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Ljungman P, Chemaly RF, Khawaya F, Alain S, Avery R, Badshah C, Boeckh M, Fournier M, Hodowanec A, Komatsu T, Limaye AP, Manuel O, Natori Y, Navarro D, Pikis A, Razonable RR, Westman G, Miller V, Griffiths PD, Kotton CN. Consensus Definitions of Cytomegalovirus (CMV) Infection and Disease in Transplant Patients Including Resistant and Refractory CMV for Use in Clinical Trials: 2024 Update From the Transplant Associated Virus Infections Forum. Clin Infect Dis 2024:ciae321. [PMID: 39041385 DOI: 10.1093/cid/ciae321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Indexed: 07/24/2024] Open
Abstract
Cytomegalovirus (CMV) infection and disease are important causes of morbidity and mortality in transplant recipients. For the purpose of developing consistent reporting of CMV outcomes in clinical trials, definitions of CMV infection and disease were developed and most recently published in 2017. Since then, there have been major developments, including registration of new antiviral agents. Therefore, the Transplant Associated Virus Infections Forum, which consists of scientists, clinicians, regulators, and industry representatives, has produced an updated version of these definitions that incorporates recent knowledge with the aim of supporting clinical research and drug development. This also includes an update regarding the definition of resistant and refractory CMV infections previously published in 2019. As the field evolves, the need for updates of these definitions is clear, and collaborative efforts among clinicians, scientists, regulators, and industry representatives can provide a platform for this work.
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Affiliation(s)
- Per Ljungman
- Department of Cellular Therapy and Allogeneic Stem Cell Transplantation, Karolinska University Hospital Huddinge, Karolinska Comprehensive Cancer Center, Stockholm, Sweden
- Division of Hematology, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Roy F Chemaly
- Department of Infectious Diseases, Infection Control, and Employee Health, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Fareed Khawaya
- Department of Infectious Diseases, Infection Control, and Employee Health, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sophie Alain
- Laboratoire de Bactériologie-Virologie-Hygiène, French National Reference Center for Herpesviruses, CHU Limoges, Limoges, France
| | - Robin Avery
- Division of Infectious Diseases, Johns Hopkins, Baltimore, Maryland, USA
| | | | - Michael Boeckh
- Vaccine and Infectious Disease and Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | | | - Aimee Hodowanec
- Division of Antivirals, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Takashi Komatsu
- Division of Antivirals, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Ajit P Limaye
- Department of Medicine, Division of Allergy & Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Oriol Manuel
- Infectious Diseases Service and Transplantation Center, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Yoichiro Natori
- Division of Infectious Diseases, Miami Transplant Institute, Jackson Health System, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - David Navarro
- Microbiology Service, Clinic University Hospital, INCLIVA Biomedical Research Institute, Department of Microbiology, School of Medicine, University of Valencia, Valencia, Spain
- Centro de Investigación Biomédica en Red Enfermedades Infecciosas, Valencia, Spain
| | - Andreas Pikis
- Division of Antivirals, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Raymund R Razonable
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - Gabriel Westman
- Swedish Medical Products Agency, Uppsala, Sweden
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
| | - Veronica Miller
- Forum for Collaborative Research, University of California, Berkeley, California, USA
| | - Paul D Griffiths
- Institute for Immunity and Transplantation, University College London Medical School, London, United Kingdom
| | - Camille N Kotton
- Transplant and Immunocompromised Host Infectious Diseases Infectious Diseases Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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2
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Boers LS, van Someren Gréve F, van Hattem JM, de Brabander J, Zwaan T, van Willigen H, Cornelissen M, de Jong M, van der Poll T, Duitman J, Schinkel J, Bos LDJ. Pulmonary herpes simplex virus and cytomegalovirus in patients with acute respiratory distress syndrome related to COVID-19. Intensive Care Med 2024:10.1007/s00134-024-07529-x. [PMID: 39017695 DOI: 10.1007/s00134-024-07529-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 06/14/2024] [Indexed: 07/18/2024]
Abstract
PURPOSE Human herpesviruses, particularly cytomegalovirus (CMV) and herpes simplex virus (HSV), frequently reactivate in critically ill patients, including those with acute respiratory distress syndrome (ARDS) related to coronavirus disease 2019 (COVID-19). The clinical interpretation of pulmonary herpesvirus reactivation is challenging and there is ongoing debate about its association with mortality and benefit of antiviral medication. We aimed to quantify the incidence and pathogenicity of pulmonary CMV and HSV reactivations in critically ill COVID-19 patients. METHODS Mechanically ventilated COVID-19 patients seropositive for CMV or HSV were included in this observational cohort study. Diagnostic bronchoscopy with bronchoalveolar lavage was performed routinely and analyzed for alveolar viral loads and inflammatory biomarkers. Utilizing joint modeling, we explored the dynamic association between viral load trajectories over time and mortality. We explored alveolar inflammatory biomarker dynamics between reactivated and non-reactivated patients. RESULTS Pulmonary reactivation (> 104 copies/ml) of CMV occurred in 6% of CMV-seropositive patients (9/156), and pulmonary reactivation of HSV in 37% of HSV-seropositive patients (63/172). HSV viral load dynamics prior to or without antiviral treatment were associated with increased 90-day mortality (hazard ratio [HR] 1.24, 95% confidence interval [CI] 1.04-1.47). The alveolar concentration of several inflammatory biomarkers increased with HSV reactivation, including interleukin (IL)-6, IL-1β, granulocyte colony stimulating factor (G-CSF), and tumor necrosis factor (TNF). CONCLUSION In mechanically ventilated COVID-19 patients, HSV reactivations are common, while CMV reactivations were rare. HSV viral load dynamics prior to or without antiviral treatment are associated with mortality. Alveolar inflammation is elevated after HSV reactivation.
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Affiliation(s)
- Leonoor S Boers
- Intensive Care Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Room G3-228, 1105 AZ, Amsterdam, The Netherlands.
| | - Frank van Someren Gréve
- Medical Microbiology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Jarne M van Hattem
- Medical Microbiology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Justin de Brabander
- Center for Experimental and Molecular Medicine (CEMM), Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Tom Zwaan
- Intensive Care Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Room G3-228, 1105 AZ, Amsterdam, The Netherlands
| | - Hugo van Willigen
- Medical Microbiology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Marion Cornelissen
- Medical Microbiology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Menno de Jong
- Medical Microbiology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Tom van der Poll
- Center for Experimental and Molecular Medicine (CEMM), Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Infection and Immunity, Inflammatory Diseases, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - JanWillem Duitman
- Infection and Immunity, Inflammatory Diseases, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Pulmonary Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Experimental Immunology (EXIM), Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Janke Schinkel
- Medical Microbiology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Lieuwe D J Bos
- Intensive Care Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Room G3-228, 1105 AZ, Amsterdam, The Netherlands
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3
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Albert E, Giménez E, Alberola J, Torres I, López Y, Marcos A, Reinhardt B, Navarro D. Performance evaluation of the Alinity m system for quantifying cytomegalovirus DNA in samples of the respiratory, gastrointestinal, and urinary tract. Microbiol Spectr 2024; 12:e0420123. [PMID: 38842363 PMCID: PMC11218520 DOI: 10.1128/spectrum.04201-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 04/21/2024] [Indexed: 06/07/2024] Open
Abstract
Quantitation of cytomegalovirus (CMV) DNA load in specimens other than blood such as bronchoalveolar lavages, intestinal biopsies, or urine has become a common practice as an ancillary tool for the diagnosis of CMV pneumonitis, intestinal disease, or congenital infection, respectively. Nevertheless, most commercially available CMV PCR platforms have not been validated for CMV DNA detection in these specimen types. In this study, a laboratory-developed test based on Alinity m CMV ("Alinity LDT") was evaluated. Reproducibility assessment using spiked bronchial aspirate (BAS) or urine samples showed low standard deviations of 0.08 and 0.27 Log IU/mL, respectively. Evaluating the clinical performance of Alinity LDT in comparison to a laboratory-developed test based on RealTime CMV ("RealTime LDT") showed good concordance across 200 clinical specimens including respiratory specimens, intestinal biopsies, urine, and stool. A high Pearson's correlation coefficient of r = 0.92, a low mean bias of -0.12 Log IU/mL, a good qualitative agreement of 90%, and a Cohen's kappa value of 0.76 (substantial agreement) were observed. In separate analyses of the sample types BAS, tracheal aspirates, bronchoalveolar lavage, biopsies, and urine, the assay results correlated well between the two platforms with r values between 0.88 and 0.99 and a bias <0.5 Log IU/mL. Overall, the fully automated, continuous, random access Alinity LDT yielded good reproducibility, high concordance, and good correlation to RealTime LDT in respiratory, gastrointestinal, and urine samples and may enhance patient management with rapid result reporting.IMPORTANCEIn transplant recipients, a major cause for morbidity and mortality is end-organ disease by primary or secondary CMV infection of the respiratory or gastrointestinal tract. In addition, sensorineural hearing loss and neurodevelopmental abnormalities are frequent sequelae of congenital CMV infections in newborns. Standard of care for highly sensitive detection and quantitation of the CMV DNA load in plasma and whole blood specimens is real-time PCR testing. Beyond that, there is a need for quantitative determination of CMV DNA levels in respiratory, gastrointestinal, and urinary tract specimens using a highly automated, random access CMV PCR assay with a short turnaround time to enable early diagnosis and treatment. In the present study, clinical performance of the fully automated Alinity m analyzer in comparison to the current RealTime LDT assay was evaluated in eight different off-label sample types.
