Herpesvirus and enteric viral infections in bone marrow transplantation: clinical presentations, pathogenesis, and therapeutic strategies

Cutaneous lumbosacral Herpes simplex virus among patients hospitalized for an advanced disease

BACKGROUND

Cutaneous Herpes simplex virus (HSV) infections are regularly observed in lumbosacral areas, and many are refractory to appropriate initial diagnosis and management.

OBJECTIVE

We aimed to evaluate the incidence of lumbosacral HSV among advanced disease patients, to estimate their survival index from HSV onset, and to describe their clinical and virological characteristics.

METHODS

A prospective, descriptive study was conducted in a palliative and continuous care centre, collecting patients with suspected cutaneous HSV lesions in the lumbosacral area.

RESULTS

From 2008 to 2010, 24 patients were included: 19 had HSV-2 confirmed by at least one laboratory test. Incidence of HSV-2 was 2.67% (1.73-4.33%, 95% CI). No age, gender or survival differences were observed compared to the global population in the centre. Most lesions were detected early as vesicles (14/24) or small ulcers. Sensitivity was good for all diagnostic methods (62.5% for immunofluorescence and 79.2% for culture and/or PCR). Outcome was favourable under classical antiherpetic drugs and topical antiseptic dressing.

CONCLUSIONS

Cutaneous lumbosacral HSV remains uncommon in patients hospitalized with advanced diseases. Most of these patients suffer from pressure ulcers or other dermatitis; we advocate increased attention of this diagnosis to avoid skin complications and added pain.

Use of an inactivated varicella vaccine in recipients of hematopoietic-cell transplants

BACKGROUND

The reactivation of varicella-zoster virus from latency causes zoster and is common among recipients of hematopoietic-cell transplants.

METHODS

We randomly assigned patients who were scheduled to undergo autologous hematopoietic-cell transplantation for non-Hodgkin's or Hodgkin's lymphoma to receive varicella vaccine or no vaccine. Heat-inactivated, live attenuated varicella vaccine was given within 30 days before transplantation and 30, 60, and 90 days after transplantation. The patients were monitored for zoster and for immunity against varicella-zoster virus for 12 months.

RESULTS

Of the 119 patients enrolled, 111 received a transplant. Zoster developed in 7 of 53 vaccinated patients (13 percent) and in 19 of 58 unvaccinated patients (33 percent) (P=0.01). After two patients in whom zoster developed before transplantation were excluded, the respective rates were 13 percent and 30 percent (P=0.02). In vitro CD4 T-cell proliferation in response to varicella-zoster virus (expressed as the mean stimulation index) was greater in patients who received the vaccine than in those who did not at 90 days, after three doses (P=0.04); at 120 days, after all four doses (P<0.001); at 6 months (P=0.004); and at 12 months (P=0.02). The risk of zoster was reduced for each unit increase in the stimulation index above 1.6; a stimulation index above 5.0 correlated with greater than 93 percent protection. Induration, erythema, or local pain at the injection site was observed in association with 10 percent of the doses.

CONCLUSIONS

Inactivated varicella vaccine given before hematopoietic-cell transplantation and during the first 90 days thereafter reduces the risk of zoster. The protection correlates with reconstitution of CD4 T-cell immunity against varicella-zoster virus.

Erythropoietin in stem cell transplantation

Anemia is universal after allogeneic and autologous stem cell transplantation, with both increased red cell utilization and decreased production playing a role. This anemia sometimes is associated with a relative erythropoietin deficiency. In allogeneic stem cell transplantation, randomized trials have demonstrated improved erythropoiesis and a decrease in red cell transfusions in recombinant human erythropoietin (rHuEPO)-treated patients. Studies of rHuEPO in patients undergoing autologous stem cell transplants, however, have not shown a benefit. The role of rHuEPO in stem cell mobilization and treatment of delayed erythropoiesis has yet to be defined and further studies are needed.

Infection control and bone marrow transplantation

BACKGROUND

Bone marrow transplantation for the treatment of malignancies is on the increase. Unfortunately, there are no well-validated infection control guidelines for this highly susceptible population.

METHODS

Literature was reviewed concerning infection risks and interventions to decrease risks for bone marrow transplant recipients.

RESULTS

Definitive information was generally lacking. However, basic "common sense" infection control recommendations for bone marrow transplantation were made in the following areas: air ventilation systems, design issues, environmental services, patient care issues, barrier precautions, nosocomial surveillance, and discharge planning. Recommendations must be tailored to each facility or setting.

CONCLUSION

We conclude that validation of many of these recommendations is necessary to provide optimum care for bone marrow transplant recipients.