLV-1. Only one HTLV-1 carrier did not present with ATL or HAM development after allo-HSCT. Among nine ATL cases after allo-HSCT, four eventually relapsed due to proliferation of recipient-derived ATL cells. However, in one ATL case, atypical HAM developed rapidly at 5 months after allo-HSCT.

Among the 31 renal transplantation cases, all donors tested negative for HTLV-1, and only recipients tested positive. Only one HTLV-1 carrier recipient did not present with ATL or HAM development after renal transplantation. However, one HTLV-1-negative recipient developed PTLD in the brain 10 years after renal transplantation.

In clinical practice, careful follow-up of HTLV-1 infected recipients after organ transplantation is important because atypical HAM can develop in ATL patients after allo-HSCT. Furthermore, to clarify the risk of ATL or HAM development in HTLV-1 infected recipients, we prospectively followed up our cohort.

HTLV-1 myelopathy after renal transplant and antiviral prophylaxis: the need for screening

The human T-lymphotropic virus type 1 (HTLV-1) is a RNA retrovirus that infects a minimum of 5-10 million people worldwide. Transmission by cell-containing blood products and solid organ transplantation has been reported. Clinical disease occurs in about 5-10% of infected individuals and consists mainly in adult T cell leukemia and HTLV-1-associated myelopathy (HAM). We present a 54-year-old woman who underwent kidney transplant from cadaveric donor in March 2015. Donor also underwent cornea extraction for another recipient (corneal transplant protocol includes HTLV-1/2 serology). Twenty-four hours after completion of kidney transplant donor, HTLV-1 serology was revealed positive. Following experts' recommendations, once donor seropositivity was demonstrated, antiviral prophylaxis including zidovudine and raltegravir was initially given to our patient, in spite of which the patient developed HAM. Once the diagnosis of HAM was established, antiretroviral therapy was restarted, and intravenous pulses of methylprednisolone were periodically administered with transient initial improvement. Later on, the patient experienced neurological deterioration becoming wheelchair dependent. Since the occurrence of this case, HTLV-1 screening has become mandatory for solid organ transplantation in the Spanish province of Navarra, and the same should happen worldwide.

Seroprevalence and geographical distribution of human T-lymphotropic virus type 1 among volunteer blood donors in endemic areas of Iran

Background

Human T-cell lymphotrophic virus type 1 (HTLV-1) has a worldwide distribution and it is endemic in some regions of Iran. One of the most important routes of HTLV-1 transmission is via transfusion of contaminated blood components. The risk of transmission through asymptomatic blood donors, particularly in endemic areas should be considered and appropriately managed. The main objective of this study was to determine the seroprevalence and description the geographic distribution of HTLV-1 among voluntary blood donors in Iran.

Methods

This retrospective study carried out using the data obtained from the main database of the seven blood transfusion centers of Iranian Blood Transfusion Organization between 2009 and 2013. The presence of anti-HTLV-1/2 antibodies were primarily assessed using Enzyme-linked Immunosorbent Assay. The Ab Kit assay, contain antigens for the screening of antibodies to HTLV type 1 and 2. So, it is expressed as HTLV 1/2 assay. Samples that were positive by the western blot confirmatory test were considered as definite positive HTLV-1 or HTLV-2 cases. The main socio-demographic variables were; age, gender, donation history and marital status. Descriptive and analytical statistics were used to summarize the gathered data. The chi-Square Statistical test was used to test the association between groups, P-value of less than 0.05 was considered significant.

Results

A total of 1864489 blood donations were evaluated. There were 1840 confirmed HTLV-1 positive donations (0.098%). None were positive for anti-HTLV-2. The overall HTLV-1 prevalence was 98.7 per 100,000 donations during the 5 year period. Seroprevalence was higher among females, married and older blood donors. The overall seropositivity among first time, regular and lapsed donors was, 0.29% (290/100000), 0.001% (1/100000) and 0.02% (20/100000) respectively. A significant difference was observed between regular and the first time (p <0.0001) and also between lapsed and regular blood donors (p <0.0001). Most of the HTLV-1 seropositive blood donors (175 per 100,000) were from northeastern regions. We observed a gradual decline in overall HTLV-1 prevalence during the course of the study, the prevalence rate decreased from 0.13% (130/100000) in 2009 to 0.07% (70/100000) in 2013.

