Pulmonary cytomegalovirus infection in immunocompromised patients

Incidence, etiology, and outcome of hospital-acquired pneumonia in patients with acute exacerbation of fibrotic idiopathic interstitial pneumonia

BACKGROUND

Acute exacerbations (AEs) of fibrotic idiopathic interstitial pneumonia (fIIP) that require hospitalization occur in some patients. During hospitalization, these patients can develop hospital-acquired pneumonia (HAP), a common hospital-acquired infection with a high mortality rate. However, the characteristics of HAP in AE-fIIP remain unknown. The purpose of this study was to determine the incidence, causative pathogens, and outcomes of HAP in patients with AE-fIIP.

METHODS

The medical records of consecutive patients who were hospitalized with AE-fIIP from January 2008 to December 2019 were analyzed for the incidence, causative pathogen, and survival of HAP. The records of patients with an obvious infection-triggered AE were excluded from analysis.

RESULTS

There were 128 patients with AE-fIIP (89 with idiopathic pulmonary fibrosis [IPF] and 39 with non-IPF fIIP) who were hospitalized a total of 155 times (111 with IPF and 44 with non-IPF fIIP). HAP occurred in 49 patients (40 with IPF and 9 with non-IPF fIIP). The incidence and the in-hospital mortality rates of HAP in patients with AE-fIIP were high, at 32.2% and 48.9%, respectively. Corynebacterium spp. was the most common causative pathogen, which was followed by human cytomegalovirus (HCMV).

CONCLUSIONS

The incidence and the in-hospital mortality rates of HAP in patients with AE-fIIP are high. To improve their survival, patients with fIIP who had AEs and HAP should receive prompt empirical treatment for possible infections with Corynebacterium spp. and testing for HCMV.

Severe Community-Acquired Pneumonia in Immunocompromised Patients

Due to higher survival rates with good quality of life, related to new treatments in the fields of oncology, hematology, and transplantation, the number of immunocompromised patients is increasing. But these patients are at high risk of intensive care unit admission because of numerous complications. Acute respiratory failure due to severe community-acquired pneumonia is one of the leading causes of admission. In this setting, the need for invasive mechanical ventilation is up to 60%, associated with a high hospital mortality rate of around 40 to 50%. A wide range of pathogens according to the reason of immunosuppression is associated with severe pneumonia in those patients: documented bacterial pneumonia represents a third of cases, viral and fungal pneumonia both account for up to 15% of cases. For patients with an undetermined etiology despite comprehensive diagnostic workup, the hospital mortality rate is very high. Thus, a standardized diagnosis strategy should be defined to increase the diagnosis rate and prescribe the appropriate treatment. This review focuses on the benefit-to-risk ratio of invasive or noninvasive strategies, in the era of omics, for the management of critically ill immunocompromised patients with severe pneumonia in terms of diagnosis and oxygenation.

Pulmonary cytomegalovirus infection: A case report and systematic review

BACKGROUND

Cytomegalovirus (CMV) is a common virus that can cause the first infection in childhood or adolescence and reactivate later in life due to immunosuppression. CMV pneumonia is a rare illness in immunocompetent patients but is one of the most significant opportunistic infections in immunocompromised patients.

AIM

To report a case and review published cases of pulmonary CMV infection in both immunocompromised and immunocompetent patients.

METHODS

We conducted a systematic search on the MEDLINE (PubMed) database, without date or language restrictions, to identify relevant studies using Medical Subject Headings and Health Science Descriptors. We manually searched the reference lists of the included studies. Simple descriptive analysis was used to summarize the results.

RESULTS

Our search identified 445 references, and after screening, 43 studies reporting 45 cases were included in the final analysis, with 29 (64%) patients being immunocompromised and 16 (36%) being immunocompetent. Fever (82%) and dyspnea (75%) were the most common clinical findings. Thoracic computed tomography showed bilateral ground-glass opacities, a relevant differential diagnosis for severe acute respiratory syndrome coronavirus 2 infection. The majority of patients (85%) received antiviral therapy, and 89% of patients recovered, while 9% of patients died.

CONCLUSION

CMV pneumonia should be considered as a differential diagnosis for coronavirus disease 2019 pneumonia, especially in immunocompromised patients. Clinicians should be aware of the clinical presentation, management, and outcomes of CMV pneumonia to guide appropriate treatment decisions.

Investigating Viral Involvement in Immunocompromised Patients Using Comprehensive Infectious Disease Testing Including FilmArray Respiratory Panel 2.1 on Bronchoscopy: A Retrospective Study

Introduction Reports are rare on the usefulness of the FilmArray Respiratory Panel 2.1 (FARP) using lower respiratory tract specimens. This retrospective study assessed its use, as part of a comprehensive infectious disease panel, to detect the viral causes of pneumonia using bronchoalveolar lavage samples from immunosuppressed patients. Methods This study included immunocompromised patients who underwent bronchoalveolar lavage or bronchial washing by bronchoscopy between April 1, 2021, and April 30, 2022. The collected samples were submitted for comprehensive testing, including FARP test; reverse transcription polymerase chain reaction (RT-PCR) for cytomegalovirus, varicella-zoster virus DNA, and herpes simplex virus; PCR for Pneumocystis jirovecii DNA; antigen testing for Aspergillus and Cryptococcus neoformans; and loop-mediated isothermal amplification method for Legionella. Results Out of 23 patients, 16 (70%) showed bilateral infiltrative shadows on computed tomography and three (13%) were intubated. The most common causes of immunosuppression were anticancer drug use (n=12, 52%) and hematologic tumors (n=11, 48%). Only two (9%) patients tested positive for severe acute respiratory syndrome coronavirus 2 and adenovirus by FARP. Four patients (17%) tested positive for cytomegalovirus by RT-PCR, but no inclusion bodies were identified cytologically. Nine (39%) patients tested positive for Pneumocystis jirovecii by PCR, but cytology confirmed the organism in only one case. Conclusions Comprehensive infectious disease testing, performed using bronchoalveolar lavage samples collected from lung lesions in immunosuppressed patients, showed low positive detection by FARP. The viruses currently detectable by FARP may be less involved in viral pneumonia diagnosed in immunocompromised patients.

A Prospective Study of Plasma and Bronchoalveolar Lavage Fluid CMV DNA Load Quantification for the Diagnosis and Outcome of CMV Pneumonitis in Immunocompromised Hosts

BACKGROUND

Molecular testing has been utilized for cytomegalovirus (CMV) pneumonitis (CMVP) diagnosis, although its validity and optimal cut-off values remain limited.

METHODS

A prospective study of CMVP diagnosis among immunocompromised patients was conducted by measuring quantitative CMV DNA polymerase chain reaction in plasma and bronchoalveolar lavage fluid (BALF).

