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Venturini C, Colston JM, Charles O, Lankina A, Best T, Atkinson C, Forrest C, Williams CA, Rao K, Worth A, Thorburn D, Harber M, Griffiths P, Breuer J. Persistent Low-Level Variants in a Subset of Viral Genes Are Highly Predictive of Poor Outcome in Immunocompromised Patients With Cytomegalovirus Infection. J Infect Dis 2024; 230:e427-e436. [PMID: 38181168 PMCID: PMC11326829 DOI: 10.1093/infdis/jiae001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 12/15/2023] [Accepted: 01/02/2024] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND Human cytomegalovirus (HCMV) is the most common and serious opportunistic infection after solid organ and hematopoietic stem cell transplantation. In this study, we used whole-genome HCMV data to investigate viral factors associated with the clinical outcome. METHODS We sequenced HCMV samples from 16 immunocompromised pediatric patients with persistent viremia. Eight of the 16 patients died of complications due to HCMV infection. We also sequenced samples from 35 infected solid organ adult recipients, of whom 1 died with HCMV infection. RESULTS We showed that samples from both groups have fixed variants at resistance sites and mixed infections. Next-generation sequencing also revealed nonfixed variants at resistance sites in most of the patients who died (6/9). A machine learning approach identified 10 genes with nonfixed variants in these patients. These genes formed a viral signature that discriminated patients with HCMV infection who died from those who survived with high accuracy (area under the curve = 0.96). Lymphocyte numbers for a subset of patients showed no recovery posttransplant in the patients who died. CONCLUSIONS We hypothesize that the viral signature identified in this study may be a useful biomarker for poor response to antiviral drug treatment and indirectly for poor T-cell function, potentially identifying early those patients requiring nonpharmacological interventions.
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Affiliation(s)
- Cristina Venturini
- Infection, Immunity and Inflammation, Institute of Child Health, University College London (UCL)
| | - Julia M Colston
- North Bristol National Health Service (NHS) Trust, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol
| | - Oscar Charles
- Infection, Immunity and Inflammation, Institute of Child Health, University College London (UCL)
| | - Anastasia Lankina
- Infection, Immunity and Inflammation, Institute of Child Health, University College London (UCL)
| | - Timothy Best
- Virology Department, Great Ormond Street Hospital for Children NHS Foundation Trust
| | - Claire Atkinson
- Applied Science, London South Bank University
- Division of Infection and Immunity, Institute for Immunity and Transplantation, UCL
| | - Calum Forrest
- Division of Infection and Immunity, Institute for Immunity and Transplantation, UCL
| | - Charlotte A Williams
- Department of Genetics and Genomic Medicine, Great Ormond Street Institute of Child Health, UCL
| | | | - Austen Worth
- Department of Immunology, Great Ormond Street Hospital for Children NHS Foundation Trust, London
| | - Doug Thorburn
- Department of Nephrology, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Mark Harber
- Department of Nephrology, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Paul Griffiths
- Division of Infection and Immunity, Institute for Immunity and Transplantation, UCL
| | - Judith Breuer
- Infection, Immunity and Inflammation, Institute of Child Health, University College London (UCL)
- Virology Department, Great Ormond Street Hospital for Children NHS Foundation Trust
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2
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Piret J, Boivin G. Management of Cytomegalovirus Infections in the Era of the Novel Antiviral Players, Letermovir and Maribavir. Infect Dis Rep 2024; 16:65-82. [PMID: 38247977 PMCID: PMC10801527 DOI: 10.3390/idr16010005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/08/2024] [Accepted: 01/12/2024] [Indexed: 01/23/2024] Open
Abstract
Cytomegalovirus (CMV) infections may increase morbidity and mortality in immunocompromised patients. Until recently, standard antiviral drugs against CMV were limited to viral DNA polymerase inhibitors (val)ganciclovir, foscarnet and cidofovir with a risk for cross-resistance. These drugs may also cause serious side effects. This narrative review provides an update on new antiviral agents that were approved for the prevention and treatment of CMV infections in transplant recipients. Letermovir was approved in 2017 for CMV prophylaxis in CMV-seropositive adults who received an allogeneic hematopoietic stem cell transplant. Maribavir followed four years later, with an indication in the treatment of adult and pediatric transplant patients with refractory/resistant CMV disease. The target of letermovir is the CMV terminase complex (constituted of pUL56, pUL89 and pUL51 subunits). Letermovir prevents the cleavage of viral DNA and its packaging into capsids. Maribavir is a pUL97 kinase inhibitor, which interferes with the assembly of capsids and the egress of virions from the nucleus. Both drugs have activity against most CMV strains resistant to standard drugs and exhibit favorable safety profiles. However, high-level resistance mutations may arise more rapidly in the UL56 gene under letermovir than low-grade resistance mutations. Some mutations emerging in the UL97 gene under maribavir can be cross-resistant with ganciclovir. Thus, letermovir and maribavir now extend the drug arsenal available for the management of CMV infections and their respective niches are currently defined.