Conclusions

The Seroprevalence of HTLV-1 among Iranian blood donors in the regions of our study still is considerable, but there is an obvious declining prevalence over the course of present study. Blood transfusion centers should continually evaluate the residual risk of infection in the country, especially in endemic areas.

Two Cases of Human T-Lymphotropic Virus Type I-Associated Myelopathy/Tropical Spastic Paraparesis Caused by Living-Donor Renal Transplantation

In rare instances, recipients of organ transplants from human T-lymphotropic virus type I- (HTLV-I-) positive donors reportedly developed neurologic symptoms due to HTLV-I-associated myelopathy (HAM). We present herein two cases of HAM associated with renal transplantation from HTLV-I seropositive living-donors. The first patient was a 42-year-old woman with chronic renal failure for twelve years and seronegative for HTLV-I. She underwent renal transplantation with her HTLV-I seropositive mother as the donor, and she developed HAM three years after the transplantation. The second patient was a 65-year-old man who had been suffering from diabetic nephropathy. He was seronegative for HTLV-I and underwent renal transplantation one year previously, with his HTLV-I seropositive wife as the donor. He developed HAM eight months after renal transplantation. Both cases showed neurological improvements after the immunomodulating therapies. We tried to shed some light on the understanding of immunological mechanisms of transplantation-associated HAM, focusing on therapeutic strategies based on the immunopathogenesis of the condition.

HTLV-1-associated myelopathy in a solid organ transplant recipient

Human T-cell lymphotropic virus type-1 (HTLV-1) is endemic in Japan, the Caribbean and in South American countries such as Ecuador. This virus is the cause of HTLV-1-associated myelopathy or tropical spastic paraparesis (HAM/TSP), a myelopathy characterised by chronic progressive paraparesis, spasticity and urinary symptoms. We report the case of a 40-year-old man who received a kidney transplant from a living donor and developed HAM/TSP, 24 months after transplant. The diagnosis was confirmed by detection of HTLV-1 in blood and cerebrospinal fluid by the ELISA and Western Blot tests. For myelopathy, the patient was treated with pulse methylprednisolone, but had poor response to treatment. We recommend that all patients receiving transplants and their donors who come from endemic countries be given a mandatory screening for HTLV-1 through an ELISA test, in an effort to inform candidates for renal transplantation of the potential risk of infection and the development of this disease.

Screening and Monitoring for Infectious Complications When Immunosuppressive Agents Are Studied in the Treatment of Autoimmune Disorders

Significant progress has been made in the development, investigation, and clinical application of immunosuppressive agents to treat a variety of autoimmune disorders. The expansion of clinical applications of these new agents requires the performance of large multicenter clinical trials. These large clinical trials are particularly important as one considers these agents for the treatment of type 1 diabetes, which although autoimmune in its pathogenesis, is not classically treated as an autoimmune disorder. Although these agents hold promise for amelioration or cure of this disease, they have the potential to facilitate infectious complications. There are limited data regarding the prospective assessment of infectious risks with these agents in trials of this nature. Pediatric subjects may be at greater risk due to the higher likelihood of primary infection. A subgroup of experts associated with TrialNet (a National Institutes of Health [NIH]-funded Type 1 diabetes mellitus research network) with expertise in infectious diseases, immunology, and diagnostics developed an approach for screening and monitoring of immunosuppression-associated infections for prospective use in clinical trials. The goals of these recommendations are to provide a structured approach to monitor for infections, to identify specific laboratory testing and surveillance methods, and to consider therapies for treatment of these potential complications. Prospective evaluations of these infectious risks allow for greater scientific rigor in the evaluation of risk, which must be balanced with the potential benefits of these therapies. Our experience supports an important role for investigators with expertise in infections in immunocompromised individuals in protocol development of immunosuppressive trials in type 1diabetes and potentially other autoimmune diseases.