RESULTS

Forty-five adult immunocompromised patients were investigated. Thirty-two patients (71%) received immunosuppressive therapy. Eleven patients (24%) were confirmed to have CMVP. Of those, three and eight patients were classified as proven and probable CMVP, respectively. Median (IQR) plasma CMV DNA loads in CMVP and non-CMVP were 41,939 (4,424-122,608) and 0 (0-44) IU/mL, respectively (p<0.001). Median (IQR) BALF CMV DNA loads in CMVP and non-CMVP were 379,652 (163,800-1,254,000) and 0 (0-1,348) IU/mL, respectively (p<0.001). A significant correlation was observed between plasma and BALF CMV DNA loads (r=0.887, p<0.001). Plasma CMV DNA load of 831 IU/mL was established as a cut-off value for diagnosing CMVP (AUC 0.9987, sensitivity 100%, specificity 94.1%, positive predictive value 84.5%, negative predictive value 100%).

CONCLUSIONS

A strongly positive correlation was observed between CMV DNA loads measured in plasma and BALF. CMV DNA load quantification could potentially assist in diagnosing CMVP in immunocompromised patients, although bronchoscopy remains encouraged for a definitive diagnosis.

Risk factors for cytomegalovirus reactivation in patients with kidney disease under immunosuppressive therapy

BACKGROUND

Cytomegalovirus (CMV) is a herpes virus that causes latent infections, and its reactivation due to immunosuppression can cause fatal complications. CMV reactivation is a complication frequently occurring in patients with kidney disease who require immunosuppressive therapy, and, therefore, this study retrospectively examined its risk factors.

METHODS

Patients who received immunosuppressive therapy and underwent the CMV antigenemia test (CMV antigenemia: C7-HRP) for the treatment of primary nephritis (minimal change disease, membranous nephropathy, membranoproliferative glomerulonephritis, focal glomerulosclerosis, and IgA nephropathy) and anti-neutrophil cytoplasmic autoantibody (ANCA)-associated nephritis diagnosed at Saiseikai Kurihashi Hospital from January 2014 to December 2019 were recruited as study participants. Risk factors of CMV reactivation were examined using univariable and multivariable analyses.

RESULTS

Among the 64 patients (36 men and 28 women; median age, 72 years) included, 34 had primary nephritis (20 minimal disease changes, 10 membranous nephropathy, 1 membranoproliferative glomerulonephritis, 1 focal glomerulosclerosis, and 2 IgA nephropathy) and 30 had ANCA-associated nephritis. Regarding glucocorticoid (GC), 43 patients received oral GC therapy, whereas 21 received GC pulse therapy. CMV reactivation participants showed significant differences in age, ANCA-associated nephritis, hemoglobin level, lymphocyte count, maximum GC dosage, and hemodialysis in univariable analysis. Multivariate analysis showed significantly lower lymphocyte counts in CMV-reactivated patients, but no significant difference in other factors.

CONCLUSION

In patients with kidney disease, who require immunosuppressive therapy, CMV reactivation risk is high in patients with low lymphocyte count, and monitoring CMV during the treatment course could lead to early diagnosis and treatment of CMV disease.

Pulmonary Complications in Hematopoietic Stem Cell Transplant Recipients-A Clinician Primer

Hematopoietic stem cell transplants (HSCT) are becoming more widespread as a result of optimization of conditioning regimens and prevention of short-term complications with prophylactic antibiotics and antifungals. However, pulmonary complications post-HSCT remain a leading cause of morbidity and mortality and are a challenge to clinicians in both diagnosis and treatment. This comprehensive review provides a primer for non-pulmonary healthcare providers, synthesizing the current evidence behind common infectious and non-infectious post-transplant pulmonary complications based on time (peri-engraftment, early post-transplantation, and late post-transplantation). Utilizing the combination of timing of presentation, clinical symptoms, histopathology, and radiographic findings should increase rates of early diagnosis, treatment, and prognostication of these severe illness states.

Comparing cytomegalovirus diagnostics by cell culture and quantitative nucleic acid testing in broncho-alveolar lavage fluids

Many clinical laboratories have replaced virus isolation in cell-culture (VIC) for cytomegalovirus (CMV) by quantitative-nucleic-acid testing (QNAT), rendering clinically relevant CMV-replication difficult to distinguish from CMV-shedding or latent infection. We compared direct VIC in 1109 consecutive bronchoalveolar lavage fluids (BALFs) and a well-validated CMV-QNAT (Basel-CMV-UL111a-77bp). In the retrospective Group 1 (N = 694) and Group 2 (N = 303), CMV-QNAT was performed within 48 h from 2-fold and 10-fold concentrated total nucleic acid (TNA) eluates, respectively. In Group 3 (N = 112), 2-fold and 10-fold concentrated TNA eluates were prospectively analyzed in parallel to VIC. CMV was detected by VIC in 79 of 694 (11%) and 26 of 303 (9%) of Groups 1 and 2, but in 114 of 694 (16%) and 57 of 303 (17%) by CMV-QNAT, respectively. Median CMV loads were significantly higher in VIC-positive than in VIC-negative BALF. The likelihood for CMV detection by VIC was 85% for BALF CMV- loads >4 log10 copies/ml. In the prospective Group 3, CMV was detected by VIC in 10 of 112 (9%), and in 14 of 112 (13%) and 20 of 112 (18%) by CMV-QNAT, when using 2-fold and 10-fold concentrated TNA eluates, respectively. Notably, CMV was undetectable by CMV-QNAT in 10 VIC-positive cases of Groups 1 and 2, but in none of Group 3. We conclude that CMV-QNAT can be adopted to BALF diagnostics but requires several careful steps in validation. CMV-QNAT loads >10 000 copies/ml in BALF may indicate significant CMV replication as defined by VIC, if short shipment and processing procedures can be guaranteed. Discordance of detecting CMV in time-matched plasma samples emphasises the role of local pulmonary CMV replication, for which histopathology remains the gold standard of proven CMV pneumonia.

Risk factors for cytomegalovirus disease in systemic lupus erythematosus (SLE): a systematic review

BACKGROUND

Cytomegalovirus (CMV) is an opportunistic pathogen causing reactivation and disease in Systemic Lupus Erythematosus (SLE) patients. This study aims to systematically review the literature for risk factors associated with CMV disease in SLE patients, in order to identify those more susceptible to CMV infection during their treatment.

METHODS

A systematic review was conducted on 4 different search engines and via hand search until May 2017. Studies were included after quality assessment via the Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields (HTA KMET).

RESULTS

Two studies on CMV disease were included. Elevated CMV viral load, higher steroid doses, use of immunosuppressants and disease duration were the most commonly associated risk factors for CMV disease.

CONCLUSION

High CMV viral loads, longer SLE disease duration and higher steroid doses were associated with CMV disease. Further studies studying the risk of treatment drugs and role of interventions in the development of CMV infection are needed.

Pulmonary cytomegalovirus (CMV) DNA shedding in allogeneic hematopoietic stem cell transplant recipients: Implications for the diagnosis of CMV pneumonia

OBJECTIVES

To date no definitive cut-off value for cytomegalovirus (CMV) DNA load in bronchoalveolar lavage (BAL) fluid specimens has been established to discriminate between CMV pneumonia and pulmonary CMV DNA shedding in allogeneic hematopoietic stem cell transplant (allo-HSCT) recipients.

