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Saban T, Shargian L, Eiger-Moscovitch M, Prockop S, Doubrovina E, Yeshurun M, Kramer M. Case Report: Cytomegalovirus-specific T-lymphocyte infusion for resistant cytomegalovirus retinitis. FRONTIERS IN OPHTHALMOLOGY 2023; 3:1131674. [PMID: 38983025 PMCID: PMC11182297 DOI: 10.3389/fopht.2023.1131674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 06/07/2023] [Indexed: 07/11/2024]
Abstract
Purpose We hereby describe a case of persistent cytomegalovirus (CMV) viremia and retinitis following allogeneic hematopoietic cell transplantation (HCT) that was successfully treated with infusion of CMV-specific cytotoxic T lymphocytes (CTL) despite previous treatment with Epstein Bar Virus (EBV) -specific CTL, which occurred 5 months earlier. Observations Following several anti- viral medication treatment trials that failed to eradicate the infectious process, the patient was treated with infusions of CMV-CTL from a biobank of cryopreserved virus-specific cells. Shortly after the first infusion, a remarkable response was noted. A few days after the second infusion, the retinitis resolved completely. No recurrence was noted at the one-year follow-up, and there was no evidence of GVHD. Conclusions and importance The case is unique for two reasons: use of virus-specific CTL for an indication of CMV retinitis; and successive administration, in the same patient, of third-party virus-specific CTL to treat two different infections (Epstein-Barr virus and cytomegalovirus) on two separate occasions following hematopoietic cell transplantation.
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Affiliation(s)
- Tal Saban
- Department of Ophthalmology, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel
| | - Liat Shargian
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel
| | - Maya Eiger-Moscovitch
- Hadassah Faculty of Medicine, Hadassah University Hospital, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Susan Prockop
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Center for Immune Cellular Therapy, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Ekatarina Doubrovina
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Center for Immune Cellular Therapy, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Moshe Yeshurun
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michal Kramer
- Department of Ophthalmology, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Cytomegalovirus-Specific T Cells from Third-Party Donors Successfully Treated Refractory Cytomegalovirus Retinitis after Unrelated Umbilical Cord Blood Transplantation. J Immunol Res 2022; 2022:6285510. [DOI: 10.1155/2022/6285510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/19/2022] [Accepted: 07/23/2022] [Indexed: 11/17/2022] Open
Abstract
Umbilical cord blood (UCB) transplants (UCBTs) are becoming increasingly common in the treatment of a variety of hematologic and nonhematologic conditions. The T cells from UCB are naïve T cells, which have not yet been exposed to antigens and therefore do not contain T cells with specific immune functions against viruses. Cytomegalovirus (CMV) infections occur in more than 80% of patients after UCBT compared to other types of transplantation. Anti-CMV medications are currently restricted, with ganciclovir, foscarnet, and valganciclovir being the most common in China; however, with limited efficacy and considerable side effects, all these drugs are susceptible to viral resistance. In recent years, cytomegalovirus-specific T cells (CMVST) have advanced the treatment of viral infections in immunodeficient patients. CMVST usually uses the same donor as hematopoietic stem cell transplantation. CMVST should be administered to UCBT patients because of the absence of donors after UCBT. In China, there is no report on the use of CMVST to treat CMV infection after UCBT, and foreign reports are also limited. This paper reported a 20-year-old male patient with acute myeloid leukemia who developed cytomegalovirus retinitis (CMVR) after umbilical cord blood transplantation. After ineffective viral treatment, he was treated with a third-party donor CMVST and was successfully transformed into CMV nucleic acid negative.