Human T lymphotropic virus type-1-associated myelopathy manifesting shortly after living-donor renal transplantation

A 38-year-old woman experienced numbness in both lower extremities and spastic paralysis a few months after undergoing living-donor renal transplantation. The patient was negative for human T lymphotropic virus type-1 (HTLV-1) antibodies prior to the procedure; however, she was diagnosed with HTLV-1-associated myelopathy (HAM) based on positive serum and cerebrospinal fluid antibody titers after the surgery. Because the donor was also positive for HTLV-1 antibodies, the infection likely originated from the transplanted kidney. Clinical and imaging improvements were noted following the administration of interferon-α. HAM has been reported to occur after living-donor renal transplantation; however, there are no previous reports of onset within such a short period.

Donor-transmitted HTLV-1-associated myelopathy in a kidney transplant recipient--case report and literature review

Clinical disease due to human T cell lymphotropic virus type 1 (HTLV-1), a retrovirus endemic in certain regions of the world, is rarely reported after solid organ transplantation. In 2009, universal deceased donor organ screening for HTLV-1 was discontinued in the United States. We report the first case of donor-derived HTLV-1-associated myelopathy in a kidney transplant recipient from the United States. The patient, who was HTLV-1-seronegative prior to transplantation, likely acquired HTLV-1 infection from a seropositive organ donor. In this era when screening of donors and recipients for HTLV infection is not mandatory, clinicians should be vigilant in recognizing the risk and potential occurrence of this donor-derived infection in recipients with epidemiologic exposures.

Rare and emerging viral infections in transplant recipients

Emerging viral pathogens include newly discovered viruses as well as previously known viruses that are either increasing, or threatening to increase in incidence. While often first identified in the general population, they may affect transplant recipients, in whom their manifestations may be atypical or more severe. Enhanced molecular methods have increased the rate of viral discovery but have not overcome the problem of demonstrating pathogenicity. At the same time, improved clinical diagnostic methods have increased the detection of reemerging viruses in immunocompromised patients. In this review, we first discuss viral diagnostics and the developing field of viral discovery and then focus on rare and emerging viruses in the transplant population: human T-cell leukemia virus type 1; hepatitis E virus; bocavirus; KI and WU polyomaviruses; coronaviruses HKU1 and NL63; influenza, H1N1; measles; dengue; rabies; and lymphocytic choriomeningitis virus. Detection and reporting of such rare pathogens in transplant recipients is critical to patient care and improving our understanding of posttransplant infections.

Transfusion-transmitted human T-lymphotropic virus Type I infection in a United States military emergency whole blood transfusion recipient in Afghanistan, 2010

BACKGROUND

The United States introduced human T-lymphotropic virus Type I (HTLV-I) screening of blood donors in 1988. The US military uses freshly collected blood products for life-threatening injuries when available stored blood components in theater have been exhausted or when these components are unsuccessful for resuscitation. These donors are screened after donation by the Department of Defense (DoD) retrospective testing program. All recipients of blood collected in combat are tested according to policy soon after and at 3, 6, and 12 months after transfusion.

CASE REPORT

A 31-year-old US Army soldier tested positive for HTLV-I 44 days after receipt of emergency blood transfusions for severe improvised explosive device blast injuries. One donor's unit tested HTLV-I positive on the DoD-mandated retrospective testing. Both the donor and the recipient tested reactive with enzyme immunoassay and supplemental confirmation by HTLV-I Western blot. The donor and recipient reported no major risk factors for HTLV-I. Phylogenetic analysis of HTLV-I sequences indicated Cosmopolitan subtype, Subgroup B infections. Comparison of long terminal repeat and env sequences revealed molecular genetic linkage of the viruses from the donor and recipient.

CONCLUSION

This case is the first report of transfusion transmission of HTLV-I in the US military during combat operations. The emergency fresh whole blood policy enabled both the donor and the recipient to be notified of their HTLV-I infection. While difficult in combat, predonation screening of potential emergency blood donors with Food and Drug Administration-mandated infectious disease testing as stated by the DoD Health Affairs policy should be the goal of every facility engaged with emergency blood collection in theater.

Extended donors in liver transplantation

Several criteria are used to differentiate between standard and extended allograft donors. These criteria include deceased after cardiac death, advanced donor age, steatosis, previous malignancy in the donor, hepatitis C virus-positive allografts, human T-cell lymphotropic virus-positive allografts, active infections in the donor, high-risk donors, split liver transplantations, and living donor liver transplantations. Review of the literature can lead each practitioner to incorporate extended criteria donors into their transplant program, thereby individualizing the use of these allografts, increasing the donor pool, and decreasing overall waitlist mortality.