METHODS

The current retrospective study is aimed at assessing the range of CMV DNA loads quantified in BAL fluid specimens from allo-HSCT patients with pneumonia in which different microorganisms were causally involved.

RESULTS

A total of 144 BAL specimens from 123 patients were included. CMV DNA was detected in 56 out of 144 BAL fluid specimens and the median CMV DNA load from patients in whom CMV pneumonia was unlikely or could be tentatively ruled out was 1210 (31-68, 920) IU/ml. The frequency of CMV DNA detection and median CMV DNA loads were comparable, irrespective of the attributable cause of pneumonia. Detection of CMV DNA loads in BAL fluid specimens >500 IU/ml was independently associated with pneumonia-attributable mortality.

CONCLUSIONS

The current study highlights the difficulty in establishing universal CMV DNA load thresholds in BAL fluid specimens for distinguishing between CMV pneumonia and pulmonary CMV DNA shedding, and suggests that the presence of CMV DNA in BAL fluid specimens beyond a certain level may have a deleterious impact on patient outcome.

Diagnostic discrepancy between bronchoalveolar lavage and transbronchial biopsy from bronchoscopies of HIV patients with pneumonia: toward an integral diagnosis

Background

The key diagnostic method for the evaluation of lung diseases associated with HIV infection is bronchoscopy, with bronchoalveolar lavage (BAL) being the most commonly used sampling technique. Transbronchial biopsy (TBB) is often complementary.

Setting

This is a retrospective cross-sectional study to determine the diagnostic usefulness of bronchoscopy with simultaneous samples obtained through BAL and TBB in HIV-infected patients with pneumonia at the National Institute of Respiratory Diseases Ismael Cosío Villegas.

Methods

In this cross-sectional study (January 2014-December 2015), the diagnostic yield of bronchoscopic samples from all HIV-positive patients with pneumonia aged >18 years, from procedures performed in the Interventional Pulmonology Unit, was analyzed and recorded in its database. The diagnostic yield concordance between BAL and TBB samples was evaluated by kappa index calculation.

Results

A total of 198 procedures on 189 HIV-infected patients with pneumonia were performed. A total of 167/189 (88.4%) patients were male, and the mean age was 34.7 years (SD ±9.0). Overall, the diagnostic yield for either technique was 87.9% (174/198), but it was higher for TBB, its yield being 78.8% (156/198). In contrast, that of BAL was 62.1% (123/198) (P=0.001). The overall diagnostic yield concordance between TBB and BAL was insignificant (k=0.213, P<0.001). It improved for fungal infections, pneumocystosis, and tuberculosis (k=0.417, 0.583, and 0.462, respectively, all P<0.001).

Conclusion

Our results show that the simultaneous obtainment of BAL and TBB samples is useful and complementary in the diagnosis of infections and malignancies in HIV-infected patients. Additionally, they are safe procedures in this group of patients.

Viral Pneumonia in Patients with Hematologic Malignancy or Hematopoietic Stem Cell Transplantation

Viral pneumonias in patients with hematologic malignancies and recipients of hematopoietic stem cell transplantation cause significant morbidity and mortality. Advances in diagnostic techniques have enabled rapid identification of respiratory viral pathogens from upper and lower respiratory tract samples. Lymphopenia, myeloablative and T-cell depleting chemotherapy, graft-versus-host disease, and other factors increase the risk of developing life-threatening viral pneumonia. Chest imaging is often nonspecific but may aid in diagnoses. Bronchoscopy with bronchoalveolar lavage is recommended in those at high risk for viral pneumonia who have new infiltrates on chest imaging.

Cardio-pulmonary involvement in juvenile systemic lupus erythematosus

Cardio-pulmonary manifestations of systemic lupus erythematosus (SLE) are well recognized in adults. We report the occurrence of clinically significant cardio-pulmonary disease in a cohort of predominantly Caucasian children with SLE. All children with SLE attending the Royal Liverpool Children’s NHS Trust between 1995 and 2003 were reviewed. Of 29 children with SLE, 27 (93%) were Caucasian. Nine (31%) had cardio-respiratory complications: cardiac only (n = 1); respiratory only (n = 4); both cardiac and respiratory manifestations (n = 4). Median (range) duration of follow-up of affected children: four years (six months to 11 years). Six out of eight (75%) presented with respiratory complications before SLE was diagnosed. Three children had pericardial effusions, one requiring pericardiocentesis for tamponade. One had cardiac conduction defects and another significant pulmonary hypertension. Respiratory complications comprised: interstitial lung disease (n = 4), with two showing evidence of pulmonary fibrosis; pleural effusions (n = 2), pulmonary haemorrhage (n = 1) and lupus pneumonitis (n = 1). Disease course was complicated by CMV infection in one child. Lung biopsy was performed in five cases. Seven were treated with cyclophosphamide with significant improvement in symptoms/lung function. Of this predominantly Caucasian paediatric cohort with SLE, 31% had significant cardio-pulmonary involvement. All children with SLE should have regular monitoring of their cardio-respiratory status.

Molecular and Culture-Based Bronchoalveolar Lavage Fluid Testing for the Diagnosis of Cytomegalovirus Pneumonitis

Background.  Cytomegalovirus (CMV) is a major cause of morbidity and mortality in immunocompromised patients, with CMV pneumonitis among the most severe manifestations of infection. Although bronchoalveolar lavage (BAL) samples are frequently tested for CMV, the clinical utility of such testing remains uncertain. Methods.  Retrospective analysis of adult patients undergoing BAL testing via CMV polymerase chain reaction (PCR), shell vial culture, and conventional viral culture between August 2008 and May 2011 was performed. Cytomegalovirus diagnostic methods were compared with a comprehensive definition of CMV pneumonitis that takes into account signs and symptoms, underlying host immunodeficiency, radiographic findings, and laboratory results. Results.  Seven hundred five patients underwent 1077 bronchoscopy episodes with 1090 BAL specimens sent for CMV testing. Cytomegalovirus-positive patients were more likely to be hematopoietic cell transplant recipients (26% vs 8%, P < .0001) and less likely to have an underlying condition not typically associated with lung disease (3% vs 20%, P < .0001). Histopathology was performed in only 17.3% of CMV-positive bronchoscopy episodes. When CMV diagnostic methods were evaluated against the comprehensive definition, the sensitivity and specificity of PCR, shell vial culture, and conventional culture were 91.3% and 94.6%, 54.4% and 97.4%, and 28.3% and 96.5%, respectively. Compared with culture, PCR provided significantly higher sensitivity and negative predictive value (P ≤ .001), without significantly lower positive predictive value. Cytomegalovirus quantitation did not improve test performance, resulting in a receiver operating characteristic curve with an area under the curve of 0.53. Conclusions.  Cytomegalovirus PCR combined with a comprehensive clinical definition provides a pragmatic approach for the diagnosis of CMV pneumonitis.

Effect of ganciclovir for the treatment of severe cytomegalovirus-associated pneumonia in children without a specific immunocompromised state

BACKGROUND

This study aimed to evaluate the effectiveness of gancyclovir (GCV) treatment for severe cytomegalovirus (CMV)-associated pneumonia in immunocompetent children.

