2062. Impact of Indeterminate HIV Test Results on Efficacy of Emergency Department Routine HIV Screening

Background

In 2019, 36,801 new HIV cases were reported in the United States. Emergency Department routine HIV testing is crucial to identify new asymptomatic HIV infections. Early diagnosis followed by prompt antiretroviral therapy decreases morbidity and mortality and reduces HIV transmission. The Emergency Department (ED) at Memorial Hermann Hospital (MHH) - Texas Medical Center (TMC) in Houston, Texas, implemented an ED-routine HIV screening program in June 2017. At times, the testing for HIV yields indeterminant results. Consequences of indeterminate HIV tests include individuals unaware of their HIV infection status transmitting infection and not receiving antiretroviral therapy.

Methods

39,288 adults who presented to ED MHH –TMC from June 2017 to March 2022 with a Glasgow score > 9 were tested using an Opt-Out protocol for HIV infection. Testing comprised a screening assay (HIV 4^th Generation (GEN) ADVIA Centaur ^TM Ag/Ab COMBO (Siemens)) followed by a confirmatory test (Gennius^TM HIV1/HIV2). A second confirmatory test is performed if screening and first confirmatory tests yield conflicting (indeterminant) results (HIV1 RNA PCR or a repeat 4th GEN test).

Results

824 (2.0 %) patients tested positive for HIV infection; 94 (0.2%) yielded indeterminate test results. 61 (64.8%) of the patients with indeterminate findings received confirmatory testing; 37 (39.4%) before leaving the hospital (35 HIV negative, 2 positive). Of the 57 (60.1%) who left the hospital before confirmatory testing, 24 (42.1%) were traced and tested (21 HIV negative, 3 positive). 33 (35.1%) were lost to follow-up (11 of whom were reported homeless or in unstable housing).

Conclusion

The primary cause of failure to follow up testing on patients who tested indeterminant during an ED visit is a loss of contact with the patients after leaving the ED. In turn, failure to link these patients to HIV care relates to a failure to complete confirmatory testing before completion of the hospital visit. Therefore, the quantitative results presented will enable the assessment of the best deployment of resources in capturing those patients currently lost to follow-up.

Disclosures

Norma Perez, DO, Theratecnologies, Inc: Advisor/Consultant.

1931. Antibodies to SARS-CoV-2 in a Medical School Department of Pediatrics

Background

Healthcare workers are at high risk of Covid-19 (C19) infection and received priority for C19 vaccinations. Therefore, we conducted a serosurvey to determine anti-C19 antibodies and evidence of C19 infection in health care employees who did or did not have direct contact with patients.

Methods

49 participants provided finger stick blood samples collected onto filter papers and tested for antibodies to C19 using Bio-Plex Pro Human SARS-CoV-2 IgG reagents. Antibodies to C19 nucleocapsid (N), receptor-binding domain (RBD), spike 1 (S1), and spike 2 (S2) were measured. Samples were collected 8 to 11 months after C19 vaccines were made available.

Results

All participants received two doses of Pfizer BioNTech or Moderna RNA-based C19 vaccines, and all showed serological evidence of antibodies to C19 RBD, S1, and S2. Antibodies to N, considered a marker of C19 infection, were detected in 16 individuals, of whom 10 reported having a PCR documented C19 infections. 6 individuals had evidence of C19 infection of which they were not aware. Antibody levels were notably higher following infection and for not infected participants following Pfizer-BioNTech vaccination. There was a 20% higher infection rate in participants with direct patient contact.

Conclusion

This vaccinated population had significant rates of strong antibody responses to C19 infection and a notable rate of C19 infections, most notable in those providing direct patient care.

Disclosures

All Authors: No reported disclosures.

845. Impact of the COVID-19 Pandemic on Routine HIV Screening in an Emergency Department

Background

The Emergency Department (ED) at Memorial Hermann Hospital (MHH) - Texas Medical Center (TMC), Houston, Texas has a long established screening program targeted at detection of HIV infections. The impact of the COVID-19 pandemic on this screening program is unknown.

Methods

The Routine HIV screening program includes opt-out testing of all adults 18 years and older with Glasgow score > 9. HIV 4th generation Ag/Ab screening, with reflex to Gennius confirmatory tests are used. Pre-pandemic (March 2019 to February 2020) to Pandemic period (March 2020 to February 2021) intervals were compared.

Results

72,929 patients visited MHH_ED during the pre-pandemic period and 57,128 in the pandemic period, a 22% decline. The number of patients tested for HIV pre-pandemic was 9433 and 6718 pandemic, a 29% decline. When the pandemic year was parsed into first and last 6 months interval and compared to similar intervals in the year pre pandemic, 39% followed by 16% declines in HIV testing were found. In total, 354 patients were HIV positives, 209, (59%) in the pre-pandemic and 145 (41%) in the pandemic period.The reduction in new HIV infections found was directly proportional to the decline in patients visiting the MHH-ED where the percent of patients HIV positive was constant across intervals (2.21% vs 2.26%). Demographic and outcome characteristics were constant across the compared intervals.

