Clinical aspects of cytomegalovirus infection in kidney-graft recipients

[Detection of IgM antibodies in primary and secondary infections by cytomegalovirus in patients subjected to renal transplantation]

Foram acompanhados 27 pacientes submetidos a transplante renal para avaliação do comportamento dos anticorpos IgM e IgG CMV-específicos. Dos 27 casos estudados, 17 (63,0%) tinham anticorpos IgG, detectados pela reação de fixação de complemento (RFC), antes de serem submetidos ao transplante, e 10 (37,0%) eram soro negativos. A pesquisa de anticorpos IgM (técnica de imunofluorescência indireta) foi negativa em todas as amostras pré transplante. Num período de acompanhamento que variou de 28 a 425 dias (média de 115 dias) após o transplante, observou-se que 20 dos 27 (74,1%) apresentaram evidências sorológicas de infecçáo pelo CMV, ocorrendo a maioria dos casos (14/20, 70%) em pacientes que já tinham anticorpos para o CMV antes do transplante. A pesquisa de anticorpos IgM CMV-específicos foi positiva em 12 dos 14 pacientes com evidências sorológicas de reinfecção ou reativação da infecção pelo CMV, e em 100% (6/6) dos pacientes com infecção primária. Dentre os 10 pacientes acompanhados por mais de 4 meses, somente 1 (10%) negativou o IgM neste período.

Studies of cytomegalovirus infection in renal allograft recipients

A prospective study of cytomegalovirus (CMV) infections has been carried out in 28 renal graft recipients. The protocol called for frequent blood and urine sampling during the first year after transplantation, but death or graft loss caused earlier termination in nearly half the patients. In this material 5/7 (71%) susceptible patients developed primary infections and 20/21 experienced a secondary infection (95%). Viruria was detected in 79% and viremia in 43%. The type of blood cell responsible for the viremic phase was studied by separating the blood cells on a density gradient. The polymorphonuclear cell fraction was the most common source of virus but virus could also be recovered from the mononuclear cell fraction. As some samples that were freeze-thawed repeatedly never yielded virus, it would appear that viable cells are needed for virus isolation. In both primary and secondary infections isolation of CMV from blood cells often preceded the isolation of CMV from urine. Among variables tested for a possible relationship to the occurrence of CMV viremia the only one to display such an association was the time at which rejection episodes occurred. In 19/28 such episodes recorded in 19 patients there was a temporal relationship to viremia (p less than 0.03). Seven of the patients experienced clinical symptoms suggestive of CMV infection as fever, cough, myalgia, arthralgia, chest pain and pneumonia. Laboratory signs included elevated amino acid transferase levels, leukopenia and thrombocytopenia and a specific anti-CMV antibody response.

Pneumocystis carinii pneumonia and mucosal candidiasis in previously healthy homosexual men: evidence of a new acquired cellular immunodeficiency

Four previously healthy homosexual men contracted Pneumocystis carinii pneumonia, extensive mucosal candidiasis, and multiple viral infections. In three of the patients these infections followed prolonged fevers of unknown origin. In all four cytomegalovirus was recovered from secretions. Kaposi's sarcoma developed in one patient eight months after he presented with esophageal candidiasis. All patients were anergic and lymphopenic; they had no lymphocyte proliferative responses to soluble antigens, and their responses to phytohemagglutinin were markedly reduced. Monoclonal-antibody analysis of peripheral-blood T-cell subpopulations revealed virtual elimination of the Leu-3 / helper/inducer subset, an increased percentage of the Leu-2 + suppressor/cytoxic subset, and an increased percentage of cells bearing the thymocyte-associated antigen T10. The inversion of the T/ helper to suppressor/cytotoxic ratio suggested that cytomegalovirus infection was an important factor in the pathogenesis of the immunodeficient state. A high level of exposure of male homosexuals to cytomegalovirus-infected secretions may account for the occurrence of this immune deficiency.

Gastric cytomegalovirus infection in bone marrow transplant patients: an indication of generalized disease

Cytomegalovirus infection in immunosuppressed patients is well known. It usually appears as an interstitial pneumonitis that may progress to a disseminated viral infection. The authors report on two patients who, after bone marrow transplantation, had signs and symptoms of gastric ulceration as the initial manifestation of cytomegalovirus infection. Both died with disseminated cytomegalovirus infection. Though gastric presentation is unusual for cytomegalovirus infection, epigastric pain and gastrointestinal hemorrhage in a bone marrow transplant patient may herald a potentially lethal viral infection.

Herpesviruses

Images

Cytomegalovirus retinitis in adults. A manifestation of disseminated viral infection

Retinitis caused by cytomegalovirus (CMV) infection is unusual in adults. Sixteen of the 17 cases reported have occurred in immunologically compromised patients, most frequently renal transplant recipients. CMV retinitis is associated with a distinctive ophthalmoscopic appearance and, in the majority of cases, was the first clinical manifestation of systemic viral infection. Severe and permanent visual deficits are characteristic. Since retinitis is a reliable sign of disseminated disease and ophthalmoscopic examination a rapid method of establishing its presence, recognition of this manifestation should allow earlier diagnosis of serious CMV infection.

Cytomegalovirus infection in the neonate and its prevention

About 0.5% of infants are infected in utero with cytomegalovirus (CMV). As many as 20% become mentally retarded and a further substantial proportion suffer lesser degrees of brain damage. The need for a vaccine is greater than in the case of rubella. A live, tissue culture-adapted strain of CMV has been shown to produce neutralizing antibody in volunteers without significant side effects or detectable virus excretion. The problems of developing such a vaccine for use in man, namely, attenuation, antigenic differences among virus strains, reactivation of latent infection and oncogenicity, are briefly discussed.

Transmission of cytomegalovirus infection with renal allograft

Fifty-four patients who received a renal allograft between October 1971 and October 1974 were followed prospectively to correlate pretransplant serum antibody to cytomegalovirus (CMV) with shedding of CMV following transplantation. Twenty-five of 54 patients had antibody demonstrable to CMV using immunofluorescent techniques, but only 20 of 54 using complement-fixing techniques. All 24 who had antibody and survived one month or longer, and seven of nine without antibody but who received a kidney from a seropositive donor shed virus after transplantation, whereas none of 12 individuals without antibody and who received a kidney from a seronegative donor (P less than 0.005) shed virus. Three of eight other seronegative patients for whom donor sera were not available for analysis shed virus. Viremia occurred in eight of ten individuals who developed new antibody after transplantation, versus seven of 24 with antibody prior to transplant (P less than 0.02), and virus shedding in seroconverters from other sites was significantly more persistent than in pretransplant antibody-positive patients. Thus, CMV infection was due either to reactivation of latent infection or was transmitted along with the renal allograft and manifested as a primary infection.