METHOD

We enrolled patients with CMV-associated severe pneumonia admitted to the Vietnam National Hospital of Pediatrics, Hanoi, Vietnam, from January 2010 to December 2011. On admission, though respiratory bacteria and viruses were not detected in tracheal aspirates, more than 5 × 10(3) copies/mL of CMV-DNA were detected in both tracheal aspirates and in blood plasma. GCV was given intravenously at a dose of 10 mg/kg/24 h for a duration of 14 days at most. The dose was then reduced to 5 mg/kg/24 h until CMV-DNA was not detected in plasma. The main study variables included clinical symptoms, complete blood count, hepatic and renal function, chest X-ray, CMV viral load, duration of GCV treatment and outcome.

RESULTS

Forty-three patients were enrolled in the study. The median age of patients was 57 (interquartile range [IQR] 45-85) days. Clinical and laboratory findings included anemia (67.4%), leukocytosis (90.7%), hepatosplenomegaly (60.5%), elevated liver enzymes (74.4%), decreased ratio of CD4: CD8-positive T lymphocytes (69.4%), and decreased serum IgG concentration (25.7%). The median duration of GCV treatment was 12 days (IQR 7-21). Thirty-seven patients (86.0%) showed normal chest X-rays at the end of treatment. One infant died (2.3%); the other children (97.7%) were discharged in good condition. There was no severe toxicity associated with GCV treatment.

CONCLUSION

GCV is safe and effective for the treatment of severe CMV-associated pneumonia in children.

Pulmonary infections in transplant recipients

PURPOSE OF REVIEW

Hematopoietic stem cell as well as solid-organ transplantation is being carried out with increasing frequency throughout the world. Lower respiratory tract infections (LRTIs) remain a common life-threatening complication faced by the transplant recipients. The purpose of this review is to provide up-to-date information on pulmonary infections among the transplant recipients, especially emphasizing the endemicity of microorganisms, epidemiology, work-up of infections, and principles of their management.

RECENT FINDINGS

A lower respiratory tract infection such as pneumonia is the most frequent of all the infections and is associated with high morbidity and mortality. Factors increasing the risk of pulmonary infections include surgical techniques, immune status, chemoradiotherapy, alloimmune mechanisms between the host and the graft, and the environment. A high degree of suspicion, computed tomography (CT) scan of the chest, and flexible bronchoscopy are required in most to establish the diagnosis.

SUMMARY

Proper management of LRTI in transplant recipients requires a high degree of suspicion, thorough knowledge of the epidemiology and endemicity of the suspected organisms, CT scan of the chest, and expertise at bronchoscopy. Utmost teamwork among transplant physicians, infectious disease specialist, and bronchoscopist is essential.

Cytomegalovirus pneumonia in hematopoietic stem cell recipients

Cytomegalovirus (CMV) is a frequently encountered infection following hematopoietic cell transplantation, and tissue invasive pneumonia is a dreaded complication of the virus in this population. In this review of CMV pneumonia, we address epidemiology, pathogenesis, diagnostics, current therapy, and strategies to prevent the development of CMV. We also review emerging treatment and prevention options for this challenging disease.

Aspergillus-PCR in bronchoalveolar lavage for detection of invasive pulmonary aspergillosis in immunocompromised patients

BACKGROUND

Invasive fungal disease (IFD) is a frequent and serious infectious complication in immunocompromised patients. Culture and cytology in bronchoalveolar lavage (BAL) have a high specificity but low sensitivity for the diagnosis of IFD as assessed by histology. Molecular methods are expected to allow a rapid diagnosis of IFD with a high sensitivity. We evaluated the diagnostic accuracy of conventional nested PCR in the bronchoalveolar fluid to diagnose IFD in severely immunocompromised patients.

METHODS

Consecutive immunosuppressed patients undergoing bronchoscopy for suspected pulmonary infection in a tertiary care hospital were included. Patients were classified as having "proven", "probable", "possible", and "no" IFD based on definitions of the European Organization for Research and Treatment of Cancer and National Institute of Allergy and Infectious Diseases (EORTC/NIAID) and on clinical grounds. Conventional nested PCR for aspergillus fumigatus, flavus, niger, glaucus, terreus and tomarrii were applied to 2.5 ml bronchoalveolar fluid.

RESULTS

A total of 191 patients were included. Mean age was 51 y, 61% were male. There were 129 patients with hematological conditions, 26 solid organ transplant recipients, 24 auto-immune disorders, and 12 HIV. According to the EORTC/NIAID classification, there were 53 patients with potential IFD: 3 (2%) had proven, 8 (4%) probable, 42 (22%) possible and 138 (72%) no IFD. A total of 111 (58%) of the patients - 10 (90.9%) proven or probable IFD, 32 (76.2%) possible IFD and 69 (50%) "no" IFD) were on anti-fungal therapy at the time of bronchoscopy. Conventional nested PCR for Aspergillus was positive in 55 cases (28.8%). According to these results, sensitivity, specificity, PPV and NPV for "proven" IFD was 0%, 71%, 0%, 98%, respectively and "probable" IFD was 36%, 72%, 7%, 95%, respectively. In 53 (28%) cases there was a strong clinical suspicion of IFD in the chest-x-ray and/or chest-CT irrespective of the EORTC/NIAID classification. However, from those, only 15 (28%) had a positive conventional nested PCR.

CONCLUSION

In our experience, conventional nested Aspergillus PCR in the BAL seems to be of limited usefulness for detection of invasive fungal disease in immunocompromised patients due to the limited sensitivity and specificity of the method.

Diffuse alveolar hemorrhage following allogeneic peripheral blood stem cell transplantation: a case report and a short review

Pulmonary complications are one of the most common causes of morbidity and mortality in patients undergoing peripheral blood stem cell transplantation. Both infective and non-infective etiologies can involve the lungs during this period and differentiating them clinically is a challenging task and management differs in each case. We present here a case of acute myeloid leukemia, in whom following allogeneic peripheral blood stem cell transplantation, diffuse alveolar hemorrhage developed.

Risk factors associated with elevated blood cytomegalovirus pp65 antigen levels in patients with autoimmune diseases

OBJECTIVES

To further assess the relationship between elevated levels of cytomegalovirus (CMV) pp65 antigen in blood, as indicative of viral load, during treatment-free follow-up and CMV diseases in patients with autoimmune diseases and to identify any risk factors associated with elevated viral loads.

METHODS

This was a retrospective review of the electronic medical charts of 148 patients with autoimmune diseases who tested positive for CMV pp65 antigen in the blood.

RESULTS

A total of 106 patients were analyzed. During follow-up, elevated viral loads were detected in 35 patients who were not on antiviral therapy, of whom five developed CMV diseases. Elevated viral load was significantly associated with CMV diseases [5/35 vs. 0/71 (no elevated viral load); P = 0.001). Multivariate analysis revealed that lymphopenia [lymphocyte numbers <700/mm(3), odds ratio (OR) 34.44, 95 % confidence interval (CI), 7.82-151.66; P < 0.001], systemic lupus erythematosus (SLE) (OR 6.71, 95 % CI, 1.23-36.49; P = 0.028), and polymyositis/dermatomyositis (PM/DM) (OR 10.62, 95 % CI 1.41-79.77; P = 0.022) were significantly associated with elevated viral load.