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Affiliation(s)
- Eliseo Albert
- Hospital Clínico Universitario de Valencia, INCLIVA Health Research Institute, Microbiology Service, Valencia, Spain
| | - Estela Giménez
- Hospital Clínico Universitario de Valencia, INCLIVA Health Research Institute, Microbiology Service, Valencia, Spain
| | - Juan Alberola
- Hospital Universitario Doctor Peset, Microbiology Service, Valencia, Spain
| | - Ignacio Torres
- Hospital Clínico Universitario de Valencia, INCLIVA Health Research Institute, Microbiology Service, Valencia, Spain
| | - Yolanda López
- Hospital Clínico Universitario de Valencia, INCLIVA Health Research Institute, Microbiology Service, Valencia, Spain
| | - Ana Marcos
- Hospital Clínico Universitario de Valencia, INCLIVA Health Research Institute, Microbiology Service, Valencia, Spain
| | | | - David Navarro
- Hospital Clínico Universitario de Valencia, INCLIVA Health Research Institute, Microbiology Service, Valencia, Spain
- Department of Microbiology, School of Medicine, University of Valencia, Valencia, Spain
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4
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Kostera J, Hubbard M, Jackson D, Liesman RM. Evaluation of Alinity m CMV assay performance for detecting CMV in plasma, cerebrospinal fluid, and bronchoalveolar lavage specimens. Diagn Microbiol Infect Dis 2024; 109:116301. [PMID: 38723453 DOI: 10.1016/j.diagmicrobio.2024.116301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 03/28/2024] [Accepted: 04/09/2024] [Indexed: 05/28/2024]
Abstract
Accurate detection and quantification of cytomegalovirus (CMV) is crucial to preventing adverse outcomes in immunocompromised individuals. Current assays were developed for use with plasma specimens, but CMV may be present in bronchoalveolar lavage (BAL) fluid and cerebrospinal fluid (CSF). We evaluated the performance of the Abbott Alinity m CMV assay compared to the Abbott RealTime CMV assay for quantification of CMV in plasma, BAL, and CSF specimens. To evaluate clinical performance, 190 plasma, 78 BAL, and 20 CSF specimens were tested with the Alinity m assay and compared to the RealTime assay. The Alinity m CMV assay showed high precision (SD <0.01 to 0.13) for all 3 specimen types. Clincal plasma and BAL specimens with quantifiable CMV DNA demonstrated strong correlation to RealTime CMV assay results (r2 = 0.9779 for plasma, r2 = 0.9373 for BAL). The Alinity m CMV assay may be useful for quantification of CMV in plasma, BAL, and CSF specimens.
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Affiliation(s)
| | - Mark Hubbard
- Department of Pathology and Laboratory Medicine, The University of Kansas Health System, Kansas City, KS, USA
| | - Dillon Jackson
- Department of Pathology and Laboratory Medicine, The University of Kansas Health System, Kansas City, KS, USA
| | - Rachael M Liesman
- Department of Pathology and Laboratory Medicine, The University of Kansas Health System, Kansas City, KS, USA; Department of Pathology, Medical College of Wisconsin, Milwaukee, WI, USA.
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5
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Perrotta F, Piscopiello D, Rizzo D, Iosa G, Garzya G, Calò P, Gemma D. Cytomegalovirus Pneumonia in a Patient with Down Syndrome. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:242. [PMID: 38399530 PMCID: PMC10890385 DOI: 10.3390/medicina60020242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/16/2024] [Accepted: 01/25/2024] [Indexed: 02/25/2024]
Abstract
Down syndrome (DS) is a chromosomal disorder due to the presence of an additional chromosome 21 that causes intellectual deficit and physical anomalies and predisposes patients to develop infections throughout their lives. Pneumonias are more serious in patients with DS, requiring hospitalization, and they represent an important cause of mortality in this population. Cytomegalovirus (CMV) causes widespread and serious infections in immunocompromised individuals, affecting the respiratory tract and, when causing interstitial pneumonia, associated with a high mortality rate. However, CMV-induced pneumonia is not reported in DS patients. The prevalence and severity of CMV respiratory infections in subjects with DS is unknown. This case describes a 50-year-old female patient with DS who developed extensive bilateral pneumonia with severe respiratory failure which required hospitalization in intensive care, intubation, and mechanical ventilation after approximately 10 days of empiric antibiotic and anitimycotic therapy for fever, cough, and dyspnea. The patient was diagnosed with CMV pneumonia and recovered after treatment with ganciclovir. To the best of our knowledge, this is the first reported case of CMV pneumonia in a patient with DS. This case aims to highlight that CMV pneumonia in individuals with DS can be a life-threatening condition. It also clarifies the importance of early diagnosis of infections from opportunistic pathogens such as CMV to ensure timely and efficient treatment.
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Affiliation(s)
- Francesco Perrotta
- Department of Anesthesia and Intensive Care, Azienda Ospedaliera Cardinale Panico, 73039 Tricase, Italy; (D.P.); (D.R.); (G.I.); (G.G.); (P.C.); (D.G.)
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6
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Kanika A, Soldera J. Pulmonary cytomegalovirus infection: A case report and systematic review. World J Meta-Anal 2023; 11:151-166. [DOI: 10.13105/wjma.v11.i5.151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 04/08/2023] [Accepted: 06/09/2023] [Indexed: 06/16/2023] Open
Abstract
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.
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Affiliation(s)
- Awotar Kanika
- Department of Acute Medicine, University of South Wales, Cardiff CF37 1DL, United Kingdom
| | - Jonathan Soldera
- Department of Acute Medicine, University of South Wales, Cardiff CF37 1DL, United Kingdom
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7
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Sepassi A, Saunders IM, Bounthavong M, Taplitz RA, Logan C, Watanabe JH. Cost Effectiveness of Letermovir for Cytomegalovirus Prophylaxis Compared with Pre-Emptive Therapy in Allogeneic Hematopoietic Stem Cell Transplant Recipients in the United States. PHARMACOECONOMICS - OPEN 2023; 7:393-404. [PMID: 36840894 PMCID: PMC10169956 DOI: 10.1007/s41669-023-00398-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/13/2023] [Indexed: 05/11/2023]
Abstract
PURPOSE The aim of this study was to assess the cost effectiveness of letermovir prophylaxis with the option for subsequent pre-emptive therapy (PET) for the prevention of cytomegalovirus (CMV) infection compared with a PET-only scenario in adult allogeneic hematopoietic stem cell transplant (allo-HCT) recipients in the United States over a 10-year time horizon. MATERIALS AND METHODS A publicly available decision tree model was constructed using a commercial third-party payer perspective to simulate an allo-HCT recipient's clinical trajectory in the first-year post-transplant, followed by entry to a Markov model to simulate years 2 through 10. Clinical inputs and utility estimates were derived from published literature. Costs were derived from published literature and US Department of Veterans Affairs Federal Supply Schedule drug pricing. Outcomes assessed included life expectancy, quality-adjusted life-years (QALYs), direct medical costs, and the incremental cost-effectiveness ratio (ICER). One-way and probabilistic sensitivity analyses (PSA) were performed to test the robustness of the findings. RESULTS Compared with PET alone, letermovir prophylaxis was projected to increase life-years per person (4.99 vs. 4.70 life-years), and increase QALYs (3.29 vs. 3.08) and costs (US$83.411 vs. US$70,698), yielding an ICER of US$59,356 per QALY gained. One-way sensitivity analyses indicated our model was sensitive to mortality (ICER: $164,771/QALY) and utility (letermovir ICER: $117,447/QALY; PET ICER: $107,290/QALY) in the first-year post-transplant. In 57.1% of the PSA simulations, letermovir was a cost-effective option using a willingness-to-pay threshold of US$100,000 per QALY. CONCLUSIONS Letermovir prophylaxis is cost effective compared with PET alone with a willingness-to-pay threshold of US$100,000 per QALY gained. Sensitivity analysis results indicate future research is required to understand the impact of mortality and quality of life in the first-year post-transplant to arrive at a conclusive decision on letermovir adoption.