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Ocular Outcomes after Treatment of Cytomegalovirus Retinitis Using Adoptive Immunotherapy with Cytomegalovirus-Specific Cytotoxic T Lymphocytes. Ophthalmol Retina 2021; 5:838-849. [PMID: 33892135 DOI: 10.1016/j.oret.2021.04.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 04/13/2021] [Indexed: 11/20/2022]
Abstract
PURPOSE To describe ocular outcomes in eyes with cytomegalovirus (CMV) retinitis treated with adoptive immunotherapy using systemic administration of CMV-specific cytotoxic Tlymphocytes (CMV-specific CTLs). DESIGN Retrospective cohort study. PARTICIPANTS Patients with active CMV retinitis evaluated at a tertiary care academic center. METHODS Treatment of CMV retinitis with standard-of-care therapy (systemic or intravitreal antivirals) or CMV-specific CTLs (with or without concurrent standard-of-care therapies). MAIN OUTCOME MEASURES The electronic medical record was reviewed to determine baseline characteristics, treatment course, and ocular outcomes, including best-corrected visual acuity (BCVA), treatments administered (CMV-specific CTLs, systemic antivirals, intravitreal antivirals), resolution of CMV retinitis, any occurrence of immune recovery uveitis, cystoid macular edema, retinal detachment, or a combination thereof. RESULTS Seven patients (3 of whom had bilateral disease [n = 10 eyes]) were treated with CMV-specific CTLs, whereas 20 patients (6 of whom had bilateral disease [n = 26 eyes]) received standard-of-care treatment. Indications for CMV-specific CTL therapy included persistent or progressive CMV retinitis (71.4% of patients); CMV UL54 or UL97 antiviral resistance mutations (42.9%); side effects or toxicity from antiviral agents (57.1%); patient intolerance to longstanding, frequent antiviral therapy for persistent retinitis (28.6%); or a combination thereof. Two patients (28.6%; 4 eyes [40%]) received CMV-specific CTL therapy without concurrent systemic or intravitreal antiviral therapy for active CMV retinitis, whereas 5 patients (71.4%; 6 eyes [60%]) continued to receive concurrent antiviral therapies. Resolution of CMV retinitis was achieved in 9 eyes (90%) treated with CMV-specific CTLs, with BCVA stabilizing (4 eyes [40%]) or improving (4 eyes [40%]) in 80% of eyes over an average follow-up of 33.4 months. Rates of immune recovery uveitis, new-onset cystoid macular edema, and retinal detachment were 0%, 10% (1 eye), and 20% (2 eyes), respectively. These outcomes compared favorably with a nonrandomized cohort of eyes treated with standard-of-care therapy alone, despite potentially worse baseline characteristics. CONCLUSIONS CMV-specific CTL therapy may represent a novel monotherapy or adjunctive therapy, or both, for CMV retinitis, especially in eyes that are resistant, refractory, or intolerant of standard-of-care antiviral therapies. More generally, adoptive cell transfer and adoptive immunotherapy may have a role in refractory CMV retinitis. Larger prospective, randomized trials are necessary.
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Adoptive T-cell therapy for pediatric cytomegalovirus-associated retinitis. Blood Adv 2020; 3:1774-1777. [PMID: 31186253 DOI: 10.1182/bloodadvances.2019000121] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 04/15/2019] [Indexed: 11/20/2022] Open
Abstract
Key Points
TCRαβ+/CD19+-depleted haploidentical HSCT was used to restore immunity in a pediatric patient with combined immunodeficiency syndrome. Posttransplant drug-resistant CMV retinitis was successfully treated with T cells expanded from a haploidentical HSCT donor.
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Munro M, Yadavalli T, Fonteh C, Arfeen S, Lobo-Chan AM. Cytomegalovirus Retinitis in HIV and Non-HIV Individuals. Microorganisms 2019; 8:microorganisms8010055. [PMID: 31905656 PMCID: PMC7022607 DOI: 10.3390/microorganisms8010055] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 12/18/2019] [Accepted: 12/25/2019] [Indexed: 02/07/2023] Open
Abstract
Cytomegalovirus retinitis (CMVR) is a severe, vision-threatening disease that primarily affects immunosuppressed patients. CMVR is the most common ocular opportunistic infection in human immunodeficiency virus (HIV) infected patients and is the leading cause of blindness in this group; however, the incidence of CMVR in HIV patients has dramatically decreased with antiretroviral therapy. Other causes of immunosuppression, including organ transplantation, hematologic malignancies, and iatrogenic immunosuppression, can also lead to the development of CMVR. Herein, we describe the pathogenesis of CMVR and compare clinical features, epidemiology, and risk factors in HIV and non-HIV infected individuals with CMVR.
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Affiliation(s)
- Monique Munro
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Tejabhiram Yadavalli
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL 60612, USA
- Department of Microbiology and Immunology, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Cheryl Fonteh
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Safa Arfeen
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Ann-Marie Lobo-Chan
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL 60612, USA
- Correspondence:
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The Third International Consensus Guidelines on the Management of Cytomegalovirus in Solid-organ Transplantation. Transplantation 2019; 102:900-931. [PMID: 29596116 DOI: 10.1097/tp.0000000000002191] [Citation(s) in RCA: 708] [Impact Index Per Article: 141.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Despite recent advances, cytomegalovirus (CMV) infections remain one of the most common complications affecting solid organ transplant recipients, conveying higher risks of complications, graft loss, morbidity, and mortality. Research in the field and development of prior consensus guidelines supported by The Transplantation Society has allowed a more standardized approach to CMV management. An international multidisciplinary panel of experts was convened to expand and revise evidence and expert opinion-based consensus guidelines on CMV management including prevention, treatment, diagnostics, immunology, drug resistance, and pediatric issues. Highlights include advances in molecular and immunologic diagnostics, improved understanding of diagnostic thresholds, optimized methods of prevention, advances in the use of novel antiviral therapies and certain immunosuppressive agents, and more savvy approaches to treatment resistant/refractory disease. The following report summarizes the updated recommendations.