CONCLUSIONS

Elevated viral load was significantly associated with CMV diseases. Patients with SLE or PM/DM and lymphopenia would therefore benefit from a detailed viral load follow-up and careful physical examination.

Outcomes of non-HIV-infected patients with Pneumocystis pneumonia and concomitant pulmonary cytomegalovirus infection

BACKGROUND

The pathogenic effect of concomitant pulmonary cytomegalovirus (CMV) infection on morbidity and mortality of Pneumocystis jirovecii pneumonia (PCP) has been questioned in the case of non-HIV-infected patients.

METHODS

We conducted a retrospective cross-sectional study of patients who were diagnosed with PCP by bronchoalveolar lavage. We compared demographics, clinical characteristics, morbidity, and mortality in non-HIV-infected PCP patients with (n = 31) and without (n = 75) pulmonary CMV infection. Morbidity was assessed by length of hospital stay, admission to the intensive care unit, and use of mechanical ventilation. Mortality was defined as 30-day and 90-day all-cause mortality.

RESULTS

Morbidity and mortality did not differ between PCP patients with and without pulmonary CMV infection. In multivariate analysis using the Cox proportional hazard model, haematological malignancy (relative risk (RR) 0.20, 95% confidence interval (95% CI) 0.06-0.71), PCP treatment duration (RR 0.81, 95% CI 0.75-0.88), changing to a second-line regimen due to treatment failure (RR 4.51, 95% CI 1.61-12.64), and mechanical ventilation (RR 17.99, 95% CI 4.83-67.04) were independently associated with 30-day all-cause mortality. Being a solid organ transplant recipient (RR 0.17, 95% CI 0.05-0.56) and the use of mechanical ventilation (RR 6.49, 95% CI 2.84-14.83) were independently associated with 90-day all-cause mortality. However, concomitant pulmonary CMV infection was not associated with either 30-day or 90-day mortality.

CONCLUSIONS

Our results suggest that concomitant pulmonary CMV infection does not significantly affect the prognosis of PCP, as indicated by morbidity and mortality in non-HIV-infected patients with PCP. Based on this result, we propose that it is not essential to administer an anti-CMV regimen when CMV is co-isolated from the bronchoalveolar lavage in patients with PCP.

Prevalence and outcome of cytomegalovirus-associated pneumonia in relation to human immunodeficiency virus infection

AIM

To investigate the antemortem prevalence and outcome of cytomegalovirus (CMV)-associated pneumonia in African children.

METHODS

A total of 202 children (median age, 3.2 months; 124 human immunodeficiency virus [HIV]-infected, 62%; 87 severely malnourished, 43%) sequentially hospitalized for severe pneumonia were prospectively investigated. In addition to routine microbiologic investigations, respiratory tract secretions and blood were submitted for CMV culture and qualitative and quantitative CMV polymerase chain reaction.

RESULTS

CMV-associated pneumonia was common (28%, 47/169) and more prevalent in HIV-infected than uninfected children (36% vs. 15%; odds ratio [OR], 3.0; 95% confidence interval, 1.3-7.4). CMV-associated pneumonia was more common than Pneumocystis pneumonia (27%) and other viral-associated pneumonia (19%) in HIV-infected children. In-hospital mortality was 25% (51/202) with increased mortality in HIV-infected compared with uninfected children (43/124 [35%] vs. 8/76 [11%]; OR, 4.5; 1.9-11.8). Increased mortality occurred in HIV-infected children with CMV-associated pneumonia (OR, 2.5; 1.04-6.5) but this association was not evident after adjusting for CD4 <15% (adjusted OR, 1.78; 0.6-4.6).

CONCLUSIONS

CMV-associated pneumonia is common and associated with a poor outcome in children with advanced HIV disease. Improved diagnostic testing and increased access to antiviral therapy might improve the outcome of HIV-infected children with CMV-associated pneumonia.

Pneumomediastinum in an HIV-infected patient with cytomegalovirus pneumonitis

A pneumomediastinum is an unusual complication of respiratory infections in HIV-positive patients, usually reported in association with pneumocystis pneumonia. We describe a case of an HIV-positive patient with a pneumomediastinum who had cytomegalovirus pneumonitis. This is an important reminder to clinicians, since cytomegalovirus pneumonitis and pneumocystis pneumonia have a similar clinical and radiological presentation.

Presence of human herpes virus 6 (HHV6) in pediatric lymphomas: impact on clinical course and association with cytomegalovirus infection

Background

Activation of herpes virus 6 (HHV6) has seen in Hodgkin's and non-Hodgkin's Lymphoma (HL&NHL) as a result of lymphoma associated immunosuppression. Multiple studies have suggested an association between both HHV6 and cytomegalovirus CMV for development of CMV disease affecting the pathogenesis of lymphoma. Therefore, this study investigated the frequency of HHV6, its impact on clinical manifestations of lymphoma and its possible association with risk for development of CMV infection in pediatric lymphoma patients.

Methods

Presence of HHV6 DNA and CMV DNA was investigated by PCR assay in both WBC's and plasma samples from 50 patients diagnosed with HL or NHL. CMV antibody titer was also determined in sera obtained from each patient. Twenty apparently healthy siblings were used as a control group.

Results

In a study group of 50 patients diagnosed with HL or NHL, 23/50 (46%) were found to be positive for herpes virus DNA (HHV6 or CMV) in WBC's or plasma by PCR assay and this was significantly higher than its presence in the pediatric control group 2/20 (10%) (p = 0.005). Ten out of these 23 (43%) were found to have active CMV infection. Fifty six percent of patients with CMV infection were found among NHL cases with B- subtype. The presence of both herpes viruses DNA was significantly associated with more frequent episodes of febrile neutropenia (median 3 episodes), absolute neutrophil count (< 0.8), lymphocytes (< 0.5), and low hemoglobin level (< 9.1), (p < 0.05).

Conclusion

The presence of HHV6 can be considered as a predicting indicator of cellular immunosuppression preceding the onset of CMV infection which may result in a severe outcome among pediatric lymphoma patients.

Pneumonitis in human cytomegalovirus infection

Human cytomegalovirus (HCMV) is a beta herpes virus with a double stranded DNA genome of 240kbp. The virus is prevalent and establishes a latent infection in most adults. HCMV is an opportunistic pathogen for patients with impaired cellular immunity. HCMV pneumonia is a common presentation of HCMV disease in immunocompromised patients. The incidence of HCMV pneumonitis can be as high as 90% in lung transplant recipients. This paper takes a fresh look at the challenging perspectives of molecular, immunologic, cellular, diagnostic, clinical, and therapeutic characteristics of HCMV infection as future targets for development of antiviral strategies.

[Massive alveolar hemorrhage due to cytomegalovirus (CMV) and HIV infection]

Alveolar hemorrhage may be a complication of diseases with local and systemic manifestations. Both share the same pathophysiological concept: damage to the alveolar microcirculation. It is a clinical entity that generates a diagnostic challenge for the physician. Early recognition favors aggressive treatment, which can improve the outcome. Despite the technological advances in its diagnosis and treatment, it is still a condition having high morbidity and mortality. We present the case of a 42-year old woman diagnosed of massive alveolar hemorrhage induced by cytomegalovirus (CMV) and HIV infection. Its presentation is atypical because most reported cases have occurred as a pneumonic process, episodes of massive hemorrhage being uncommon. The diagnosis was documented by bronchoscopy with bronchoalveolar lavage and etiological diagnosis with molecular techniques using reverse transcription polymerase chain reaction.

Diagnostic approach of pulmonary disease in the HIV negative immunocompromised host

The advances in medicine have resulted in increasing number of immunocompromised patients with complications related to their underlying disease or the treatment of these conditions. Pulmonary infectious and non-infectious conditions are a major cause of morbidity and mortality in these patients, and represent a diagnostic challenge. This article reviews the major conditions causing pulmonary symptoms in the HIV negative immunocompromised host. It also discusses the role of the different diagnostic methods, including the recent advances in non-invasive studies, in reaching a diagnosis of pulmonary disease in this patient population.

[Pneumocystis and cytomegalovirus pneumonia in HIV patients - two clinical cases]

Cytomegalovirus is capable of causing disease in immunocompromised patients. In people infected by the Human Immunodeficiency Virus (HIV) it becomes an important agent when there is advanced immunosupression. Its role as a pulmonary pathogen in these patients has been questioned. In the case of pneumocystosis the presence of Cytomegalovirus doesn't seem to worsen prognosis, except in cases where corticosteroids are used. Authors present two cases of patients with HIV infection and advanced immunosupression who were admitted in the intensive care unit for respiratory failure. In both Pneumocystis jirovecii was isolated from.

BAL neutrophils, serum procalcitonin, and C-reactive protein to predict bacterial infection in the immunocompromised host

BACKGROUND

Bacterial pulmonary infection is a common life-threatening complication in immunocompromised patients. The results of BAL cultures are not immediately available, and their microbiological yield might be limited by empiric antibiotic prescriptions. We evaluated clinical signs and symptoms, leukocyte counts, C-reactive protein (CRP) levels, procalcitonin levels, and BAL fluid neutrophil percentages as potential markers for bacterial infection in a cohort of immunocompromised patients with pulmonary complications.

METHODS

One hundred seven consecutive patients who had been referred for bronchoscopy due to suspected pulmonary infection were included in this study. Based on clinical, laboratory, radiologic, microbiological, and histologic results, patients were classified as having proven bacterial infection (n = 27), possible bacterial infection (n = 11), and no bacterial infection (n = 69).

RESULTS

Most common underlying conditions were hematologic malignancy (n = 62) and solid organ transplantation (n = 20). Clinical parameters were similar in patients with and without bacterial infection (difference was not significant). The percentage of BAL fluid neutrophils had the highest area under the curve (0.818; 95% confidence interval [CI], 0.700 to 0.935; p < 0.001), followed by absolute neutrophil counts (0.797; 95% CI, 0.678 to 0.916; p < 0.001), procalcitonin level (0.746; 95% CI, 0.602 to 0.889; p = 0.001), and CRP level (0.688; 95% CI, 0.555 to 0.821; p = 0.015) to predict proven bacterial infection (in opposition to no or possible bacterial infection) in the receiver operating characteristic analysis. Conversely, neither infiltrates (p = 0.123) nor leukocyte counts (p = 0.429) were useful in diagnosing bacterial infection. The percentage of BAL fluid neutrophils and procalcitonin level were independent predictors of bacterial infection in the multivariate regression.

CONCLUSIONS

Neutrophil percentage in BAL fluid, procalcitonin level, and CRP level might be potentially useful to differentiate bacterial infection from nonbacterial conditions in immunocompromised hosts with pulmonary complications.

Pulmonary infections diagnosed by BAL: A 12-year experience in 1066 immunocompromised patients

Bronchoalveolar lavage (BAL) is a useful tool in the diagnosis of pulmonary infections in immunocompromised patients. We aimed to compare the spectrum of infectious pulmonary complications diagnosed using BAL in a large consecutive cohort of immunocompromised patients. The diagnostic yield of 1066 BAL specimens was analyzed in 4 different groups of immunocompromised patients (HIV; solid organ transplants; high-dose chemotherapy and/or stem cell transplants; other immunosuppressive therapy) suffering from fever, respiratory symptoms and/or infiltrates on chest X-ray. Specimens were analyzed for bacteria, mycobacteria, fungi, Pneumocystis jiroveci, cytomegalovirus (CMV) and other viruses. Two time periods were compared (1992-1996; 1997-2003). The overall diagnostic yield of BAL was 34% for bacteria, 22% for CMV, 15% for P. jiroveci, 6% for other viruses, 6% for mycobacteria and 2% for aspergillus. There were significant changes in the pattern of opportunistic infections between the 2 time periods. Mycobacterial infections decreased considerably in the HIV group (17.9 vs. 8.5%, P=0.02), while the incidence of P. jiroveci decreased mainly in the transplant group (32.6 vs. 7.9%, P<0.00001). This study demonstrates a changed pattern of pulmonary infections in immunocompromised patients diagnosed by BAL. The overall diagnostic yield of BAL remains high in immunocompromised patients with respiratory symptoms.

Thin-Section CT Findings in Hematopoietic Stem Cell Transplantation Recipients with Respiratory Virus Pneumonia

OBJECTIVE

The purpose of this study was to use serial thin-section CT scans to assess the incidence of respiratory viral infection and lung abnormalities in a large patient population at high risk of pulmonary complications.

MATERIALS AND METHODS

The study population consisted of 26 recipients of hematopoietic stem cell transplants who had proven respiratory viral pneumonia. In all cases, thin-section CT scans were obtained before fiberoptic bronchoscopy and bronchoalveolar lavage. The study included only patients in whom bronchoalveolar lavage fluid showed no evidence of organisms other than respiratory viruses. The CT scans were assessed for the presence, extent, and anatomic distribution of ground-glass attenuation, air-space consolidation, nodules, centrilobular branching structures (tree-in-bud), thickening of the bronchovascular bundles, and pleural effusion.

RESULTS

Areas of ground-glass attenuation were identified in 24 (92%) of 26 patients and were the only finding in eight patients. Multiple nodules, seen in 17 (65%) of 26 patients, measured 3-10 mm in diameter or were larger than 10 mm. The nodules had a centrilobular or random distribution. A tree-in-bud appearance was seen in six of the patients with centrilobular nodules. This pattern had a bilateral distribution and involved mainly the lower lung zones. CT revealed thickening of the bronchovascular bundles in 16 (61%) of the patients. Thickening was bilateral in 14 and unilateral in two patients. Bronchial wall thickening involved the lower lobes in six patients and had a patchy random distribution in the remaining nine patients. Air-space consolidation was present in nine (35%) of the cases. It had a lobular or subsegmental distribution in eight of the patients and a segmental distribution in one patient. Areas of consolidation were randomly distributed throughout the lungs in all cases. Less common findings included bilateral pleural effusion and bronchial dilatation.