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Affiliation(s)
| | - Guy Boivin
- Centre de Recherche en Infectiologie, CHU de Québec-Université Laval, Quebec City, QC G1V 4G2, Canada;
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3
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Szmit Z, Frączkiewicz J, Salamonowicz-Bodzioch M, Król A, Ussowicz M, Mielcarek-Siedziuk M, Liszka K, Marschollek P, Gorczyńska E, Kałwak K. The Impact of High CMV Viral Load and Refractory CMV Infection on Pediatric HSCT Recipients with Underlying Non-Malignant Disorder. J Clin Med 2022; 11:jcm11175187. [PMID: 36079123 PMCID: PMC9456677 DOI: 10.3390/jcm11175187] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 08/25/2022] [Accepted: 08/29/2022] [Indexed: 11/16/2022] Open
Abstract
Hematopoietic stem cell transplantation (HSCT) is a curative therapy for an increasing number of nonmalignant indications. Its use is restricted by severe transplant-related complications, including CMV infection; despite various prophylactic and therapeutic strategies, CMV reactivation has remarkable morbidity and mortality. The analysis included 94 children with nonmalignant disorder who underwent allogeneic HSCT in the Department of Pediatric Hematology, Oncology, and Bone Marrow Transplantation in Wrocław during years 2016–2020. Twenty-seven (29%) children presented with CMV infection, including ten (10/27; 37%) with high level CMV viremia (10,000 copies/mL). Six patients experienced subsequent CMV reactivation. The first-line ganciclovir-based (GCV) treatment was insufficient in 40% (11/27) of children. Overall survival (OS) was significantly lower in children with high CMV viremia compared to those with low levels/no CMV [1yrOS High CMV = 0.80 (95% CI 0.41–0.95) vs. 1yrOS others = 0.96 (95% CI 0.89–0.99)]. Similarly, patients with resistant and recurrent infections had greater risk of death. CMV reactivation at any level relevantly prolonged the hospital stay. CMV reactivation with high viremia load and resistant/recurrent CMV infections lead to a significant decrease in OS in children with nonmalignant disorders treated with HSCT. Our data proves there is an urgent need to introduce an effective anti-CMV prophylaxis in this cohort of patients.
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4
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Jinnouchi F, Mori Y, Yoshimoto G, Yamauchi T, Nunomura T, Yurino A, Hayashi M, Yuda J, Shima T, Odawara J, Takashima S, Kamezaki K, Kato K, Miyamoto T, Akashi K, Takenaka K. Incidence of refractory cytomegalovirus infection after allogeneic hematopoietic stem cell transplantation. Int J Hematol 2021; 115:96-106. [PMID: 34652633 DOI: 10.1007/s12185-021-03218-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 09/06/2021] [Accepted: 09/06/2021] [Indexed: 10/20/2022]
Abstract
Post-transplant cytomegalovirus (CMV) disease can be almost completely avoided by current infection control procedures. However, CMV reactivation occurs in more than half of patients, and some patients can develop clinically resistant CMV infections. Whether resistance is due to the host's immune status or a viral resistance mutation is challenging to confirm. Therefore, a prospective observational analysis of refractory CMV infection was conducted in 199 consecutive patients who received allogeneic hematopoietic stem cell transplantation at a single institution. Among them, 143 (72%) patients received anti-CMV drugs due to CMV reactivation, and only 17 (8.5%) exhibited refractory CMV infection. These patients had clinically refractory infection. However, viral genome analysis revealed that only one patient exhibited a mutation associated with the anti-CMV drug resistance. Clinical resistance was mainly correlated with host immune factors, and the incidence of resistance caused by gene mutations was low at the early stage after a transplantation.
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Affiliation(s)
- Fumiaki Jinnouchi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Yasuo Mori
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Goichi Yoshimoto
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Takuji Yamauchi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Takuya Nunomura
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Ayano Yurino
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Masayasu Hayashi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Junichiro Yuda
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Takahiro Shima
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Jun Odawara
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Shuichiro Takashima
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Kenjiro Kamezaki
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Koji Kato
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Toshihiro Miyamoto
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Koichi Akashi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Katsuto Takenaka
- Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Toon, Ehime, 791-0295, Japan.