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Affiliation(s)
- Aryana Sepassi
- Department of Clinical Pharmacy Practice, University of California, Irvine School of Pharmacy and Pharmaceutical Sciences, Irvine, CA, USA.
| | - Ila M Saunders
- Division of Clinical Pharmacy, University of California, San Diego Skaggs School of Pharmacy & Pharmaceutical Sciences, La Jolla, CA, USA
| | - Mark Bounthavong
- Division of Clinical Pharmacy, University of California, San Diego Skaggs School of Pharmacy & Pharmaceutical Sciences, La Jolla, CA, USA
- Department of Veteran Affairs, Health Economic Resource Center, Menlo Park, CA, USA
| | | | - Cathy Logan
- Division of Infectious Diseases and Global Health, University of California, San Diego, La Jolla, CA, USA
| | - Jonathan H Watanabe
- Department of Clinical Pharmacy Practice, University of California, Irvine School of Pharmacy and Pharmaceutical Sciences, Irvine, CA, USA
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8
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Berengua C, Miró E, Gutiérrez C, Sánchez M, Mulero A, Ramos P, Del Cuerpo M, Torrego A, García-Cadenas I, Pajares V, Navarro F, Martino R, Rabella N. Detection of cytomegalovirus in bronchoalveolar lavage fluid from immunocompromised patients with pneumonitis by viral culture and DNA quantification. J Virol Methods 2023; 317:114743. [PMID: 37116585 DOI: 10.1016/j.jviromet.2023.114743] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 04/22/2023] [Accepted: 04/25/2023] [Indexed: 04/30/2023]
Abstract
PURPOSE To compare the detection of human cytomegalovirus (HCMV) in bronchoalveolar lavage (BAL) fluid by viral culture and quantitative polymerase chain reaction (qPCR), and to establish a viral load threshold that can identify cases of HCMV replication indicative of pneumonitis. There is currently no universal viral load cut-off to differentiate between patients with and without pneumonitis, and the interpretation of qPCR results is challenging. METHODS 176 consecutive BAL samples from immunosuppressed hosts with signs and/or symptoms of respiratory infection were prospectively studied by viral culture and qPCR. RESULTS Concordant results were obtained in 81.25% of the BAL samples. The rest were discordant, as only 34% of the qPCR-positive BAL samples were positive by culture. The median HCMV load was significantly higher in culture-positive than in culture-negative BAL samples (5,038 vs 178 IU/mL). Using a cut-off value of 1,258 IU/mL of HCMV in BAL, pneumonia was diagnosed with a sensitivity of 76%, a specificity of 100%, a VPP of 100% and VPN of 98%, and HCMV was isolated in 100% of the BAL cultures. CONCLUSION We found that a qPCR-negative was a quick and reliable way of ruling out HCMV pneumonitis, but a positive result did not always indicate clinically significant replication in the lung. However, an HCMV load in BAL fluid of ≥1,258 IU/mL was always associated with disease, whereas <200 IU/mL rarely so.
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Affiliation(s)
- C Berengua
- Genetics and Microbiology Department. Universitat Autònoma de Barcelona. Spain; Microbiology Department. Hospital de la Santa Creu i Sant Pau. Barcelona. Spain; Sant Pau Institute of Biomedical Research (IIb Sant Pau) Barcelona. Spain.
| | - E Miró
- Genetics and Microbiology Department. Universitat Autònoma de Barcelona. Spain; Microbiology Department. Hospital de la Santa Creu i Sant Pau. Barcelona. Spain; Sant Pau Institute of Biomedical Research (IIb Sant Pau) Barcelona. Spain
| | - C Gutiérrez
- Microbiology Department. Hospital de la Santa Creu i Sant Pau. Barcelona. Spain
| | - M Sánchez
- Microbiology Department. Hospital de la Santa Creu i Sant Pau. Barcelona. Spain
| | - A Mulero
- Microbiology Department. Hospital de la Santa Creu i Sant Pau. Barcelona. Spain
| | - P Ramos
- Microbiology Department. Hospital de la Santa Creu i Sant Pau. Barcelona. Spain
| | - M Del Cuerpo
- Microbiology Department. Hospital de la Santa Creu i Sant Pau. Barcelona. Spain
| | - A Torrego
- Pneumology Department. Hospital de la Santa Creu i Sant Pau. Barcelona. Spain; Sant Pau Institute of Biomedical Research (IIb Sant Pau) Barcelona. Spain
| | - I García-Cadenas
- Pneumology Department. Hospital de la Santa Creu i Sant Pau. Barcelona. Spain; Sant Pau Institute of Biomedical Research (IIb Sant Pau) Barcelona. Spain
| | - V Pajares
- Pneumology Department. Hospital de la Santa Creu i Sant Pau. Barcelona. Spain; Sant Pau Institute of Biomedical Research (IIb Sant Pau) Barcelona. Spain
| | - F Navarro
- Genetics and Microbiology Department. Universitat Autònoma de Barcelona. Spain; Microbiology Department. Hospital de la Santa Creu i Sant Pau. Barcelona. Spain; Sant Pau Institute of Biomedical Research (IIb Sant Pau) Barcelona. Spain
| | - R Martino
- Hematology Department. Hospital de la Santa Creu I Sant Pau. Barcelona. Spain; Sant Pau Institute of Biomedical Research (IIb Sant Pau) Barcelona. Spain
| | - N Rabella
- Genetics and Microbiology Department. Universitat Autònoma de Barcelona. Spain; Microbiology Department. Hospital de la Santa Creu i Sant Pau. Barcelona. Spain; Sant Pau Institute of Biomedical Research (IIb Sant Pau) Barcelona. Spain
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9
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Bos LDJ, de Grooth HJ, Tuinman PR. A structured diagnostic algorithm for patients with ARDS. Crit Care 2023; 27:94. [PMID: 36941668 PMCID: PMC10027589 DOI: 10.1186/s13054-023-04368-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2023. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2023 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .
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Affiliation(s)
- Lieuwe Durk Jacobus Bos
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - Harm Jan de Grooth
- Department of Intensive Care, Amsterdam UMC, Location VUMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Pieter Roel Tuinman
- Department of Intensive Care, Amsterdam UMC, Location VUMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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10
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Quantitative PCR for the Diagnosis of HCMV Pneumonia in HSCT Recipients and Other Immunocompromised Hosts. HEMATO 2023. [DOI: 10.3390/hemato4010008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Pneumonia is among the most serious manifestations of HCMV infection, with high morbidity and mortality. Probable pneumonia is defined as the detection of HCMV in bronchoalveolar lavage (BAL) by viral isolation or DNA quantification (qPCR) combined with symptoms and/or signs of respiratory infection. However, currently, there is no reproducible and well-defined viral load (VL) from BAL that can reliably differentiate patients with pneumonia from the much more common detection of viral DNA in seropositive patients without true HCMV pneumonia. Several studies have been published with the aim of establishing an optimal VL for differentiating pneumonia from viral lung shedding. The aim of this review is to collect and analyze the methodology and the conclusions obtained in studies whose objectives included the correlation between HCMV VL in BAL and/or the plasma and the occurrence of HCMV pneumonia. For this purpose, a total of 14 articles have been included. There are some conclusions on which they all agree. PCR techniques were more sensitive and had a higher NPV than culture techniques but were less specific and had a low PPV. The mean HCMV loads in both BAL and the plasma were significantly higher in patients with pneumonitis than in those without. The HCMV load in patients with pneumonitis was higher in BAL than in the plasma, making qPCR in BAL a better predictor of HCMV pneumonitis than in the plasma. Nevertheless, this review highlights the difficulty of establishing a universal VL value, both in BAL and in the blood, to differentiate patients with HCMV pneumonia from those without. To complete the information available in these studies, prospective multicentre studies would be required. Methodologically, a large number of patients with HCMV pneumonitis would have to be included, and a subclassification of the type of immunosuppression of each patient should be made in order to obtain an optimal VL threshold in different host groups.