CONCLUSION

Respiratory viral infection is common among adult recipients of hematopoietic stem cell transplants, occurring over a wide time span after transplantation. The presence of respiratory viral infection must be considered in any patient with new respiratory symptoms, fever, or findings at CT such as extensive or patchy areas of ground-glass opacities or a mixture of patterns, most commonly ground-glass attenuation, thickening of the bronchial walls, and multiple small nodules.

Clinical utility of CMV early and late transcript detection with NASBA in bronchoalveolar lavages

BACKGROUND

Cytomegalovirus (CMV) infection can cause severe disease in immunocompromised individuals, with CMV pneumonia, most commonly seen in lung or bone marrow transplant recipients, carrying a particularly high fatality rate. Early and accurate diagnosis of CMV pneumonia is therefore critical.

OBJECTIVES

Current diagnostic tests for CMV pneumonia in bronchoalveolar lavage (BAL) specimens are either insensitive or poor prognostic indicators of disease. We therefore examined nucleic acid sequence-based amplification (NASBA) assays for CMV transcripts in BAL for the prediction of CMV pneumonia and associated diseases.

STUDY DESIGN

A total of 220 BAL specimens from lung transplant recipients and other patients with suspected viral pneumonia were studied. Ninety-nine samples had previously tested positive for CMV by shell vial (SV) culture, while the other 121 had tested negative. All specimens were assayed for CMV pp67 and immediate early (IE) transcripts by NASBA. Results were correlated with evidence of concurrent or subsequent CMV pneumonia, rejection, and infection with other microbes.

RESULTS

From a total of 220 BAL specimens, 27 tested positive for pp67 mRNA, 25 tested positive for IE mRNA, and 17 tested positive for both. Only 10 specimens tested positive for CMV by either or both NASBA assays while testing negative by SV assay. However, 74 specimens were SV positive but negative in both NASBA assays. Detection of CMV by any of the three methods was associated with an increased prevalence of pneumonia (i.e., pulmonary interstitial inflammation with radiographic or clinical evidence of lung injury), but not with pulmonary CMV pathology. Detection of CMV by SV was associated with moderate to severe graft rejection. There was no evidence of increased bacterial or fungal pulmonary infections associated with a positive CMV result by any of the three assays.

CONCLUSIONS

Detection of either CMV pp67 or IE mRNA transcripts by NASBA in BAL specimens can occasionally identify CMV infections that are negative by conventional shell vial culture, but does not have sufficient sensitivity or positive predictive value to be employed routinely for pre emptive management of pulmonary CMV disease in transplant recipients.

Cytomegalovirus Pneumonia in Transplant Recipients

The incidence of cytomegalovirus CMV pneumonia has been reduced by routine antiviral prophylaxis in susceptible populations. Many of the complications of this infection are caused by indirect effects of the virus, including acute and chronic graft rejection, graft-versus-host disease, and superinfection by other viruses, bacteria and fungi. Distinction must be made between viral secretion and invasion. Invasive procedures are often required for the optimal management of such infections. The use of sensitive and quantitative assays have greatly improved the outcomes of CMV infection.

Cytomegalovirus pneumonia in patients with lymphoma

BACKGROUND

Even when treated with antiviral therapy, cytomegalovirus pneumonia (CMVp) is associated with high morbidity and mortality in immunocompromised patients. CMVp has been rarely reported in patients with lymphoma.

METHODS

The authors reviewed the records of patients treated at The University of Texas M. D. Anderson Cancer Center (Houston, TX) between 1997 and 2003. Collected information included demographics, use of chemotherapy, or corticosteroids, concomitant infections, and outcome.

RESULTS

Thirty-one patients with lymphoma with 36 episodes of CMVp were identified. The incidence of CMVp increased between 1997 and 2003 (0 of 1000 treated patients vs. 9 of 1000 treated patients; P = 0.07). Most episodes occurred in patients with non-Hodgkin lymphoma (89%). Most of the patients (92%) had received chemotherapy and corticosteroids (89%) before the onset of CMVp. Concomitant CMV antigenemia was detected in 11 (41%) of the 27 episodes in which testing was performed. In 19 episodes (53%), patients had coinfections within 90 days of the episode of CMVp. Coinfections were present at the onset of CMVp in 11 episodes (31%). The yield for CMV in bronchoalveolar lavage (BAL) specimens was higher with culture methods than with cytologic evaluation or immunohistochemical staining (P < 0.001). The number of CMV antigenemia tests performed increased fourfold over the study period. The CMV-attributed mortality rate was 30% (9 of 30 patients). Independent predictors of death by multivariate Cox regression analysis were high APACHE II score (> 16) at onset of CMVp (P = 0.02, hazards ratio [HR] = 15.5, 95% confidence interval [CI], 1.5-163.7), and development of toxicity to antivirals (P = 0.04, HR = 14.03, 95% CI, 1.2-169.1).

CONCLUSIONS

The incidence of CMVp in patients with lymphoma is increasing. CMV detection in BAL specimens was better with culture methods than with cytologic or immunohistochemical methods. High APACHE II score and development of antiviral toxicity were associated with a fatal outcome.

Correlation between viral loads of cytomegalovirus in blood and bronchoalveolar lavage specimens from lung transplant recipients determined by histology and immunohistochemistry

Cytomegalovirus (CMV) is an important pathogen in lung transplant recipients. Early detection of CMV end-organ disease should help with treatment management. We determined the CMV viral load by hybrid capture in bronchoalveolar lavage (BAL) fluid samples from patients who had undergone lung transplantation. For 39 of these samples (from 25 patients), corresponding transbronchial biopsy samples were available for CMV immunohistochemistry (IHC). The CMV IHC results were interpreted and categorized as positive or negative, and the positive results were subcategorized as typical if cells with both significant nuclear enlargement or Cowdry A-type inclusions and positive staining were present or as atypical if definitive nuclear staining was seen but significant nuclear enlargement was not. Diagnostic CMV viral inclusions were reported in the anatomic diagnosis, based on hematoxylin-eosin staining alone, for three (8%) of the biopsy samples. CMV was detected by IHC in 13 (33%) samples (5 typical, 8 atypical). The median CMV viral load in BAL samples was 0 copies/ml for BAL samples from patients with IHC-negative biopsy samples; 47,678 copies/ml for BAL samples from patients with biopsy samples with positive, atypical staining; and 1,548,827 copies/ml for BAL samples from patients with biopsy samples with positive, typical staining (P < 0.001). Compared to routine pathology of biopsy samples, the use of IHC increased the diagnostic yield of CMV. Also, the CMV viral load in BAL fluid samples increased along with immunoreactivity from negative to positive, atypical staining to positive, typical staining. The CMV viral load determined with the end-organ sample, the BAL fluid sample, was higher than the corresponding viral load determined with blood. Both IHC and determination of the CMV viral load in BAL samples may be useful for the detection of individuals at risk for the development of fulminant invasive CMV disease.