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5
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Global estimate of phenotypic and genotypic ganciclovir resistance in cytomegalovirus infections among HIV and organ transplant patients; A systematic review and meta-analysis. Microb Pathog 2020; 141:104012. [PMID: 32004622 DOI: 10.1016/j.micpath.2020.104012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 01/25/2020] [Accepted: 01/27/2020] [Indexed: 11/21/2022]
Abstract
Human cytomegalovirus (CMV), an opportunistic pathogen belonging to Herpesviridae family, is considered as one of the major causes of morbidity and mortality among wide variety of patients, particularly in transplant recipients and HIV positive patients. As this virus can be resistant to treatment, frequency of CMV in patients who receive organ transplantation and people suffering from AIDS was studied between 1980 and 2019. Medline (via PubMed), Embase, Web of Science, and the Iranian Database were reviewed, and Comprehensive Meta-Analysis (V2.0, Biostat) software analyzed all data. Finally, we used Cochran's Q-statistic to encounter heterogeneity between different studies. Meta-analyses indicated, GCV resistance was 14.1% (95% CI 11.2-17.7); however, in patients suffering from AIDS and organ transplantation were 19.5% (95% CI 14.7-25.4) and 11.4% (95% CI 8.1-15.8), respectively. There were increasing rates in the prevalence of GCV resistance in CMV among transplant recipients, and HIV positive patients. Therefore, evaluation of these refractory infections is beneficial.
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6
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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: 78] [Impact Index Per Article: 15.6] [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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7
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Zöllner SK, Herbrüggen H, Kolve H, Mihailovic N, Schubert F, Reicherts C, Rössig C, Groll AH. Cytomegalovirus retinitis in children and adolescents with acute leukemia following allogeneic hematopoietic stem cell transplantation. Transpl Infect Dis 2019; 21:e13089. [PMID: 30972869 DOI: 10.1111/tid.13089] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/19/2019] [Accepted: 03/23/2019] [Indexed: 11/28/2022]
Abstract
Cytomegalovirus retinitis (CMVR) may occur after allogeneic hematopoietic stem cell transplantation (HSCT). However, little is known about its incidence, strategies for ophthalmic surveillance, and timely implementation of adequate antiviral treatment in pediatric allogeneic HSCT recipients. We provide a retrospective analysis of the epidemiology and clinical features of CMVR in pediatric allogeneic HSCT patients transplanted at our center over a 16-year period. Two patients of this cohort with leukemia are presented. Our analysis is supplemented by a systematic review on pediatric patients with leukemia and CMVR in the setting of allogeneic HSCT. The overall incidence of CMVR in our cohort was 1% (4/338) and 14.2% (3/21) in leukemic patients. In published cases, CMVR occurred at a median of 143 days after transplantation, and, in the majority of patients, was preceded by CMV detection in blood by a median of 93 days. Continued immune suppression following engraftment likely triggers CMVR. Preemptive treatment with ganciclovir as standard is usually successful. Foscarnet is used in case of resistance to ganciclovir or drug-induced granulocytopenia. Overall, CMVR after HSCT in pediatric leukemic patients is rare, but a potentially higher vulnerability of this population for involvement of the eye warrants a standardized ophthalmological examination plan.