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Ventilator-Associated Pneumonia in Immunosuppressed Patients. Antibiotics (Basel) 2023; 12:antibiotics12020413. [PMID: 36830323 PMCID: PMC9952186 DOI: 10.3390/antibiotics12020413] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 02/15/2023] [Accepted: 02/16/2023] [Indexed: 02/22/2023] Open
Abstract
Immunocompromised patients-including patients with cancer, hematological malignancies, solid organ transplants and individuals receiving immunosuppressive therapies for autoimmune diseases-account for an increasing proportion of critically-ill patients. While their prognosis has improved markedly in the last decades, they remain at increased risk of healthcare- and intensive care unit (ICU)-acquired infections. The most frequent of these are ventilator-associated lower respiratory tract infections (VA-LTRI), which include ventilator-associated pneumonia (VAP) and tracheobronchitis (VAT). Recent studies have shed light on some of the specific features of VAP and VAT in immunocompromised patients, which is the subject of this narrative review. Contrary to previous belief, the incidence of VAP and VAT might actually be lower in immunocompromised than non-immunocompromised patients. Further, the relationship between immunosuppression and the incidence of VAP and VAT related to multidrug-resistant (MDR) bacteria has also been challenged recently. Etiological diagnosis is essential to select the most appropriate treatment, and the role of invasive sampling, specifically bronchoscopy with bronchoalveolar lavage, as well as new molecular syndromic diagnostic tools will be discussed. While bacteria-especially gram negative bacteria-are the most commonly isolated pathogens in VAP and VAT, several opportunistic pathogens are a special concern among immunocompromised patients, and must be included in the diagnostic workup. Finally, the impact of immunosuppression on VAP and VAT outcomes will be examined in view of recent papers using improved statistical methodologies and treatment options-more specifically empirical antibiotic regimens-will be discussed in light of recent findings on the epidemiology of MDR bacteria in this population.
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Sun YQ, Ma R, Huang XJ. Optimizing the treatment of cytomegalovirus infection in allo-HSCT recipients. Expert Rev Clin Immunol 2023; 19:227-235. [PMID: 36541485 DOI: 10.1080/1744666x.2023.2161510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Cytomegalovirus (CMV) infection continues to negatively impact the prognosis after allogeneic hematopoietic stem cell transplantation (allo-HSCT), even with active monitoring and preemptive strategies. Recent progress in pharmacology, immunotherapy, and vaccines has improved the strategy of CMV management. AREAS COVERED We summarized recent advances in managing CMV infection post allo-HSCT, including diagnosis, prophylaxis, and treatment. In this review, we mainly focused on approaches that have optimized or might optimize the management of CMV infection after allo-HSCT. EXPERT OPINION In our opinion, optimized management covers aspects including the serial monitoring of CMV-DNA and CMI, an accurate diagnosis, effective prophylaxis, and a rational preemptive therapy integrating antiviral drugs and cell therapies. Strategies based on the understanding of CMV pathogenesis and CMV-related immune reconstitution after allo-HSCT will be a direction in future studies.
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Affiliation(s)
- Yu-Qian Sun
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Rui Ma
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Xiao-Jun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
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Diagnostic Value of Metagenomic Next-Generation Sequencing for Pneumonia in Immunocompromised Patients. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2022; 2022:5884568. [PMID: 36507192 PMCID: PMC9731749 DOI: 10.1155/2022/5884568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 11/21/2022] [Accepted: 11/23/2022] [Indexed: 12/05/2022]
Abstract
Introduction The diagnosis of pulmonary infection and the identification of pathogens are still clinical challenges in immunocompromised patients. Metagenomic next-generation sequencing (mNGS) has emerged as a promising infection diagnostic technique. However, its diagnostic value in immunocompromised patients needs further exploration. Purposes This study was to evaluate the diagnostic value of mNGS compared with comprehensive conventional pathogen tests (CTs) in the etiology of pneumonia in immunocompromised patients and immunocompetent patients. Methods We retrospectively reviewed 53 patients who were diagnosed with pneumonia from May 2019 to June 2021. There were 32 immunocompromised patients and 21 immunocompetent patients with pneumonia who received both mNGS and CTs. The diagnostic performance was compared between mNGS and CTs in immunocompromised patients, using the composite diagnosis as the reference standard. And, the diagnostic value of mNGS for mixed infections was further analyzed. Results Compared to immunocompetent patients, the most commonly pathogens, followed by Cytomegalovirus, Pneumocystis jirovecii and Klebsiella pneumoniae in immunocompromised patients. Furthermore, more mixed infections were diagnosed, and bacterial-fungal-virus coinfection was the most frequent combination (43.8%). mNGS can detect more types of pathogenic microorganisms than CTs in both groups (78.1% vs. 62.5%, P = 0.016and 57.1% vs. 42.9%, P = 0.048). The overall diagnostic positive rate of mNGS for pathogens was higher in immunocompromised patients (P = 0.002). In immunocompromised patients, a comparable diagnostic accuracy of mNGS and CTs was found for bacterial, fungal, and viral infections and coinfection. mNGS had a much higher sensitivity for bacterial infections (92.9% vs. 50%, P < 0.001) and coinfections (68.8% vs. 48.3%, P < 0.05), and it had no significant advantage in the detection of fungal infections, mainly due to the high sensitivity for Pneumocystis jirovecii in both groups. Conclusion mNGS is more valuable in immunocompromised patients and exhibits apparent advantages in detecting bacterial and mixed infections. It may be an alternative or complementary diagnostic method for the diagnosis of complicated infections in immunocompromised patients.
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Zhang J, Cao J, Zheng R, Yu M, Lin Z, Wang C, McCluskey J, Yang J, Chen Z, Corbett AJ, Cao P, Mo W, Wang Z. The establishment of a cytomegalovirus -specific CD8+ T-cell threshold by kinetic modeling for the prediction of post-hemopoietic stem cell transplant reactivation. iScience 2022; 25:105340. [PMID: 36325063 PMCID: PMC9618782 DOI: 10.1016/j.isci.2022.105340] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 09/08/2022] [Accepted: 10/07/2022] [Indexed: 10/31/2022] Open
Abstract
The dynamic interaction between the CMV virus and host immune response remains obscure, thus hindering the diagnosis and therapeutic management of patients with HSCT. The current diagnosis of CMV viremia depends on viral load estimation. Medical intervention based on viral load, can be unnecessary or poorly timed for many patients. Here we examined the clinical features and blood samples of patients with HSCT and assessed the CMV reactivation kinetics and corresponding CMV antigen-specific T-cell response in individual patients based on a peptide pool stimulation T-cell assay, which showed that CMV-specific CD8+ T cells were more suitable to be a diagnosis indicator for suppressing CMV reactivation. Using ROC analysis, we defined and verified a CMV-specific CD8+ T-cell counts threshold (925 cells/106 PBMCs) as an indicator of CMV reactivation post-HSCT, and suggested that use of this threshold would provide more accurate guidance for prompt medication and better management of CMV infection post-HSCT.