Preventive and therapeutic strategies for bovine leukemia virus: lessons for HTLV

Bovine leukemia virus (BLV) is a retrovirus closely related to the human T-lymphotropic virus type 1 (HTLV-1). BLV is a major animal health problem worldwide causing important economic losses. A series of attempts were developed to reduce prevalence, chiefly by eradication of infected cattle, segregation of BLV-free animals and vaccination. Although having been instrumental in regions such as the EU, these strategies were unsuccessful elsewhere mainly due to economic costs, management restrictions and lack of an efficient vaccine. This review, which summarizes the different attempts previously developed to decrease seroprevalence of BLV, may be informative for management of HTLV-1 infection. We also propose a new approach based on competitive infection with virus deletants aiming at reducing proviral loads.

Susceptible and protective HLA class 1 alleles against dengue fever and dengue hemorrhagic fever patients in a Malaysian population

Background

The human leukocyte antigen alleles have been implicated as probable genetic markers in predicting the susceptibility and/or protection to severe manifestations of dengue virus (DENV) infection. In this present study, we aimed to investigate for the first time, the genotype variants of HLA Class 1(-A and -B) of DENV infected patients against healthy individuals in Malaysia.

Methodology/Principal Findings

This study was carried out with 92 dengue disease patients and 95 healthy controls from three different ethnic groups (Malay, Chinese and Indian) in Malaysia. All patients with clinical and laboratory confirmation of DENV infection were typed for the HLA-A and B loci, using polymerase chain reaction-sequence specific primer techniques. In our total population, a significant increase for HLA-B*53 (P = 0.042, Pc = 1.008) allele and a significant decrease for A*03 (P = 0.015, Pc = 0.18, OR = 5.23, 95% CI = 1.19–23.02) and B*18 (P = 0.017, Pc = 0.408) alleles were noted in DHF patients as compared to healthy donors. We also observed that in the Malay DHF patients, allele B*13 (P = 0.049, Pc = 1.176, OR = 0.18, 95% CI = 0.03–0.90) was present at a significantly higher frequency in this population while allele HLA-B*18 (P = 0.024, Pc = 0.576) was seen to be negatively associated with DHF.

Conclusions/Significance

These are the first findings on genetic polymorphisms in our population and we conclude that: (1) In our total population, HLA-B*53 probably involve in disease susceptibility, while the HLA-A*03 and HLA-B*18 may confer protection from progression to severe disease; (2) In the Malay population, HLA-B*13 and B*18 are probably associated in disease susceptibility and protection, respectively. These results could furnish as a valuable predictive tool to identify ethnically different individuals at risk and/or protection from severe forms of DENV infection and would provide valuable informations for the design of future dengue vaccine.

Evaluation of the use of real-time PCR for human T cell lymphotropic virus 1 and 2 as a confirmatory test in screening for blood donors

INTRODUCTION: HTLV-1/2 screening among blood donors commonly utilizes an enzyme-linked immunosorbent assay (EIA), followed by a confirmatory method such as Western blot (WB) if the EIA is positive. However, this algorithm yields a high rate of inconclusive results, and is expensive. METHODS: Two qualitative real-time PCR assays were developed to detect HTLV-1 and 2, and a total of 318 samples were tested (152 blood donors, 108 asymptomatic carriers, 26 HAM/TSP patients and 30 seronegative individuals). RESULTS: The sensitivity and specificity of PCR in comparison with WB results were 99.4% and 98.5%, respectively. PCR tests were more efficient for identifying the virus type, detecting HTLV-2 infection and defining inconclusive cases. CONCLUSIONS: Because real-time PCR is sensitive and practical and costs much less than WB, this technique can be used as a confirmatory test for HTLV in blood banks, as a replacement for WB.