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Affiliation(s)
- Stefan K Zöllner
- Department of Pediatric Hematology and Oncology, University Children's Hospital Muenster, Muenster, Germany
| | - Heidrun Herbrüggen
- Department of Pediatric Hematology and Oncology, University Children's Hospital Muenster, Muenster, Germany
| | - Hedwig Kolve
- Department of Pediatric Hematology and Oncology, University Children's Hospital Muenster, Muenster, Germany.,Pharmacy Department, University Hospital Muenster, Muenster, Germany
| | - Natasa Mihailovic
- Department of Ophthalmology, University Hospital Muenster, Muenster, Germany
| | - Friederike Schubert
- Department of Ophthalmology, University Hospital Muenster, Muenster, Germany
| | | | - Claudia Rössig
- Department of Pediatric Hematology and Oncology, University Children's Hospital Muenster, Muenster, Germany
| | - Andreas H Groll
- Department of Pediatric Hematology and Oncology, University Children's Hospital Muenster, Muenster, Germany
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8
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Refractory cytomegalovirus DNAemia after allogeneic hematopoietic stem cell transplantation: when should genotypic drug resistance testing be requested? Bone Marrow Transplant 2018; 53:787-790. [PMID: 29700479 DOI: 10.1038/s41409-018-0191-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 03/22/2018] [Accepted: 03/29/2018] [Indexed: 11/08/2022]
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9
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Alsuliman T, Kitel C, Dulery R, Guillaume T, Larosa F, Cornillon J, Labussière-Wallet H, Médiavilla C, Belaiche S, Delage J, Alain S, Yakoub-Agha I. Cytotect®CP as salvage therapy in patients with CMV infection following allogeneic hematopoietic cell transplantation: a multicenter retrospective study. Bone Marrow Transplant 2018; 53:1328-1335. [PMID: 29654288 DOI: 10.1038/s41409-018-0166-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 02/21/2018] [Accepted: 03/04/2018] [Indexed: 11/09/2022]
Abstract
Cytomegalovirus is one of the main contributing factors to high mortality rates in patients undergoing allogeneic hematopoietic cell transplantation (allo-HCT). The main factors of treatment failure are both drug resistance and intolerance. In some cases, Cytotect®CP CMV-hyperimmune globulin is used as salvage therapy. This study aims to investigate the safety and efficacy of Cytotect®CP as a salvage therapy in patients with CMV infection after allo-HCT. Twenty-three consecutive patients received Cytotect®CP for CMV infection after prior CMV therapy. At the time of Cytotect®CP introduction, 17 patients (74%) had developed acute GVHD and 15 patients (64%) were receiving steroid treatment; Cytotect®CP was used as monotherapy (n = 7) and in combination (n = 16). Overall, response was observed in 18 patients (78%) with a median time of 15 days (range: 3-51). Of the 18 responders, 4 experienced CMV reactivation, while 5 responders died within 100 days of beginning treatment. Of these 5 deaths, 4 were due to causes unrelated to CMV. Estimated 100-day OS from the introduction of Cytotect®CP was 69.6%. No statistically significant difference was observed in 100-day OS between responders and non-responders (73.7% vs 50.0%, p = 0.258). Cytotect®CP as salvage therapy is effective and well-tolerated. Given its safety profile, early treatment use should be considered.
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Affiliation(s)
- Tamim Alsuliman
- Maladies du sang, CHRU de Lille, 59037, Lille, France.,Service d'Hématologie, CH de Boulogne, 62321, Boulogne sur mer, France
| | | | - Rémy Dulery
- Service d'Hématologie, Hôpital Saint-Antoine, AP-HP, Université Pierre et Marie Curie (UPMC), 75012, Paris, France
| | - Thierry Guillaume
- Service d'Hématologie, CHU de Nantes, 44093, Nantes, Cedex 1, France
| | - Fabrice Larosa
- Service d'Hématologie, CHU de Besançon, 25030, Besançon, France
| | - Jérôme Cornillon
- Service d'Hématologie, IC Loire, 42270, Saint-Priest-en-Jarez, France
| | | | | | | | - Jeremy Delage
- Service d'Hématologie, CHU de Montpellier, 34295, Montpellier, cedex 5, France
| | - Sophie Alain
- National Reference Center for Herpes viruses, Inserm U1092, Université de Limoges, Laboratoire de Bactériologie-Virologie-Hygiène, CHU de Limoges, Limoges, France
| | - Ibrahim Yakoub-Agha
- Maladies du sang, CHRU de Lille, 59037, Lille, France. .,CHU de Lille, LIRIC, INSERM U995, université de Lille2, 59000, Lille, France.
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10
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Chan ST, Logan AC. The clinical impact of cytomegalovirus infection following allogeneic hematopoietic cell transplantation: Why the quest for meaningful prophylaxis still matters. Blood Rev 2017; 31:173-183. [DOI: 10.1016/j.blre.2017.01.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 12/16/2016] [Accepted: 01/31/2017] [Indexed: 11/28/2022]
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11
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Singh MP, Galhotra S, Saigal K, Kumar A, Ratho RK. Quantitative nucleic acid amplification methods and their implications in clinical virology. Int J Appl Basic Med Res 2017; 7:3-9. [PMID: 28251100 PMCID: PMC5327603 DOI: 10.4103/2229-516x.198498] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Recently, a number of techniques have been approved for quantification of viral nucleic acids in clinical samples. Viral load (VL) tests have considerable importance in the management of patients and are widely used in routine diagnosis. In clinical virology, VL testing are important to monitor the antiviral treatment, to initiate preemptive therapy, to understand pathogenesis, and to evaluate the infectivity. These tests have now become a part of many diagnostic and treatment guidelines. Considering the various challenges for in-house viral testing related to the standardization, validation, and precision; they are gradually being replaced by the United States Food and Drug Administration (US FDA) cleared tests. This review summarizes the various viral quantification methods and also discusses the clinical applicability of these in human immunodeficiency virus, Hepatitis B virus, Hepatitis C virus, Cytomegalovirus, and Epstein Barr virus infected patients. Further the challenges and future perspectives of VL testing have also been discussed.
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Affiliation(s)
- Mini P Singh
- Department of Virology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shipra Galhotra
- Department of Virology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Karnika Saigal
- Department of Virology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Archit Kumar
- Department of Virology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Radha Kanta Ratho
- Department of Virology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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12
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How I treat resistant cytomegalovirus infection in hematopoietic cell transplantation recipients. Blood 2016; 128:2624-2636. [PMID: 27760756 DOI: 10.1182/blood-2016-06-688432] [Citation(s) in RCA: 124] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 10/17/2016] [Indexed: 12/20/2022] Open
Abstract
Cytomegalovirus (CMV) infection is a significant complication in hematopoietic cell transplantation (HCT) recipients. Four antiviral drugs are used for preventing or treating CMV: ganciclovir, valganciclovir, foscarnet, and cidofovir. With prolonged and repeated use of these drugs, CMV can become resistant to standard therapy, resulting in increased morbidity and mortality, especially in HCT recipients. Antiviral drug resistance should be suspected when CMV viremia (DNAemia or antigenemia) fails to improve or continue to increase after 2 weeks of appropriately dosed and delivered antiviral therapy. CMV resistance is diagnosed by detecting specific genetic mutations. UL97 mutations confer resistance to ganciclovir and valganciclovir, and a UL54 mutation confers multidrug resistance. Risk factors for resistance include prolonged or previous anti-CMV drug exposure or inadequate dosing, absorption, or bioavailability. Host risk factors include type of HCT and degree of immunosuppression. Depending on the genotyping results, multiple strategies can be adopted to treat resistant CMV infections, albeit no randomized clinical trials exist so far, after reducing immunosuppression (if possible): ganciclovir dose escalation, ganciclovir and foscarnet combination, and adjunct therapy such as CMV-specific cytotoxic T-lymphocyte infusions. Novel therapies such as maribavir, brincidofovir, and letermovir should be further studied for treatment of resistant CMV.
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13
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Locatelli F, Bertaina A, Bertaina V, Merli P. Cytomegalovirus in hematopoietic stem cell transplant recipients - management of infection. Expert Rev Hematol 2016; 9:1093-1105. [PMID: 27690683 DOI: 10.1080/17474086.2016.1242406] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Cytomegalovirus (CMV) still causes significant morbidity and mortality in patients given allogeneic hematopoietic stem cell transplantation (HSCT). Despite effective pharmacotherapy, potentially life-threatening CMV disease occurs nowadays in up to 10% of HSCT recipients; moreover, routinely used anti-CMV agents have been shown to be associated with morbidity. Areas covered: This review examines different issues related to diagnosis and management of CMV infection in HSCT recipients, paying particular attention to the monitoring of CMV-specific immune recovery, approaches of adoptive cell therapy and new antiviral drugs. Expert commentary: Despite advances in diagnostic tests and treatment, there is still room for refining management of CMV in HSCT recipients. Immunological monitoring should be associated in the future to virological monitoring. The safety profile and efficacy of new anti-CMV agents should be compared with that of standard-of-care drugs. Donor-derived, pathogen-specific T cells adoptively transferred after transplantation could contribute to reduce the impact of CMV infection on patient's outcome.