Conclusion

The COVID -19 pandemic reduced detection of new HIV infections by screening in direct proportion to the reduction in MHH-ED patient visits. The impact of COVID-19 pandemic decreased with duration of the pandemic.

Disclosures

All Authors: No reported disclosures

259. Impact of a Multiplex Meningitis and Encephalitis PCR on the Management of CNS Infections in Adults and Children, Houston, Texas

Background

The majority of adults and children with meningitis and encephalitis have unknown etiologies fostering universal admission, prolonged length of stay, empirical antibiotic and antiviral therapies. A qualitative multiplexed nucleic acid-based in vitro diagnostic test (FilmArray) is helping clinicians identify organisms and improve clinical outcomes.

Methods

Patients presenting between July 5, 2018, to April 26, 2021, with meningitis or encephalitis, cerebrospinal fluid (CSF) with WBC >5 cells/mm^3, and leftover CSF were available for testing. All CSF specimens underwent testing with the Biofire® Film Array Meningitis Encephalitis (FAME) panel. This multiplex PCR tool utilizes 0.2 ml CSF sample to identify the presence of 14 viral, bacterial and fungal pathogens in 1 hour.

Results

Of 5291 CSF specimens screened, 285 (5.3%) met the criteria for meningitis or encephalitis and underwent FAME testing. The majority were adults (240, 84.2%), male (147, 51.5%), White (111, 38.9%), immunocompetent (213, 74.3%) and (212, 74.3%) had meningitis presentation. Median age was 41 years (0 mo-100 yrs) and (283, 99.2%) were admitted to the hospital. Median duration between CSF collection and viral PCR result as 13 hrs for Enterovirus, 31 hrs for HSV, and 57 hrs for VZV. The FAME panel detected a pathogen in 103 patients (36.1%) of whom 76 (73.7%) had a viral etiology. 166 (58.2%) patients were discharged with unknown etiology of whom FAME was positive in 24 (14.4%) [VZV (37.5%), HSV2 (16.6%), Enterovirus (16.6%), Haemophilus influenzae (8.3%), HHV6 (8.3%), Streptococcus pneumoniae (8.3%) and HSV1 (4.1%)]. The addition of the FAME panel to the standard of care evaluation increased the known etiologies from 119 (41.7%) to 197 pathogens (69.1%), (p< 0.05). 52 patients (18.2%) underwent a repeat LP (30, 57.6% done for additional testing). Empirical antibiotic and antiviral therapy were given to 89% and 63% of patients, respectively.

Conclusion

A rapid multiplex PCR decreases the proportion of unknown etiologies and has the potential to decrease length of stay and the use of empirical antibiotic and antiviral therapies. Testing with the FA ME panel resulted in pathogen detections not previously recognized and for which treatment is recommended.

Disclosures

Rodrigo Hasbun, MD, MPH, Biofire (Speaker’s Bureau) Rodrigo Hasbun, MD, MPH, Biofire (Individual(s) Involved: Self): Consultant, Research Grant or Support

Acute Flaccid Myelitis Among Hospitalized Children in Texas, 2016

BACKGROUND

Acute flaccid myelitis is characterized by acute-onset flaccid limb weakness with predominantly gray matter lesions in the spinal cord spanning one or more segments. Rates of full recovery are poor, and there is no standard treatment or definitive cause.

METHODS

This is a retrospective review of children diagnosed with acute flaccid myelitis in Texas during 2016. Patients were identified through a Texas collaborative of six hospitals in four major metropolitan areas. Data abstraction included health history, illness presentation, medical treatments, laboratory studies, imaging data, recovery, and ability to perform activities of daily living up to approximately two years from illness onset.

RESULTS

Among all sites, 21 patients met inclusion criteria. Treatments varied with the most common being intravenous immunoglobulin, high-dose methylprednisolone, and plasmapheresis. No differences were seen in response to medical treatments. A potential etiology was found in 12 (57%) cases, including four with enterovirus D68. Five cases recovered fully. Of the 16 patients without full recovery, abilities ranged from (1) able to perform all activities of daily living for age independently (n = 5), (2) mild deficits (n = 5), and (3) substantial reliance on caregivers for activities of daily living (n = 6).

CONCLUSION

Many reports describe symptoms and outcomes of acute flaccid myelitis, but limited data are available on long-term functional outcomes. We were unable to make a strong case for any single cause or treatment modality. Fortunately, the majority of patients (15, 71%) were able to perform activities of daily living with complete independence or only mild deficits.

1407. Potential Impact of the Biofire® Film Array Meningitis and Encephalitis (ME) Panel in Reducing Repeat Lumbar Punctures in Patients with Meningitis and Encephalitis

Background

The Biofire® FilmArray Meningitis Encephalitis (FAME) is a multiplex polymerase chain reaction (PCR) test can rapidly detect up to 14 pathogens that cause meningitis and encephalitis. The impact on preventing repeat lumbar punctures to obtain more diagnostic studies is currently unknown.