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Abstract
Purpose of review To review the epidemiology, diagnosis, and management of cytomegalovirus retinitis (CMVR) in the post-combined antiretroviral era (cART) era. Recent findings Although cART has dramatically reduced CMVR incidence and morbidity in the HIV population, CMVR continues to cause significant vision loss in both HIV and non-HIV patients, especially amongst patients without immune reconstitution. Advances in imaging including ultra-widefield fundus and autofluorescence imaging, optical coherence tomography, and adaptive optics may reflect CMVR activity; however, the diagnosis remains a clinical one. There have been minimal advances in therapy, with several agents no longer available due to market concerns. Summary Despite reduced incidence and morbidity in the post-cART HIV population, CMVR continues to cause vision loss amongst HIV and non-HIV patients. Diagnosis remains primarily clinical, and therapy centers upon immune reconstitution along with systemic and/or intravitreal antivirals. Further studies are necessary to determine whether advanced imaging can influence management, and whether novel antiviral agents or adoptive immune transfer have a role in treatment of drug-resistance CMVR.
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Gupta MP, Patel S, Orlin A, Marlow E, Chee RI, Nadelmann J, Chan R, D'Amico DJ, Kiss S. SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY FINDINGS IN MACULA-INVOLVING CYTOMEGALOVIRUS RETINITIS. Retina 2018; 38:1000-1010. [PMID: 28376042 PMCID: PMC5943072 DOI: 10.1097/iae.0000000000001644] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate the microstructural features of cytomegalovirus (CMV) retinitis by spectral domain optical coherence tomography (OCT). METHODS Subjects were patients with macula-involving CMV retinitis with OCT imaging. The leading edge of retinitis in the macula was identified based on fundus imaging, and OCT findings were longitudinally evaluated in three areas: within the area of active retinitis, at the leading edge of retinitis, and just beyond the leading edge of retinitis. RESULTS Optical coherence tomography imaging of macular CMV retinitis identified vitreous cells in 10 eyes (100%), posterior vitreous detachment in four eyes (40%), broad-based vitreomacular traction in one eye (10%), epiretinal membrane in eight eyes (80%), and lamellar hole-associated epiretinal proliferation associated with an atrophic hole in one eye (10%). Retinal architectural disruption, disruption of inner retinal layers, disruption of the external limiting membrane, and ellipsoid zone abnormalities were noted within the area of retinitis in all eyes and decreased in frequency and severity at and beyond the leading edge of retinitis, although all 10 eyes (100%) exhibited one of these abnormalities, especially outer retinal microabnormalities, beyond the leading edge of retinitis. CONCLUSION Microstructural abnormalities were frequently noted on OCT of CMV retinitis, including within the retina beyond the leading edge of retinitis identified by corresponding fundus imaging. Outer retinal abnormalities were noted more frequently than inner retinal abnormalities beyond the leading edge of retinitis. These findings provide insight into the effects of CMV retinitis on retinal microstructure and potentially on vision and highlight the potential utility of OCT for monitoring microprogression of macula-involving CMV retinitis.