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Affiliation(s)
- Franco Locatelli
- a Dipartimento di Oncoematologia Pediatrica , IRCSS Ospedale Pediatrico Bambino Gesù , Rome , Italy.,b Dipartimento di Scienze Pediatriche , Università di Pavia , Pavia , Italy
| | - Alice Bertaina
- a Dipartimento di Oncoematologia Pediatrica , IRCSS Ospedale Pediatrico Bambino Gesù , Rome , Italy
| | - Valentina Bertaina
- a Dipartimento di Oncoematologia Pediatrica , IRCSS Ospedale Pediatrico Bambino Gesù , Rome , Italy
| | - Pietro Merli
- a Dipartimento di Oncoematologia Pediatrica , IRCSS Ospedale Pediatrico Bambino Gesù , Rome , Italy
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14
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Houldcroft CJ, Bryant JM, Depledge DP, Margetts BK, Simmonds J, Nicolaou S, Tutill HJ, Williams R, Worth AJJ, Marks SD, Veys P, Whittaker E, Breuer J. Detection of Low Frequency Multi-Drug Resistance and Novel Putative Maribavir Resistance in Immunocompromised Pediatric Patients with Cytomegalovirus. Front Microbiol 2016; 7:1317. [PMID: 27667983 PMCID: PMC5016526 DOI: 10.3389/fmicb.2016.01317] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 08/09/2016] [Indexed: 11/13/2022] Open
Abstract
Human cytomegalovirus (HCMV) is a significant pathogen in immunocompromised individuals, with the potential to cause fatal pneumonitis and colitis, as well as increasing the risk of organ rejection in transplant patients. With the advent of new anti-HCMV drugs there is therefore considerable interest in using virus sequence data to monitor emerging resistance to antiviral drugs in HCMV viraemia and disease, including the identification of putative new mutations. We used target-enrichment to deep sequence HCMV DNA from 11 immunosuppressed pediatric patients receiving single or combination anti-HCMV treatment, serially sampled over 1–27 weeks. Changes in consensus sequence and resistance mutations were analyzed for three ORFs targeted by anti-HCMV drugs and the frequencies of drug resistance mutations monitored. Targeted-enriched sequencing of clinical material detected mutations occurring at frequencies of 2%. Seven patients showed no evidence of drug resistance mutations. Four patients developed drug resistance mutations a mean of 16 weeks after starting treatment. In two patients, multiple resistance mutations accumulated at frequencies of 20% or less, including putative maribavir and ganciclovir resistance mutations P522Q (UL54) and C480F (UL97). In one patient, resistance was detected 14 days earlier than by PCR. Phylogenetic analysis suggested recombination or superinfection in one patient. Deep sequencing of HCMV enriched from clinical samples excluded resistance in 7 of 11 subjects and identified resistance mutations earlier than conventional PCR-based resistance testing in 2 patients. Detection of multiple low level resistance mutations was associated with poor outcome.
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Affiliation(s)
- Charlotte J Houldcroft
- Infection, Immunity, Inflammation and Physiological Medicine, Institute of Child Health, University College LondonLondon, UK; Division of Infection and Immunity, University College LondonLondon, UK
| | - Josephine M Bryant
- Division of Infection and Immunity, University College London London, UK
| | - Daniel P Depledge
- Division of Infection and Immunity, University College London London, UK
| | - Ben K Margetts
- Infection, Immunity, Inflammation and Physiological Medicine, Institute of Child Health, University College LondonLondon, UK; Centre for Mathematics and Physics in the Life Sciences and Experimental Biology (CoMPLEX), University College LondonLondon, UK
| | - Jacob Simmonds
- Great Ormond Street Hospital for Children NHS Foundation Trust London, UK
| | - Stephanos Nicolaou
- Division of Infection and Immunity, University College London London, UK
| | - Helena J Tutill
- Division of Infection and Immunity, University College London London, UK
| | - Rachel Williams
- Division of Infection and Immunity, University College London London, UK
| | - Austen J J Worth
- Great Ormond Street Hospital for Children NHS Foundation Trust London, UK
| | - Stephen D Marks
- Infection, Immunity, Inflammation and Physiological Medicine, Institute of Child Health, University College LondonLondon, UK; Great Ormond Street Hospital for Children NHS Foundation TrustLondon, UK
| | - Paul Veys
- Great Ormond Street Hospital for Children NHS Foundation Trust London, UK
| | | | - Judith Breuer
- Infection, Immunity, Inflammation and Physiological Medicine, Institute of Child Health, University College LondonLondon, UK; Division of Infection and Immunity, University College LondonLondon, UK; Great Ormond Street Hospital for Children NHS Foundation TrustLondon, UK
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15
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Response to antiviral therapy in haematopoietic stem cell transplant recipients with cytomegalovirus (CMV) reactivation according to the donor CMV serological status. Clin Microbiol Infect 2015; 22:289.e1-7. [PMID: 26627339 DOI: 10.1016/j.cmi.2015.11.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 11/13/2015] [Accepted: 11/16/2015] [Indexed: 01/21/2023]
Abstract
Pre-emptive antiviral treatment efficiently prevents occurrence of cytomegalovirus (CMV) disease in allogeneic stem cell transplant recipients. However, successive treatment courses can be necessary. The current study was aimed at determining factors that could influence the response to antiviral treatment, in particular the donor CMV serostatus. A total of 147 consecutive CMV-seropositive recipients (R+) were included and prospectively monitored for 6 months after transplantation. Reactivation of CMV occurred in 111 patients, 61 of 78 with a CMV-positive donor (D+) and in 50 of 69 with a CMV-negative donor (D-) (p 0.45). Baseline viral loads and initial viral doubling times did not differ between D+/R+ and D-/R+. Fifteen D+/R+ and four D-/R+ had self-resolving CMV infections. A total of 92 patients received antiviral treatment and 81 (88%) had a significant decrease in CMV load under therapy. Repeated CMV episodes were observed in 67% of those and were significantly more frequent in D-/R+ than in D+/R+ (p <0001). Half-life of CMV under treatment was significantly longer in D-/R+ than in D+/R+. Treatment failure observed in eight recipients was associated with low leucocyte count at reactivation onset, and was significantly more frequent in D-/R+ (six patients) than in D+/R+ (two patients) (p <0.0001). CMV strains resistant to antivirals were found in two D-/R+. Donor CMV serostatus influenced neither CMV reactivation occurrence nor the kinetics of CMV DNA load in the early phase of CMV replication but had a significant impact on response to antiviral therapy. Virological drug-resistance remained rare.