Methods

Patients admitted to Memorial Hermann Hospital (MHH) between July 2018-February 2019 with community-acquired symptoms of meningitis or encephalitis, CSF with white blood cell count >5 cells/mm3, and with leftover CSF at the MHH microbiology laboratory were eligible for the study. Testing FAME was performed after discharge for specimens that had not been centrifuged, had a volume of ≥200 μL, were appropriately stored, and were collected by lumbar puncture (LP) for evaluation of suspected meningitis/encephalitis.

Results

Of 1,382 CSF specimens screened, 70 (5.0%) met the criteria and were tested with FAME. The majority was adults (72.8%), non-Caucasian (68.6%), male (60%), immunocompetent (75.7%) and had a meningitis presentation (75.7%). Mean age was 36.9 years (1 mo-89 years). The mean duration between CSF collection and any PCR result done in the hospital was 60 hours. Fifteen patients (21.4%) required 25 repeat LPs [13 (86.6%) for additional testing (7 (53.8%) pediatric patients) and 2 (13.3%) for cryptococcal meningitis assessment]. The FAME could have prevented repeat LPs in 86.6% of patients. Five of the 13 repeat LP (38.4%) FA ME showed a pathogen [VZV (2), HSV 1 (1), HHSV-6 (1), Neisseria meningitidis (1)]. Of 46 tests with negative FA ME, acyclovir therapy was started in 22 (47.8%) with a mean of 6 doses dispensed. 38 (26.6%) patients were discharged with an unknown etiology of whom FA ME was positive in 8 (21%) [HSV2 (37.5%), VZV (25%), Enterovirus (25%) and HSV1 (12.5%)]. PCR was ordered in the hospital for only 4 (50%) of these patients.

Conclusion

The FAME identified an etiology in 21% of patients with meningitis and encephalitis symptoms discharged with an unknown etiology. A total of 18.5% of patients required a repeat LP for additional testing. FAME testing offers an avenue for reducing the burden of repeat LPs and duration of unnecessary anti-infective therapy while increasing diagnostic yield.

Disclosures

All authors: No reported disclosures.

1293. Bundled HIV/Hep C testing 4 Years of Implementation at 9 Emergency Departments in the Houston Metropolitan Area

Background

Individuals living with HIV infection and/or Hep C infection and unaware of their infected status are at risk of significant morbidity and a risk to public health. It has been recommended that all conscious adults presenting to Emergency Departments (EDs) be tested for HIV and increasingly testing for Hep C. Testing of all arrivals is important because a majority of both infections may not present signature signs or symptoms associated with the reason for the ED visit. For these reasons, the implementation of a bundled HIV/HepC testing protocol is reported here.

Methods

Data from 4 years of HIV/Hep C screening of patients 18 to 64 years old made in 9 EDs in the Houston Metropolitan Area are reviewed. Screening for HIV was using HIV fourth-generation ADVIA Centaur™ Ag/Ab COMBO (Siemens) and Hep C was tested for using Gilead Hep C Ab testing.

Results

During January 2013 until October 2016, 3,976 HIV/Hep C test bundles were performed. There were 40 (1.0%) HIV+ and 407 (10.2%) Hep C positive detected. Nine (0.2%) of these individuals were positive for both HIV and Hep C. A 22.5% of HIV-positive patients were co-infected with Hep C. The population had a median age of 53 years, comprising an equal number of males and females.

Conclusion

A significant prevalence of Hep C (10%) and HIV (1%) was found in patients presenting for any cause of major EDs in the Houston region. Bundled HIV/Hep C testing of all arrivals to EDs is an effective way to identify individuals that need to be directed to antiviral and linkage to care.

Disclosures

All authors: No reported disclosures.

1296. Should HIV Disclosure at ED Based on Preliminary Results?

Background

It is recommended that all adults presenting to Emergency Departments (ED) be offered opt out testing for HIV. There is evidence that detection of HIV infection, disclosure of infected status to the patient, and enrollment into HIV care are best accomplished during the ED visit. Any delay results in loss of patients. Among critical variables are capacities to conduct screening and confirmatory testing during the time the patient is a resident in the ED. We report on a facility where HIV screening is performed during ED patient dwell times but confirmatory results follow in ≥24h. The conundrum is whether patients found HIV positive by a screening test should be informed of the positive screening finding before confirmatory results are in hand.

Methods

Data obtained from a routine opt-out HIV screening program for the interval June 2017 to March 2019 conducted at the ED in Houston, Texas were evaluated. Patients between 18–65 years with Glasgow Score >9 were eligible for testing. HIV fourth-generation ADVIA Centaur™ Ag/Ab COMBO (Siemens) was used for screening. Positives screening tests were followed by Gennius™ HIV1/HIV2 confirmatory test.

Results

12,040 HIV fourth-generation tests were performed; 232 (1.9%) were positive; the specificity of the screening testing was 98.2%. Twenty-two (9.5%) of screening test positive individuals were found HIV false positive (Ag/Ab positive and Gennius negative). The population had a mean age of 43.8 years (21–64), was predominately female (63.6%) and white (40.9%). