The impact of pre-transplant valganciclovir on early cytomegalovirus reactivation after allogeneic hematopoietic stem cell transplantation

Prevention and management of human cytomegalovirus in pediatric HSCT recipients: A review

Cytomegalovirus (CMV), like other herpesviruses, has the unique ability to establish latent infection with subsequent reactivation during periods of stress and immunosuppression. Herpesviruses cause potentially devastating disease, particularly in hematopoietic stem cell transplant (HSCT) recipients. CMV is especially of concern in HSCT recipients given the high community seroprevalence, high risk of reactivation and high risk of transmission from HSCT donors to recipients causing primary infection after transplantation. The risk of CMV infection and severity of CMV disease varies depending on the underlying disease of the HSCT recipient, donor and recipient CMV status prior to HSCT, type of conditioning therapy in preparation for HSCT, allogeneic versus autologous HSCT, donor graft source, timing of infection in relation to HSCT, and other patient comorbidities. Different strategies exist for prevention (e.g., preemptive therapy vs. universal prophylaxis) as well as management of CMV disease (e.g., antiviral therapy, augmenting immune reconstitution, cytotoxic T-cell therapy). The purpose of this narrative review is to discuss diagnosis, prevention, and management of CMV infection and disease at different stages of HSCT, including key points illustrated through presentations of complex cases and difficult clinical scenarios. Traditional and novel strategies for CMV management will be discussed in the context of these unique clinical cases.

Phase I trials using Sleeping Beauty to generate CD19-specific CAR T cells

BACKGROUND

T cells expressing antigen-specific chimeric antigen receptors (CARs) improve outcomes for CD19-expressing B cell malignancies. We evaluated a human application of T cells that were genetically modified using the Sleeping Beauty (SB) transposon/transposase system to express a CD19-specific CAR.

METHODS

T cells were genetically modified using DNA plasmids from the SB platform to stably express a second-generation CD19-specific CAR and selectively propagated ex vivo with activating and propagating cells (AaPCs) and cytokines. Twenty-six patients with advanced non-Hodgkin lymphoma and acute lymphoblastic leukemia safely underwent hematopoietic stem cell transplantation (HSCT) and infusion of CAR T cells as adjuvant therapy in the autologous (n = 7) or allogeneic settings (n = 19).

RESULTS

SB-mediated genetic transposition and stimulation resulted in 2,200- to 2,500-fold ex vivo expansion of genetically modified T cells, with 84% CAR expression, and without integration hotspots. Following autologous HSCT, the 30-month progression-free and overall survivals were 83% and 100%, respectively. After allogeneic HSCT, the respective 12-month rates were 53% and 63%. No acute or late toxicities and no exacerbation of graft-versus-host disease were observed. Despite a low antigen burden and unsupportive recipient cytokine environment, CAR T cells persisted for an average of 201 days for autologous recipients and 51 days for allogeneic recipients.

CONCLUSIONS

CD19-specific CAR T cells generated with SB and AaPC platforms were safe, and may provide additional cancer control as planned infusions after HSCT. These results support further clinical development of this nonviral gene therapy approach.

TRIAL REGISTRATION

Autologous, NCT00968760; allogeneic, NCT01497184; long-term follow-up, NCT01492036.

FUNDING

National Cancer Institute, private foundations, and institutional funds. Please see Acknowledgments for details.

Drug reaction with eosinophilia and systemic symptoms, or virus reactivation with eosinophilia and systemic symptoms as a manifestation of immune reconstitution inflammatory syndrome in a patient with HIV?

We report a case of drug reaction with eosinophilia and systemic symptoms (DRESS) in a patient with HIV receiving antitoxoplasmic drugs (adiazine and pyrimethamine) and levetiracetam along with highly active antiretroviral therapy (tenofovir-emtricitabine, darunavir and ritonavir). Cytomegalovirus (CMV) infection was reactivated in the 7 weeks before the development of DRESS but was successfully treated with ganciclovir and corticosteroids. DRESS flare was concomitant with another CMV reactivation after the withdrawal of ganciclovir. This case report is an example of DRESS that may be considered real DRESS or virus reactivation with eosinophilia and systemic symptoms (VRESS) as a manifestation of immune reconstitution inflammatory syndrome. The case confirms that herpesvirus reactivation precedes DRESS or VRESS, and suggests the need to monitor herpesvirus infection in patients at risk for the infection or after the initiation of culprit drugs.