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Affiliation(s)
- Mrinali P. Gupta
- Department of Ophthalmology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York
| | - Sarju Patel
- Department of Ophthalmology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York
| | - Anton Orlin
- Department of Ophthalmology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York
| | - Elizabeth Marlow
- Department of Ophthalmology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York
| | - Ru-Ik Chee
- Department of Ophthalmology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York
| | | | - R.V.Paul Chan
- Department of Ophthalmology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York
- Department of Ophthalmology, Illinois Eye & Ear Infirmary, University of Illinois at Chicago, Chicago, Illinois
| | - Donald J. D'Amico
- Department of Ophthalmology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York
| | - Szilard Kiss
- Department of Ophthalmology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York
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High ocular CMV copies and mismatched receipts may predict poor visual prognosis in CMV retinitis patients following allogeneic haematopoietic stem cell transplantation. BMC Ophthalmol 2017; 17:224. [PMID: 29187167 PMCID: PMC5707780 DOI: 10.1186/s12886-017-0622-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 11/20/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To summarize the clinical characteristics and potential factors affecting the visual outcomes in patients with cytomegalovirus retinitis following allogeneic haematopoietic stem cell transplantation (HSCT). METHODS This retrospective study enrolled 12 patients (19 eyes) with cytomegalovirus retinitis after HSCT at Guangzhou First People's Hospital in China between January 2013 and December 2014. Demographic and clinical characteristics, ocular manifestations and visual outcomes were evaluated by reviewing medical records at the Departments of Hematology and Ophthalmology. All patients were followed up at least 6 months after stopping antiviral therapy. The visual outcome was defined as improvement, stabilization and deterioration. RESULTS The subjects were composed of 7 human leucocyte antigen-matched and 5 mismatched receipts. All patients received combined systemic and intravitreous antiviral therapy. Eleven eyes gained improved or stabilized visual acuity, while 8 eyes suffered deterioration. Eyes with cytomegalovirus load less than 1 × 104 copies/ml in vitreous accounted for higher rate in eyes with good visual prognosis than those with cytomegalovirus copies above 1 × 104 copies/ml (52.63% vs 5.26%, P < 0.001). Human leucocyte antigen-matched receipts gained better visual prognosis than those mismatched ones (47.37% vs10.53%, P < 0.05). The virus types, cytomegalovirus peak in the blood, involved retinal zone and size had no influence on the visual outcomes (all P > 0.05). CONCLUSIONS High ocular cytomegalovirus copies and mismatched receipts may be potential adverse factors affecting visual outcomes in cytomegalovirus retinitis patients following allogeneic HSCT.
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Port AD, Orlin A, Kiss S, Patel S, D'Amico DJ, Gupta MP. Cytomegalovirus Retinitis: A Review. J Ocul Pharmacol Ther 2017; 33:224-234. [DOI: 10.1089/jop.2016.0140] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Alexander D. Port
- Department of Ophthalmology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York
| | - Anton Orlin
- Department of Ophthalmology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York
| | - Szilard Kiss
- Department of Ophthalmology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York
| | - Sarju Patel
- Department of Ophthalmology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York
| | - Donald J. D'Amico
- Department of Ophthalmology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York
| | - Mrinali P. Gupta
- Department of Ophthalmology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York
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Rifkin LM, Minkus CL, Pursell K, Jumroendararasame C, Goldstein DA. Utility of Leflunomide in the Treatment of Drug Resistant Cytomegalovirus Retinitis. Ocul Immunol Inflamm 2015; 25:93-96. [PMID: 26652481 DOI: 10.3109/09273948.2015.1071406] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To describe leflunomide use in the treatment of drug resistant cytomegalovirus retinitis. Leflunomide has been shown to be effective in the treatment of systemic CMV viremia. METHODS Retrospective chart review of patients with CMV retinitis treated with leflunomide. RESULTS Two HIV-negative organ transplant recipients with UL 97 mutation resistant-genotype CMV were identified. Patient 1 developed CMV viremia post-kidney transplant and subsequently bilateral CMV retinitis. Retinitis progressed, despite intravitreal injection of ganciclovir and foscarnet, and IV foscarnet and oral valganciclovir. Retinitis control was achieved with the addition of oral leflunomide. Disease remained inactive for 22 months. Patient 2 developed CMV retinitis after lung transplant. Disease progressed despite intravitreal foscarnet injections and oral valganciclovir. Control of retinitis was achieved with addition of oral leflunomide, allowing cessation of intravitreal therapy. Disease remained inactive until his death. CONCLUSIONS Leflunomide may be considered as a treatment option for resistant CMV retinitis.
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Affiliation(s)
- Lana M Rifkin
- a Department of Ophthalmology , Northwestern University, Feinberg School of Medicine , Chicago , Illinois , USA
| | - Caroline L Minkus
- a Department of Ophthalmology , Northwestern University, Feinberg School of Medicine , Chicago , Illinois , USA
| | - Kenneth Pursell
- b Department of Infectious Disease , University of Chicago , Chicago , Illinois , USA
| | - Chaisiri Jumroendararasame
- a Department of Ophthalmology , Northwestern University, Feinberg School of Medicine , Chicago , Illinois , USA
| | - Debra A Goldstein
- a Department of Ophthalmology , Northwestern University, Feinberg School of Medicine , Chicago , Illinois , USA
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