Retinal and extraocular cytomegalovirus end-organ disease in HIV-infected patients in Europe: a EuroSIDA study, 1994-2001

This multicentre prospective cohort study by the EuroSIDA study group was designed to determine the factors affecting the incidence of cytomegalovirus (CMV) end-organ disease (CMVD) and the rate of survival after diagnosis in patients with AIDS during the years 1994-2001. This period includes two eras, the pre-HAART era and the HAART era, because HAART affects the natural history of HIV infection, especially with respect to opportunistic infections, including CMV infection. Clinical and laboratory data were collected from the charts of 8,556 patients in 63 AIDS clinics in Europe. A total of 707 patients had CMVD at recruitment and at follow-up: 449 with retinitis (CMVR), 190 with extraocular CMV disease (EOCMVD), and 58 with both. Of the cases of EOCMVD, 66% involved the gastrointestinal tract and 17% the central nervous system. Of patients with a CD4+ count of < or =200 mm(-3) initially, 1.8% on HAART developed CMVD within a 24-month period, as compared to 11.1% on dual therapy and 14.3% without treatment (P<0.0001). There were highly significant differences in survival according to the calendar year (P<0.0001), with mortality declining from 79% during the years 1994-1995 to 42% in 2000-2001. The incidence of death after any CMVD was 28.4 per 100 patient-years of follow-up. Median survival of CMVR patients and EOCMVD patients was 11 and 7 months, respectively, the prognosis being better among patients with gastrointestinal rather than neurological CMVD. The initiation of HAART was associated with a 37% decrease in mortality (P<0.05). Eighteen percent of all deaths were caused by EOCMVD itself. This study describes a decline in the incidence and mortality of CMVR and EOCMVD during the HAART era of the HIV epidemic. It furthermore serves as a reminder of the importance of EOCMVD as a cause of morbidity and mortality in AIDS in the pre-HAART era.

Ganciclovir prophylaxis to prevent CMV disease in kidney recipients undergoing anti-lymphocyte globulin treatment for acute rejection

Kidney recipients (n = 51) at risk of cytomegalovirus (CMV) disease, and requiring anti-lymphocyte globulin therapy because of biopsy-proven rejection, received high-dose ganciclovir, three times a week, for a total of nine doses. CMV disease was observed in seven (14%) patients within 6 months. Six of these patients were in a group of 45 CMV-seropositive recipients, and one was in a high-risk group of CMV-seronegative recipients. High-dose intravenous ganciclovir, three times a week, seems to be an efficient, safe and easy way to prevent CMV disease in patients treated with anti-lymphocyte globulins for acute rejection.

The diagnosis of pneumonia in renal transplant recipients using invasive and noninvasive procedures

STUDY OBJECTIVES

We used invasive and noninvasive procedures to determine the causes of pneumonia in renal transplant recipients.

SUBJECTS AND METHODS

We retrospectively surveyed 565 renal transplant recipients (transplants received March 1984 to August 2001) to find those with pneumonia. Noninvasive diagnostic methods included serologic testing, and blood and sputum cultures with stains. Invasive procedures included fiberoptic bronchoscopy and percutaneous transthoracic procedures.

RESULTS

A total of 92 patients were enrolled. Of these, 71 patients had a definite etiologic diagnosis of pneumonia. The major infectious pathogens were bacterial (n = 21) and mixed bacterial infection (n = 10), Mycobacterium tuberculosis (TB) [n = 18], and fungi (n = 8). Noninvasive and invasive procedures led to the diagnosis of pneumonia in 31.5% (n = 29) and 45.6% (n = 42) of patients, respectively. Bronchoscopy was used in 64 patients, with a diagnostic yield of 38 cases (59.3%). Patients were 3.62 times more likely to contract pneumonia within 12 months of renal transplantation than they were > or =12 months thereafter (95% confidence interval, 1.33 to 9.84). Twenty-seven of the 92 patients (29.3%) died. The pneumonia mortality rate has dropped significantly since 1996 (41.8% vs 10.8%, p = 0.002).

CONCLUSION

Both invasive and noninvasive procedures are useful in the diagnosis of pneumonia, with declining mortality, in renal transplant recipients. Bacterial and mixed bacterial infection, TB, and fungal infection are the most common pathogens; cases are most likely to occur within 1 year after renal transplantation.

Pulmonary involvement during cytomegalovirus infection in immunosuppressed patients

Although cytomegalovirus (CMV) pulmonary involvement after solid organ transplantation is infrequently seen nowadays, CMV pneumonitis is still a potential lethal complication. Introduction of the pp65 antigenemia assay enabled early and rapid diagnosis of CMV viremia in transplant patients prior to symptoms. Also, in asymptomatic patients with CMV viremia, a decreased pulmonary diffusion capacity could be demonstrated. In this review, we discuss clinical and subclinical pulmonary involvement of CMV infection in the immunocompromised host with an emphasis on transplant recipients. The clinical course, diagnosis, therapy, prophylaxis, and pathophysiology of CMV pneumonitis are discussed.

Infectious pulmonary nodules in immunocompromised patients: usefulness of computed tomography in predicting their etiology

PURPOSE

To review the high-resolution computed tomography (CT) findings in immunocompromised patients who had nodular opacities and a proven diagnosis to determine whether the various infectious pulmonary nodules have distinguishing features on CT.

MATERIALS AND METHODS

The high-resolution CT scans obtained in 78 immunocompromised patients with solitary or multiple nodular opacities of proven infectious etiology were reviewed retrospectively by 2 independent thoracic radiologists. Patients whose predominant abnormality consisted of branching linear or nodular opacities (tree-in-bud pattern) characteristic of infectious bronchiolitis and endobronchial spread of tuberculosis were excluded. The CT scans were assessed for the presence, appearance, size, and distribution of parenchymal nodules. Relations between findings at CT and the different infectious etiologies of nodules were assessed with regression analysis. Agreement between the 2 observers was assessed using the kappa statistic.

RESULTS

The infectious causes included mycobacteria (n = 24), fungi (n = 22), bacteria (n = 20), and viruses (n = 12). Multivariate analysis demonstrated that a diameter <10 mm was the only independent predictor of etiology (P < 0.0001) and that patients whose nodules all measured less than 10 mm in diameter were most likely to have a viral infection. Nodules limited in size to less than 10 mm in diameter were seen in 83% of viral infections compared with 5% of bacterial infections (odds ratio [OR] = 95.0; 95% confidence interval (CI): 6.08-4,321.5, P < 0.0001), 0% of mycobacterial infections (OR = 91.7; 95% CI: 7.21-4,090.22, P < 0.0001), and 14% of fungal infections (OR = 31.67; 95% CI: 3.56-375.09, P = 0.0003).

CONCLUSION

Although some overlap exists, nodule size is helpful in the differential diagnosis of infectious causes of nodules in immunocompromised patients. Patients whose nodules are all less than 10 mm in diameter are most likely to have a viral infection.

The pulmonary physician in critical care. Illustrative case 2: interstitial lung disease

The case history of a patient admitted to the ICU with interstitial lung disease deteriorating to respiratory failure is presented. Problems in distinguishing between infection and disease progression are discussed and the role of transplantation in ventilated patients is examined.