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Shi Y, Peng JM, Qin HY, Du B. Metagenomic next-generation sequencing: A promising tool for diagnosis and treatment of suspected pneumonia in rheumatic patients with acute respiratory failure: Retrospective cohort study. Front Cell Infect Microbiol 2022; 12:941930. [PMID: 35992169 PMCID: PMC9381725 DOI: 10.3389/fcimb.2022.941930] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 07/12/2022] [Indexed: 11/17/2022] Open
Abstract
Background The effectiveness of metagenomic next-generation sequencing (mNGS) in respiratory pathogen detection and clinical decision-making in critically rheumatic patients remains largely unexplored. Methods A single-center retrospective study of 58 rheumatic patients who were admitted to ICU due to suspected pneumonia with acute respiratory failure if they underwent both bronchoalveolar lavage fluid specimen mNGS and combined microbiological tests (CMTs) was conducted to compare their diagnostic performance, using clinical composite diagnosis as the gold standard. Treatment modifications based on mNGS results were also reviewed. Results Forty-three patients were diagnosed with microbiologically confirmed pneumonia and 15 were considered as a non-infectious disease. mNGS outperformed CMTs in the accurate diagnosis of infectious and non-infectious lung infiltration (98.1% [57/58] vs. 87.9% [51/58], P = 0.031). A total of 94 causative pathogens were defined by the gold standard and 27 patients had polymicrobial pneumonia. The sensitivity of pathogen detection and complete concordance with the gold standard by mNGS exceeded those by CMTs (92.6% [87/94] vs. 76.6% [72/94], P < 0.001 and 72.1% [31/43] vs. 51.2% [22/43], P = 0.004, respectively). Moreover, 22 pathogens were detected only by mNGS and confirmed by orthogonal test. Accordingly, the etiological diagnosis changed in 19 cases, and the empirical treatment improved in 14 cases, including 8 cases of rescue treatment and 11 of antibiotics de-escalation. At the pathogen-type level, both methods were comparable for bacteria, but mNGS was advantageous to identify viruses (accuracy: 100% vs. 81%, P = 0.004). For Pneumocystis jirovecii detection, mNGS improved the sensitivity compared with Gomori’s methenamine silver stain (91.7% vs. 4.2%, P < 0.001) and was higher than polymerase chain reaction (79.2%), but the difference was not significant (P = 0.289). In terms of Aspergillus, the better sensitivity with a combination of culture and galactomannan test than that with mNGS was found (100% vs. 66.7%, P = 0.033). Conclusions mNGS has an excellent accuracy in etiological diagnosis and pathogen detection of suspected pneumonia in critically rheumatic patients, which has potential significance for clinical decision-making. Its superiority to different types of pathogens depends on the comprehensiveness of CMTs.
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Nonimaging Diagnostic Tests for Pneumonia. Radiol Clin North Am 2022; 60:521-534. [DOI: 10.1016/j.rcl.2022.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Clinical characteristics and viral load patterns in children with cytomegalovirus gastrointestinal disease after allogeneic hematopoietic stem cell transplantation. Bone Marrow Transplant 2021; 56:2813-2819. [PMID: 34274956 DOI: 10.1038/s41409-021-01394-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 06/15/2021] [Accepted: 06/23/2021] [Indexed: 11/08/2022]
Abstract
Cytomegalovirus (CMV) reactivation in allogeneic hematopoietic stem cell transplantation (allo-HSCT) causes significant morbidity and mortality. This study aimed to investigate the clinical characteristics of children diagnosed with CMV GI disease after allo-HSCT. This was a retrospective cohort study of patients <19 years old that underwent allo-HSCT during an 11-year period. Of the 756 patients, 55.5% (n = 420) experienced post-transplant CMV DNAemia, 2.9% (n = 22) were diagnosed with proven CMV GI diseases, and the highest incidence was found in familial mismatched donors (5.6%, P = 0.029). CMV GI disease was diagnosed <100 days of transplant in 68.2% (n = 15/22), and 13.6% (n = 3/22) did not have concurrent CMV DNAemia. Patients were divided into five groups based on the patterns of CMV viremia initiation and duration post-HSCT. At 3 months post-transplant, lower CD4+ (P = 0.006) and CD8+ (P = 0.011) T-cell counts were observed in patients with waxing and waning CMV viral load titers >100 days post-transplant (groups 1-3) compared to those with CMV DNAemia only prior to 100 days post-transplant and those without concurrent CMV DNAemia (groups 4-5). A higher 1-year all-cause mortality was observed in groups 1-3 compared to groups 4-5 (42.8% vs. 0%; P = 0.051). Active surveillance and aggressive management of CMV reactivation is crucial, especially in children with delayed CD4+ and CD8+ T-cell reconstitution after allo-HSCT.
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Peng JM, Du B, Qin HY, Wang Q, Shi Y. Metagenomic next-generation sequencing for the diagnosis of suspected pneumonia in immunocompromised patients. J Infect 2021; 82:22-27. [PMID: 33609588 DOI: 10.1016/j.jinf.2021.01.029] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 12/18/2020] [Accepted: 01/12/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To evaluate the potential of metagenomic next-generation sequencing (mNGS), compared with that of comprehensive conventional microbiological tests (CMTs), of bronchoalveolar lavage fluid (BALF) as a front-line diagnostic for immunocompromised patients with suspected pneumonia. METHODS Sixty critically ill immunocompromised patients undergoing both mNGS of BALF and CMTs for suspected pneumonia were retrospectively analysed. The diagnostic performance was compared between mNGS and CMTs, using the composite diagnosis as the reference standard. RESULTS Forty-nine patients were diagnosed with microbiologically confirmed pneumonia, with 55% having polymicrobial infections. There was no significant difference in the overall diagnostic accuracy between mNGS and CMTs (61.7% vs 76.7%; P = 0.11). mNGS and CMTs had comparable diagnostic accuracy for bacterial and viral infections. Although mNGS identified more viral pneumonia, it had a much lower diagnostic accuracy for fungal infections (76.7% vs 99.2%; P < 0.001), mainly due to the low sensitivity for invasive pulmonary aspergillosis (45.5% vs 100%; P < 0.001). CONCLUSION The overall diagnostic performance of BALF mNGS as a first-line diagnostic was similar to that of comprehensive CMTs, except in the case of a lack of consideration of potential pathogens or limited CMTs. The combination of mNGS and CMTs may be the best diagnostic strategy.
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Affiliation(s)
- Jin-Min Peng
- Department of Medical Intensive Care Unit, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Bin Du
- Department of Medical Intensive Care Unit, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Han-Yu Qin
- Department of Medical Intensive Care Unit, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Qian Wang
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing 100730, China; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID) , Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing 100730, China
| | - Yan Shi
- Department of Medical Intensive Care Unit, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing 100730, China
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Alacam S, Karabulut N, Bakir A, Onel M, Buyuk M, Gulluoglu M, Agacfidan A. Diagnostic significance of cytomegalovirus DNA quantitation in gastrointestinal biopsies: comparison with histopathological data and blood cytomegalovirus DNA. Eur J Gastroenterol Hepatol 2021; 33:40-45. [PMID: 32658013 DOI: 10.1097/meg.0000000000001840] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES This study aims to improve the diagnosis of gastrointestinal (GI) cytomegalovirus (CMV) disease. It presents the results of a novel study in which CMV blood viral load (BVL), tissue viral load (TVL) determined by PCR and hematoxylin-eosin (HE)/immunohistochemistry (IHC) results of GI biopsies are examined comparatively. METHODS CMV DNA was investigated by quantitative real-time PCR in blood and GI biopsy specimens of 76 patients suspected of CMV disease. Biopsies were also performed HE/IHC stainings in the pathology laboratory. RESULTS This study included 76 patients whose median age was 34.5 years and 58% (44) were male. Tissue CMV PCR positivity was detected in the highest colon (40/53;75.5%) samples. HE, IHC, blood and tissue CMV PCR positivity rates of all samples were 15.8, 25, 50 and 71.1%, respectively. When IHC was used as the gold standard test for ROC analysis, the optimal cutoff values for the maximum sensitivity and specificity for BVL and TVL were 1.91 log10 copies/ml and 3.82 log10 copies/mg, respectively. Sensitivity and specificity for the cutoff value of tissue CMV DNA were 78.9 and 74.3%, respectively (P < 0.001). CONCLUSION In this study, CMV DNA was detected in 71.1% of the tissue samples of the cases by PCR. Since the sensitivity of the histopathological examinations accepted as the gold standard is low, simultaneous with the histopathological examinations, determination of BVL, TVL and the identification of optimal cutoff values have been shown to support the diagnosis of GI CMV disease.
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Affiliation(s)
- Sema Alacam
- Division of Virology and Fundamental Immunology, Department of Medical Microbiology, Istanbul Faculty of Medicine, Istanbul University
| | - Nuran Karabulut
- Division of Virology and Fundamental Immunology, Department of Medical Microbiology, Istanbul Faculty of Medicine, Istanbul University
| | - Ayfer Bakir
- Division of Virology and Fundamental Immunology, Department of Medical Microbiology, Istanbul Faculty of Medicine, Istanbul University
| | - Mustafa Onel
- Division of Virology and Fundamental Immunology, Department of Medical Microbiology, Istanbul Faculty of Medicine, Istanbul University
| | - Melek Buyuk
- Department of Pathology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Mine Gulluoglu
- Department of Pathology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ali Agacfidan
- Division of Virology and Fundamental Immunology, Department of Medical Microbiology, Istanbul Faculty of Medicine, Istanbul University
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Limaye AP, Babu TM, Boeckh M. Progress and Challenges in the Prevention, Diagnosis, and Management of Cytomegalovirus Infection in Transplantation. Clin Microbiol Rev 2020; 34:34/1/e00043-19. [PMID: 33115722 PMCID: PMC7920732 DOI: 10.1128/cmr.00043-19] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Hosts with compromised or naive immune systems, such as individuals living with HIV/AIDS, transplant recipients, and fetuses, are at the highest risk for complications from cytomegalovirus (CMV) infection. Despite substantial progress in prevention, diagnostics, and treatment, CMV continues to negatively impact both solid-organ transplant (SOT) and hematologic cell transplant (HCT) recipients. In this article, we summarize important developments in the field over the past 10 years and highlight new approaches and remaining challenges to the optimal control of CMV infection and disease in transplant settings.
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Affiliation(s)
- Ajit P Limaye
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Tara M Babu
- Division of Infectious Diseases, University of Rochester Medical Center, Rochester, New York, USA
- Department of Infectious Diseases, Overlake Medical Center, Bellevue, Washington, USA
| | - Michael Boeckh
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
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21
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Regulation of the MIE Locus During HCMV Latency and Reactivation. Pathogens 2020; 9:pathogens9110869. [PMID: 33113934 PMCID: PMC7690695 DOI: 10.3390/pathogens9110869] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 10/19/2020] [Accepted: 10/20/2020] [Indexed: 12/20/2022] Open
Abstract
Human cytomegalovirus (HCMV) is a ubiquitous herpesviral pathogen that results in life-long infection. HCMV maintains a latent or quiescent infection in hematopoietic cells, which is broadly defined by transcriptional silencing and the absence of de novo virion production. However, upon cell differentiation coupled with immune dysfunction, the virus can reactivate, which leads to lytic replication in a variety of cell and tissue types. One of the mechanisms controlling the balance between latency and reactivation/lytic replication is the regulation of the major immediate-early (MIE) locus. This enhancer/promoter region is complex, and it is regulated by chromatinization and associated factors, as well as a variety of transcription factors. Herein, we discuss these factors and how they influence the MIE locus, which ultimately impacts the phase of HCMV infection.
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Li S, Shen ZH, Wan LP, Bao AH, Yang J, Tong Y, Wang C. [Clinical study of 34 patients with cytomegalovirus pneumonia after allogeneic hematopoietic stem cell transplantation]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:843-847. [PMID: 33190442 PMCID: PMC7656065 DOI: 10.3760/cma.j.issn.0253-2727.2020.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Indexed: 11/29/2022]
Abstract
Objective: To analyze the clinical features and prognosis of cytomegalovirus pneumonia after allogeneic hematopoietic stem cell transplantation(allo-HSCT). Methods: We reviewed the clinical features and laboratory data of cytomegalovirus pneumonia patients after allogeneic peripheral blood HSCT from March 1, 2016 to June 30, 2019 at the hematology department of the Shanghai general hospital and analyze the prognostic factors. Results: Of the 411 allo-HSCT patients, 34(8.3%)developed CMV pneumonia after transplantation, including 18 men and 16 women, with a median age of 32(8-62)y. Total 14 patients had acute myeloid leukemia, 10 had acute lymphoblastic leukemia, 5 had myelodysplastic syndrome, 3 had non-Hodgkin's lymphoma, and 2 had aplastic anemia. The median onset time for CMV pneumonia was 53(36-506)d after transplantation. The main symptoms were cough(26 cases, 76.5%), fever(23 cases, 67.6%), and shortness of breath(14 cases, 41.2%). Only 17.6%(6/34)patients had expectoration, and 2 cases(5.9%)had no obvious symptoms in the early stage, but were diagnosed on routine chest CT examination. Twenty-eight(82.4%)patients showed signs of typical interstitial pneumonia, such as lobular central nodule and diffuse ground glass opacity; 6(17.6%)patients showed atypical imaging changes of patch, nodule, and consolidation. Further, 26 patients(76.5%)were positive for CMV-DNA, and the copy number was lower than that of BALF[1.70×10(7)(5.44×10(5)-4.45×10(9))copies/L vs 1.45×10(8)(1.10×10(7)-1.10×10(11))copies/L, P=0.004]. Thirteen(38.24%)patients with CMV pneumonia had mixed infection with other lower respiratory tract pathogens(10 strains of fungi, 6 strains of bacteria, and 1 of adenoviruses). The median follow-up duration was 12.8(0.4-46.5)months. The OS rate was 58.82%. Age ≥ 40 y and high flow ventilation were independent risk factors for poor prognosis in CMV pneumonia patients(P=0.049, P=0.009). Conclusion: Bronchoscopic bronchoalveolar lavage fluid detection helps in improving the accuracy of the etiological diagnosis of CMV pneumonia after allo-HSCT. Age ≥ 40 y and high flow ventilation were independent risk factors for poor prognosis in patients with CMV pneumonia.
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Affiliation(s)
- S Li
- Nanjin Medical University, Nanjing 211166, China; Department of Hematology, Shanghai General Hospital, Shanghai 200080, China
| | - Z H Shen
- Department of Hematology, Shanghai General Hospital, Shanghai 200080, China
| | - L P Wan
- Department of Hematology, Shanghai General Hospital, Shanghai 200080, China
| | - A H Bao
- Department of Hematology, Shanghai General Hospital, Shanghai 200080, China
| | - J Yang
- Department of Hematology, Shanghai General Hospital, Shanghai 200080, China
| | - Y Tong
- Department of Hematology, Shanghai General Hospital, Shanghai 200080, China
| | - C Wang
- Department of Hematology, Shanghai General Hospital, Shanghai 200080, China
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Hogea SP, Tudorache E, Pescaru C, Marc M, Oancea C. Bronchoalveolar lavage: role in the evaluation of pulmonary interstitial disease. Expert Rev Respir Med 2020; 14:1117-1130. [PMID: 32847429 DOI: 10.1080/17476348.2020.1806063] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Bronchoalveolar lavage (BAL), a noninvasive, well-tolerated procedure is an important diagnostic tool that can facilitate the diagnosis of various lung diseases. This procedure allows the assessment of large alveolar compartments, by providing cells as well as non-cellular constituents from the lower respiratory tract. Alterations in BAL fluid and cells ratio reflects pathological changes in the lung parenchyma. In some cases, clinicians use BAL as a differential diagnosis guide for interstitial lung disease. AREAS COVERED In this review, we summarized the diagnostic criteria for BAL in interstitial lung diseases, pulmonary infections, lung cancer and other pathologies such as fat embolism, gastroesophageal reflux and collagen vascular disease. For this review, we have selected scientific papers published in the PubMed database in our area of interest. We aimed to highlight the usefulness of BAL in respiratory pathology. EXPERT OPINION Although BAL fluid analyzes has an essential role in the diagnostic work-up of many lung pathologies, it should be performed in selected patients. For accurate results, the BAL technique is very important to be standardized.
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Affiliation(s)
- Stanca-Patricia Hogea
- Department of Pulmonology, University of Medicine and Pharmacy "Victor Babeș" , Timișoara, Romania
| | - Emanuela Tudorache
- Department of Pulmonology, University of Medicine and Pharmacy "Victor Babeș" , Timișoara, Romania
| | - Camelia Pescaru
- Department of Pulmonology, University of Medicine and Pharmacy "Victor Babeș" , Timișoara, Romania
| | - Monica Marc
- Department of Pulmonology, University of Medicine and Pharmacy "Victor Babeș" , Timișoara, Romania
| | - Cristian Oancea
- Department of Pulmonology, University of Medicine and Pharmacy "Victor Babeș" , Timișoara, Romania
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Meng XY, Fu HX, Zhu XL, Wang JZ, Liu X, Yan CH, Zhang YY, Mo XD, Wang Y, Han W, Chen YH, Chen DB, Liu HX, Chang YJ, Xu LP, Liu KY, Huang XJ, Zhang XH. Comparison of different cytomegalovirus diseases following haploidentical hematopoietic stem cell transplantation. Ann Hematol 2020; 99:2659-2670. [PMID: 32734550 DOI: 10.1007/s00277-020-04201-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/24/2020] [Indexed: 12/20/2022]
Abstract
Cytomegalovirus (CMV) can cause end-organ diseases including pneumonia, gastroenteritis, retinitis, and encephalitis in hematopoietic stem cell transplantation recipients. Potential differences among different CMV diseases remain uncertain. This study aimed to compare the clinical characteristics, risk factors, and mortality among different CMV diseases. A retrospective nested case-control study was performed based on a cohort of 3862 patients who underwent haploidentical hematopoietic stem cell transplantation at a single-center. CMV diseases occurred in 113 (2.92%) of 3862 haplo-HSCT recipients, including probable CMV pneumonia (CMVP, n = 34), proven CMV gastroenteritis (CMVG, n = 34), CMV retinitis (CMVR, n = 31), probable CMV encephalitis (CMVE, n = 7), and disseminated CMV disease (Di-CMVD, n = 7). Most (91.2%) cases of CMVG developed within 100 days, while most (90.3%) cases of CMVR were late onset. Refractory CMV infection and CMV viral load at different levels were associated with an increased risk of CMVP, CMVG, and CMVR. Compared with patients without CMV diseases, significantly higher non-relapse mortality at 1 year after transplantation was observed in patients with CMVP and CMVR, rather than CMVG. Patients with CMVP, Di-CMVD, and CMVE had higher overall mortality after diagnosis than that of patients with CMVG and CMVR (61.7%, 57.1%, 40.0% vs 27.7%, 18.6%, P = 0.001). In conclusion, the onset time, viral dynamics, and mortality differ among different CMV diseases. The mortality of CMV diseases remains high, especially for CMVP, Di-CMVD, and CMVE.
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Affiliation(s)
- Xing-Ye Meng
- Peking University Institute of Hematology, Peking University People's Hospital, Xicheng District Xizhimen South Street No. 11, Beijing, 100044, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Hai-Xia Fu
- Peking University Institute of Hematology, Peking University People's Hospital, Xicheng District Xizhimen South Street No. 11, Beijing, 100044, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiao-Lu Zhu
- Peking University Institute of Hematology, Peking University People's Hospital, Xicheng District Xizhimen South Street No. 11, Beijing, 100044, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Jing-Zhi Wang
- Peking University Institute of Hematology, Peking University People's Hospital, Xicheng District Xizhimen South Street No. 11, Beijing, 100044, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiao Liu
- Peking University Institute of Hematology, Peking University People's Hospital, Xicheng District Xizhimen South Street No. 11, Beijing, 100044, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Chen-Hua Yan
- Peking University Institute of Hematology, Peking University People's Hospital, Xicheng District Xizhimen South Street No. 11, Beijing, 100044, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yuan-Yuan Zhang
- Peking University Institute of Hematology, Peking University People's Hospital, Xicheng District Xizhimen South Street No. 11, Beijing, 100044, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiao-Dong Mo
- Peking University Institute of Hematology, Peking University People's Hospital, Xicheng District Xizhimen South Street No. 11, Beijing, 100044, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yu Wang
- Peking University Institute of Hematology, Peking University People's Hospital, Xicheng District Xizhimen South Street No. 11, Beijing, 100044, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Wei Han
- Peking University Institute of Hematology, Peking University People's Hospital, Xicheng District Xizhimen South Street No. 11, Beijing, 100044, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yu-Hong Chen
- Peking University Institute of Hematology, Peking University People's Hospital, Xicheng District Xizhimen South Street No. 11, Beijing, 100044, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Ding-Bao Chen
- Department of Pathology, Peking University People's Hospital, Beijing, China
| | - Hui-Xin Liu
- Department of Clinical Epidemiology and Biostatistics, Peking University People's Hospital, Beijing, China
| | - Ying-Jun Chang
- Peking University Institute of Hematology, Peking University People's Hospital, Xicheng District Xizhimen South Street No. 11, Beijing, 100044, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Lan-Ping Xu
- Peking University Institute of Hematology, Peking University People's Hospital, Xicheng District Xizhimen South Street No. 11, Beijing, 100044, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Kai-Yan Liu
- Peking University Institute of Hematology, Peking University People's Hospital, Xicheng District Xizhimen South Street No. 11, Beijing, 100044, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiao-Jun Huang
- Peking University Institute of Hematology, Peking University People's Hospital, Xicheng District Xizhimen South Street No. 11, Beijing, 100044, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiao-Hui Zhang
- Peking University Institute of Hematology, Peking University People's Hospital, Xicheng District Xizhimen South Street No. 11, Beijing, 100044, China. .,Collaborative Innovation Center of Hematology, Peking University, Beijing, China. .,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China. .,National Clinical Research Center for Hematologic Disease, Beijing, China.
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25
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Azoulay E, Russell L, Van de Louw A, Metaxa V, Bauer P, Povoa P, Montero JG, Loeches IM, Mehta S, Puxty K, Schellongowski P, Rello J, Mokart D, Lemiale V, Mirouse A. Diagnosis of severe respiratory infections in immunocompromised patients. Intensive Care Med 2020; 46:298-314. [PMID: 32034433 PMCID: PMC7080052 DOI: 10.1007/s00134-019-05906-5] [Citation(s) in RCA: 115] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 12/19/2019] [Indexed: 12/23/2022]
Abstract
An increasing number of critically ill patients are immunocompromised. Acute hypoxemic respiratory failure (ARF), chiefly due to pulmonary infection, is the leading reason for ICU admission. Identifying the cause of ARF increases the chances of survival, but may be extremely challenging, as the underlying disease, treatments, and infection combine to create complex clinical pictures. In addition, there may be more than one infectious agent, and the pulmonary manifestations may be related to both infectious and non-infectious insults. Clinically or microbiologically documented bacterial pneumonia accounts for one-third of cases of ARF in immunocompromised patients. Early antibiotic therapy is recommended but decreases the chances of identifying the causative organism(s) to about 50%. Viruses are the second most common cause of severe respiratory infections. Positive tests for a virus in respiratory samples do not necessarily indicate a role for the virus in the current acute illness. Invasive fungal infections (Aspergillus, Mucorales, and Pneumocystis jirovecii) account for about 15% of severe respiratory infections, whereas parasites rarely cause severe acute infections in immunocompromised patients. This review focuses on the diagnosis of severe respiratory infections in immunocompromised patients. Special attention is given to newly validated diagnostic tests designed to be used on non-invasive samples or bronchoalveolar lavage fluid and capable of increasing the likelihood of an early etiological diagnosis.
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Affiliation(s)
- Elie Azoulay
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital and Paris University, Paris, France.