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16
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Hanson KE, Swaminathan S. Cytomegalovirus antiviral drug resistance: future prospects for prevention, detection and management. Future Microbiol 2015; 10:1545-8. [PMID: 26437628 DOI: 10.2217/fmb.15.82] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Kimberly E Hanson
- Department of Medicine, Division of Infectious Diseases, University of Utah, UT, USA.,Department of Pathology, ARUP Laboratories, University of Utah, UT, USA
| | - Sankar Swaminathan
- Department of Medicine, Division of Infectious Diseases, University of Utah, UT, USA
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17
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Schnepf N, Dhédin N, Mercier-Delarue S, Andreoli A, Mamez AC, Ferry C, Deback C, Ribaud P, Robin M, Socié G, Simon F, Mazeron MC. Dynamics of cytomegalovirus populations harbouring mutations in genes UL54 and UL97 in a haematopoietic stem cell transplant recipient. J Clin Virol 2013; 58:733-6. [DOI: 10.1016/j.jcv.2013.10.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Revised: 09/14/2013] [Accepted: 10/03/2013] [Indexed: 11/25/2022]
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18
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Shmueli E, Or R, Shapira MY, Resnick IB, Caplan O, Bdolah-Abram T, Wolf DG. High rate of cytomegalovirus drug resistance among patients receiving preemptive antiviral treatment after haploidentical stem cell transplantation. J Infect Dis 2013; 209:557-61. [PMID: 23983215 DOI: 10.1093/infdis/jit475] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
We examined the rate, clinical impact, and risk factors of cytomegalovirus (CMV) drug resistance in 561 patients who underwent 616 hematopoietic stem cell transplantations (HSCTs) over 5 years. Drug resistance was exclusively identified in haploidentical (haplo)-HSCT recipients receiving preemptive therapy, among whom the rate was 14.5%. Resistance appeared after prolonged treatment (median, 70 days), was associated with higher preceding viral load (P < .001), and was the strongest predictor for disease by multivariate analysis. The high rate of drug resistance as interlinked with severe disease in haplo-HSCT recipients suggests the potential advantage of prophylactic over preemptive treatment in high-risk patients and highlights the need for better-tolerable anti-CMV drugs.