[Case report of HTLV-1 associated myelopathy (HAM) manifested after renal transplantation]

We report a 51-year-old man with human T lymphotropic virus type-1 (HTLV-1) associated myelopathy (HAM) manifested 10 months after renal transplantation. He had progressive spastic paralysis and neurogenic bladder for 10 years. HTLV-1 antibody are positive both serum and cerebral spinal fluid (CSF). Althoght HTLV-1 was not examined in the donor, it was suspected that the patient was infected by renal transplantation. After treatment of interferon-alpha (IFN-alpha), his motor function had improved and neopterin in CSF was decreased from 158 pmol/ml to 89 pmol/ml. This is a rare case of HAM after living renal transplantation. Cyclosporin and methylpredonisolone are used as immunosuppressants for preventing graft rejection. Time for developing HAM after renal transplantation was shorter than patients after cadaveric renal transplantation. More investigations are needed to clarify the mechanisms in the development of HAM associated with renal transplantation.

Cyclosporine-induced immune suppression alters establishment of HTLV-1 infection in a rabbit model

Human T-lymphotropic virus type 1 (HTLV-1) infection causes adult T-cell leukemia and several lymphocyte-mediated inflammatory diseases. Persistent HTLV-1 infection is determined by a balance between host immune responses and virus spread. Immunomodulatory therapy involving HTLV-1-infected patients occurs in a variety of clinical settings. Knowledge of how these treatments influence host-virus relationships is not understood. In this study, we examined the effects of cyclosporine A (CsA)-induced immune suppression during early infection of HTLV-1. Twenty-four New Zealand white rabbits were split into 4 groups. Three groups were treated with either 10 or 20 mg/kg CsA or saline before infection. The fourth group was treated with 20 mg/kg CsA 1 week after infection. Immune suppression, plasma CsA concentration, ex vivo lymphocyte HTLV-1 p19 production, anti-HTLV-1 serologic responses, and proviral load levels were measured during infection. Our data indicated that CsA treatment before HTLV-1 infection enhanced early viral expression compared with untreated HTLV-1-infected rabbits, and altered long-term viral expression parameters. However, CsA treatment 1 week after infection diminished HTLV-1 expression throughout the 10-week study course. Collectively, these data indicate immunologic control is a key determinant of early HTLV-1 spread and have important implications for therapeutic intervention during HTLV-1-associated diseases.

Lookback study of HTLV-1 and 2 seropositive donors and their recipients in Belo Horizonte, Brazil

The objective of this study was to perform lookback study in recipients of blood components from human T-lymphotropic virus (HTLV) seropositive donors. HTLV-1/2 may be transmitted by blood transfusion. Brazil is an endemic area for the virus and its screening in blood donors is mandatory since 1993. Hemominas Foundation (HF) is the public transfusion centre in Minas Gerais, Brazil. Data on HTLV-1/2 seropositive donors and recipients from 1993 to 2004 were obtained at HF and 24 contracting hospitals. From 1993 to 2004, HTLV-1/2 enzyme immunoassay (EIA) was performed in 918 678 donations of approximately 422 600 blood donor candidates. Of these, 456 donors (0.1%) were reactive and confirmed by Western blot (WB): 449 HTLV-1 and 7 HTLV-2. Sixty-six (14.5%) were repeat donors and had 194 blood cellular components produced from their previous donations. Of the distributed components, 119/146 (81.5%) had the recipient traced, with a total of 114 individuals. Of these, only 13 recipients were tested: six (46%) were HTLV-1 positive (four recipients of red cell units, two of platelets) and seven (54%) were negative (six of red cell units and one of platelets). Eleven did not respond and 62/114 (54.0%) were deceased. Another 28/114 (25.0%) could not be located. All six seropositive HTLV-1 recipients identified had no symptoms suggestive of HTLV-1-associated diseases. Acellular components, when used alone, were not associated with HTLV seropositivity. HTLV-1 transmission by cellular blood components occurred before screening for the virus was introduced. Haemovigilance was difficult to perform due to unavailability of computer systems before 1999 and to inadequate medical records at hospitals.