- Université de Paris, Paris, France.
| | - Lene Russell
- Department of Intensive Care, Rigshospitalet and Copenhagen Academy for Medical Simulation and Education, University of Copenhagen, Copenhagen, Denmark
| | - Andry Van de Louw
- Division of Pulmonary and Critical Care, Penn State University College of Medicine, Hershey, PA, USA
| | - Victoria Metaxa
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Philippe Bauer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Pedro Povoa
- Polyvalent Intensive Care Unit, Hospital de São Francisco Xavier, NOVA Medical School, New University of Lisbon, Lisbon, Portugal
| | - José Garnacho Montero
- Intensive Care Clinical Unit, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Ignacio Martin Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, St James Street, Dublin 8, Ireland
| | - Sangeeta Mehta
- Department of Medicine and Interdepartmental Division of Critical Care Medicine, Sinai Health System, University of Toronto, Toronto, ON, Canada
| | - Kathryn Puxty
- Department of Intensive Care, Glasgow Royal Infirmary, Glasgow, UK
| | - Peter Schellongowski
- Department of Medicine I, Intensive Care Unit 13i2, Comprehensive Cancer Center, Center of Excellence in Medical Intensive Care (CEMIC), Medical University of Vienna, Vienna, Austria
| | - Jordi Rello
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto Salud Carlos III, Madrid, Spain
- CRIPS Department, Vall d'Hebron Institut of Research (VHIR), Barcelona, Spain
| | - Djamel Mokart
- Critical Care Department, Institut Paoli Calmettes, Marseille, France
| | - Virginie Lemiale
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital and Paris University, Paris, France
| | - Adrien Mirouse
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital and Paris University, Paris, France
- Université de Paris, Paris, France
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26
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Periselneris J, Brown JS. A clinical approach to respiratory disease in patients with hematological malignancy, with a focus on respiratory infection. Med Mycol 2019; 57:S318-S327. [PMID: 31292655 PMCID: PMC7107627 DOI: 10.1093/mmy/myy138] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 11/15/2018] [Accepted: 11/16/2018] [Indexed: 01/12/2023] Open
Abstract
Respiratory complications, in particular infections, are common in the setting of hematological malignancy and after hematopoetic stem cell transplant. The symptoms can be nonspecific; therefore, it can be difficult to identify and treat the cause. However, an understanding of the specific immune defect, clinical parameters such as speed of onset, and radiological findings, allows the logical diagnostic and treatment plan to be made. Radiological findings can include consolidation, nodules, and diffuse changes such as ground glass and tree-in-bud changes. Common infections that induce these symptoms include bacterial pneumonia, invasive fungal disease, Pneumocystis jirovecii and respiratory viruses. These infections must be differentiated from inflammatory complications that often require immune suppressive treatment. The diagnosis can be refined with the aid of investigations such as bronchoscopy, computed tomography (CT) guided lung biopsy, culture, and serological tests. This article gives a schema to approach patients with respiratory symptoms in this patient group; however, in the common scenario of a rapidly deteriorating patient, treatment often has to begin empirically, with the aim to de-escalate treatment subsequently after targeted investigations.
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Affiliation(s)
| | - J S Brown
- Centre for Inflammation & Tissue Repair, University College London
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27
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Cho SY, Lee DG, Kim HJ. Cytomegalovirus Infections after Hematopoietic Stem Cell Transplantation: Current Status and Future Immunotherapy. Int J Mol Sci 2019; 20:ijms20112666. [PMID: 31151230 PMCID: PMC6600658 DOI: 10.3390/ijms20112666] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 04/19/2019] [Accepted: 05/28/2019] [Indexed: 12/15/2022] Open
Abstract
Cytomegalovirus (CMV) infection after hematopoietic stem cell transplantation (HSCT) is one of the critical infectious complications related to host immune recovery. The spectrum of CMV infection is quite extensive, from asymptomatic CMV reactivation presenting mainly as CMV DNAemia to fatal CMV diseases involving gut, liver, lungs, or brain. In addition to organ involvement, CMV reactivation can exert indirect effects such as immunosuppression or graft failure that may result in the development of concurrent infectious complications. Currently, preemptive therapy, which is based on PCR-based monitoring of CMV from blood, is a mainstay enabling improvement in CMV-related outcomes. During the past decades, new antiviral drugs, clinical trials for prophylaxis in high-risk groups, and vaccines for preventing CMV infection have been introduced. In addition, data for immunologic monitoring and adoptive immunotherapy have also been accumulated. Here, we review the current status and recent updates in this field, with future perspectives including immunotherapy in HSCT recipients.
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Affiliation(s)
- Sung-Yeon Cho
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea.
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea.
- Catholic Hematology Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea.
| | - Dong-Gun Lee
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea.
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea.
- Catholic Hematology Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea.
| | - Hee-Je Kim
- Catholic Hematology Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea.
- Division of Hematology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea.
- Leukemia Research Institute, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea.
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28
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Pulmonary infectious complications after hematopoietic stem cell transplantation: a practical guide to clinicians. Curr Opin Organ Transplant 2019; 23:375-380. [PMID: 29889152 DOI: 10.1097/mot.0000000000000549] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW The current review highlights the most relevant articles on lung infections following hematopoietic stem cell transplantation (HCT) published over the last year. Between 30 and 50% of HCT recipients will develop pulmonary infiltrates. These pulmonary complications may be infectious (caused by virus, bacteria, fungi, or protozoa) or noninfectious (e.g., fluid overload, heart failure, transfusion reactions like transfusion associated lung injury and transfusion-associated circulatory overload, drug reactions, engraftment syndrome, idiopathic pneumonia syndrome, diffuse alveolar hemorrhage, cryptogenic organizing pneumonia, and bronchiolitis obliterans syndrome). RECENT FINDINGS New data on the yield of bronchoscopy and bronchoalveolar lavage (BAL), the prevalence and clinical manifestations of respiratory viruses and the usefulness of molecular techniques for diagnosis have been published. In addition, guidelines or meta-analyses on the management of neutropenic fever, serological diagnosis of fungal infections and diagnosis and management of Pneumocystis and aspergillosis have been published. SUMMARY Respiratory viruses are important pathogens after HCT. PCR in the BAL is becoming the diagnostic modality of choice for a variety of infections. The best approach for the empirical management of pulmonary infiltrates following HCT remains to be defined.
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29
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Cho SY, Lee HJ, Lee DG. Infectious complications after hematopoietic stem cell transplantation: current status and future perspectives in Korea. Korean J Intern Med 2018; 33:256-276. [PMID: 29506345 PMCID: PMC5840605 DOI: 10.3904/kjim.2018.036] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 02/18/2018] [Indexed: 12/28/2022] Open
Abstract
Hematopoietic stem cell transplantation (HSCT) is a treatment for hematologic malignancies, immune deficiencies, or genetic diseases, ect. Recently, the number of HSCTs performed in Korea has increased and the outcomes have improved. However, infectious complications account for most of the morbidity and mortality after HSCT. Post-HSCT infectious complications are usually classified according to the time after HSCT: pre-engraftment, immediate post-engraftment, and late post-engraftment period. In addition, the types and risk factors of infectious complications differ according to the stem cell source, donor type, conditioning intensity, region, prophylaxis strategy, and comorbidities, such as graft-versushost disease and invasive fungal infection. In this review, we summarize infectious complications after HSCT, focusing on the Korean perspectives.
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Affiliation(s)
- Sung-Yeon Cho
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
- The Catholic Blood and Marrow Transplantation Center, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyeon-Jeong Lee
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong-Gun Lee
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
- The Catholic Blood and Marrow Transplantation Center, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Correspondence to Dong-Gun Lee, M.D. Division of Infectious Diseases, Department of Internal Medicine, The Catholic Blood and Marrow Transplantation Centre, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea Tel: +82-2-2258-6003 Fax: +82-2-535-2494 E-mail:
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30
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Beam E, Germer JJ, Lahr B, Yao JD, Limper AH, Binnicker MJ, Razonable RR. Cytomegalovirus (CMV) DNA quantification in bronchoalveolar lavage fluid of immunocompromised patients with CMV pneumonia. Clin Transplant 2017; 32. [DOI: 10.1111/ctr.13149] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2017] [Indexed: 12/18/2022]
Affiliation(s)
- Elena Beam
- Division of Infectious Diseases; Mayo Clinic; Rochester MN USA
| | - Jeffrey J. Germer
- Department of Laboratory Medicine and Pathology; Mayo Clinic; Rochester MN USA
| | - Brian Lahr
- Department of Health Sciences Research; Mayo Clinic; Rochester MN USA
| | - Joseph D.C. Yao
- Department of Laboratory Medicine and Pathology; Mayo Clinic; Rochester MN USA
| | | | | | - Raymund R. Razonable
- Division of Infectious Diseases; Mayo Clinic; Rochester MN USA
- William J. von Liebig Center for Transplantation and Clinical Regeneration; Mayo Clinic; Rochester MN USA
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