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19
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Daikoku T, Saito K, Aihara T, Ikeda M, Takahashi Y, Hosoi H, Nishida T, Takemoto M, Shiraki K. Rapid detection of human cytomegalovirus UL97 and UL54 mutations for antiviral resistance in clinical specimens. Microbiol Immunol 2013; 57:396-9. [DOI: 10.1111/1348-0421.12043] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Revised: 01/25/2013] [Accepted: 02/07/2013] [Indexed: 12/11/2022]
Affiliation(s)
- Tohru Daikoku
- Department of Virology; University of Toyama; 2630 Sugitani; Toyama; 930-0194; Japan
| | - Kazuhide Saito
- Division of Urology, Department of Regenerative and Transplant Medicine; Graduate School of Medical and Dental Sciences, Niigata University; 1-757 Asahimachi Dori, Chuo Ku; Niigata; 951-8510; Japan
| | - Takamitsu Aihara
- Department of Virology; University of Toyama; 2630 Sugitani; Toyama; 930-0194; Japan
| | - Masahiro Ikeda
- Division of Urology, Department of Regenerative and Transplant Medicine; Graduate School of Medical and Dental Sciences, Niigata University; 1-757 Asahimachi Dori, Chuo Ku; Niigata; 951-8510; Japan
| | - Yoshiyuki Takahashi
- Department of Pediatrics; Nagoya University Graduate School of Medicine; 65 Tsurumai-cho, Showa-ku; Nagoya; 466-8550; Japan
| | - Hiroki Hosoi
- Department of Hematology/Oncology; Wakayama Medical University; 811-1 Kimiidera; Wakayama; 641-8519; Japan
| | - Tetsuya Nishida
- Department of Hematology and Oncology; Nagoya University Graduate School of Medicine; 65 Tsurumai-cho, Showa-ku; Nagoya; 466-8550; Japan
| | - Masaya Takemoto
- Department of Virology; University of Toyama; 2630 Sugitani; Toyama; 930-0194; Japan
| | - Kimiyasu Shiraki
- Department of Virology; University of Toyama; 2630 Sugitani; Toyama; 930-0194; Japan
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20
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Emery V, Zuckerman M, Jackson G, Aitken C, Osman H, Pagliuca A, Potter M, Peggs K, Clark A. Management of cytomegalovirus infection in haemopoietic stem cell transplantation. Br J Haematol 2013; 162:25-39. [PMID: 23647436 DOI: 10.1111/bjh.12363] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Vincent Emery
- Department of Virology; University College London School of Life and Medical Sciences; London; UK
| | - Mark Zuckerman
- Department of Virology; King's College Hospital; London; UK
| | - Graham Jackson
- Department of Haematology; Freeman Road Hospital; Newcastle; UK
| | - Celia Aitken
- West of Scotland specialist virology centre; Gartnavel General Hospital; Glasgow; UK
| | - Husam Osman
- Birmingham HPA Laboratory; Birmingham Heartlands Hospital; Birmingham; UK
| | | | - Mike Potter
- Section of Haemato-oncology; The Royal Marsden NHS Foundation Trust; London; UK
| | - Karl Peggs
- Department of Haematology; University College London Hospitals; London; UK
| | - Andrew Clark
- Blood and Marrow Transplant Unit; Beatson Oncology Centre; Glasgow; UK
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21
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Cunha-Bang CD, Kirkby N, Sønderholm M, Sørensen SS, Sengeløv H, Iversen M, Rasmussen A, Gustafsson F, Frederiksen CM, Kjaer J, Lepri AC, Lundgren JD. The time course of development and impact from viral resistance against ganciclovir in cytomegalovirus infection. Am J Transplant 2013; 13:458-66. [PMID: 23282281 DOI: 10.1111/ajt.12042] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Revised: 10/12/2012] [Accepted: 10/24/2012] [Indexed: 01/25/2023]
Abstract
(Val)ganciclovir is used to treat cytomegalovirus (CMV) infection following solid organ (SOT) or hematopoietic stem cell (HSCT) transplantation. Treatment failures occur, but the contribution from 39 known ganciclovir-related mutations (GRMs) in the CMV-UL97 gene remains controversial. We propose a categorization of these GRMs potentially useful when interpreting sequence analyses in clinical settings. The UL97 gene was sequenced from first/recurrent CMV infections among consecutive SOT or HSCT recipients during 2004-2009. GRMs were categorized as: Signature GRM (sGRM) if in vitro ganciclovir IC(50) ratio for mutated versus wild-type virus >2 (n = 24); polymorphic GRM (pGRM) if ratio <2 (n = 15). (Val)ganciclovir treatment failure was defined as persistent viremia for 30 days or switch to foscarnet within this period. Of 99 (49 HSCT and 50 SOT) recipients with one CMV infection episode, 15 (13 HSCT and 2 SOT) experienced a total of 19 recurrent infection episodes. The prevalence of sGRM was 0% at start of first episode, whereas at start of recurrent episodes, prevalence was 37%. Only one sGRM was present at a time in individual patients. Patients with CMV containing an sGRM (vs. wild type)-but not with a pGRM-were at excess risk of treatment failure (odds ratio = 70.6 [95% CI:8.2-609.6]; p < 0.001). sGRMs emerged only following longer termed use of antiherpetic drugs and usually in recurrent CMV infection episodes. Risk of ganciclovir treatment failure was raised if an sGRM was detected.
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Affiliation(s)
- C da Cunha-Bang
- Center for Viral Diseases, Department of Infectious Diseases, Copenhagen University Hospital/Rigshospitalet, Copenhagen, Denmark.
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