Human T-cell leukemia virus type I-associated myelopathy following living-donor liver transplantation

This report describes a patient who developed human T-cell leukemia virus type I-associated myelopathy (HAM) following a living-donor liver transplantation (LDLT) for liver cirrhosis due to hepatitis C virus (HCV) infection. Both the recipient and the living donor (his sister) were human T-cell leukemia virus type I (HTLV-I) carriers. Since the LDLT, he had been treated with immunosuppressive drugs such as tacrolimus and steroids as well as interferon-alpha to prevent rejection and a recurrence of the HCV infection, respectively. Even though the HTLV-I proviral load had decreased upon interferon treatment, he developed a slowly progressive gait disturbance with urinary disturbance 2 years after the LDLT and was diagnosed with HAM. This appears to be the first report of HAM development in an HLTV-I-infected LDLT recipient.

The HTLV-1 neurological complex

Human T-cell lymphotropic virus type 1 (HTLV-1) is a retrovirus that infects about 20 million people worldwide and causes immune-mediated diseases of the nervous system. The classic neurological presentation of HTLV-1 infection is a myelopathy called HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP). However, HAM/TSP is not the only neurological outcome that can result from HTLV-1 infection. In this Personal View, we show that HTLV-1 has a broader neurological spectrum than the names HAM/TSP suggest and that people infected with this virus can present with various isolated or assorted syndromes.

Allogeneic Bone Marrow Transplantation from Unrelated Human T-Cell Leukemia Virus-I–negative Donors for Adult T-Cell Leukemia/Lymphoma: Retrospective Analysis of Data from the Japan Marrow Donor Program

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) from an HLA-matched related donor has been suggested to improve the poor prognosis of adult T-cell leukemia/lymphoma (ATLL). However, the infusion of HTLV-I-infected cells from HTLV-I-positive related donors could lead to the development of donor-derived ATLL under immunosuppressive conditions. Although most ATLL patients lack a suitable HLA-matched related donor and require an HTLV-I-negative unrelated donor, little information is currently available regarding the outcome of unrelated bone marrow transplantation (UBMT) for ATLL. To evaluate the role of UBMT in treating ATLL, we retrospectively analyzed data from 33 patients with ATLL treated by UBMT through the Japan Marrow Donor Program (JMDP). Overall survival (OS), progression-free survival, and cumulative incidence of disease progression and progression-free mortality at 1 year after UBMT were 49.5%, 49.2%, 18.6%, and 32.3%, respectively. Multivariate analysis identified recipient age as an independent prognostic factor for OS (P = .044). Patients age >or=50 years who showed nonremission at transplantation tended to have higher rates of treatment-related mortality. Our observations suggest that UBMT could represent a feasible treatment option for ATLL patients and warrant further investigation based on these risk factors.

Bone marrow transplantation from unrelated donors for patients with adult T-cell leukaemia/lymphoma

Adult T-cell leukaemia/lymphoma (ATLL) is a highly aggressive haematological malignancy. More than 40 cases of ATLL treated by allogeneic bone marrow transplantation (BMT) from sibling donors have been reported, while there have been only a few cases of unrelated BMT for treatment of this disease. We began performing allogeneic BMT from unrelated donors in 1999 to improve the outcome of ATLL patients with no suitable sibling donors. Eight ATLL patients underwent unrelated BMT; five received the conventional conditioning regimen consisting of cyclophosphamide and total body irradiation, while three received a reduced-intensity preparative regimen. Two patients died due to encephalopathy of unknown aetiology on days 10 and 35, and one patient died due to progression of ATLL 25 months after BMT. Five patients are currently alive and disease-free at a median of 20 months after BMT. Proviral human T-lymphotropic virus type-I (HTLV-I) DNA load in peripheral blood mononuclear cells (PBMCs) was assessed in four cases before and after BMT. HTLV-I proviral DNA load was reduced significantly after transplantation. Unrelated BMT is feasible for treatment of ATLL. Further studies in a larger number of cases are required to determine the optimal conditioning regimen and stem cell source.

Viral infection in the renal transplant recipient

Viruses are among the most common causes of opportunistic infection after transplantation and the most important. The risk for viral infection is a function of the specific virus encountered, the intensity of immune suppression used to prevent graft rejection, and other host factors governing susceptibility. Viral infection, both symptomatic and asymptomatic, causes the "direct effects" of invasive disease and "indirect effects," including immune suppression predisposing to other opportunistic infections and oncogenesis. Rapid and sensitive microbiologic assays for many of the common viruses after transplantation have replaced, for the most part, serologic testing and in vitro cultures for the diagnosis of infection. Furthermore, quantitative molecular tests allow the individualization of antiviral therapies for prevention and treatment of infection. This advance is most prominent in the management of cytomegalovirus, Epstein-Barr, hepatitis B, and hepatitis C viruses. Diagnostic advances have not been accompanied by the development of specific and nontoxic anti-viral agents or effective antiviral vaccines. Vaccines, where available, should be given to patients as early as possible and well in advance of transplantation to optimize the immune response. Studies of viral latency, reactivation, and the cellular effects of viral infection will provide clues for future strategies in prevention and treatment of viral infections.

Viral diseases of the central nervous system

Viral diseases of the central nervous system encompass a wide range of different processes, mainly inflammation affecting the brain (encephalitis), the meninges (meningitis), or a combined meningoencephalitis. The spinal cord can be affected as well (myelitis). Another group of viral-related disorders, sometimes without a clear pathophysiological mechanism disclosed, include post-viral illnesses. All of these groups of diseases are discussed in this article, with an emphasis on their imaging presentation, using magnetic resonance imaging.

Prophylactic strategies before solid-organ transplantation

PURPOSE OF REVIEW

Prophylactic measures prior to organ transplantation are evolving based on recent reports of emerging infectious diseases, as well as an expanded understanding of the epidemiology of familiar infections. This review will highlight developments with potential impact on donor and recipient screening and pretransplant management.

RECENT FINDINGS

Key findings regarding bacterial infections include the lack of utility of mupirocin intranasal decolonization for prevention of Staphylococcus aureus infections after liver transplantation, and the description of transmission of Pseudomonas infection to multiple recipients via an innominate artery graft. The implications of donor bacterial colonization in lung transplantation are further explored. The emergence of non-Candida albicans yeast and non-Aspergillus mold infections may lead to changes in prophylactic strategies. The majority of cystic fibrosis patients have had Aspergillus colonization at some time before transplant; one-quarter of these develop tracheobronchial aspergillosis and anastomotic complications. There are several key developments regarding viral infections. Donor-derived human herpesvirus-8-infected neoplastic cells have been identified in recipients with Kaposi sarcoma. The transmission of human T-cell lymphotropic virus -1 (HTLV-1) to multiple recipients who developed myelopathy underscores the continuing need for donor screening. The striking event of West Nile virus transmission to multiple recipients from a single donor also has raised questions regarding donor screening for this virus. New information on the use of hepatitis B core antibody-positive donor livers, as well as the emergence of hepatitis B virus escape mutants, is discussed. Finally, information on successful retransplantation after BK polyomavirus (BKV) allograft nephropathy is beginning to appear.

SUMMARY

The pretransplant phase continues to be an important time period for screening and intervention in order to reduce the risk of posttransplant infections. Recent findings add to our current understanding of epidemiology and risk stratification; however, more randomized trials are needed.

Paraparesia Espástica Tropical - Mielopatia associada ao vírus HTLV- I:

Introdução: A Paraparesia Espástica Tropical/Mielopatia (PET/MAH) é uma complicação crônica e progressiva associada à infecção pelo vírus HTLV-I, que além de outras afecções, ocasiona um processo inflamatório medular, predominantemente em seus níveis baixos, devido à invasão desorganizada dos linfócitos T modificados. Devido à escassez de pesquisas em Fisioterapia voltadas para a PET/MAH, o presente artigo de revisão visa adaptar abordagens em relação à reabilitação motora, com suas respectivas justificativas teóricas. Desenvolvimento: Um dos aspectos mais limitantes da doença está na fraqueza e espasticidade dos membros inferiores, com comprometimento da funcionalidade da marcha, podendo em alguns casos confinar os pacientes à cadeira de rodas. Através de uma análise detalhada da fisiopatogenia dos sintomas, acredita-se que condutas fisioterapêuticas podem amenizar as seqüelas neurológicas e promover uma melhora da qualidade de vida dos indivíduos acometidos. Conclusão: A fisioterapia, baseada nas fundamentações teóricas propostas, parece ser eficaz na recuperação funcional dos pacientes com PET/MAH.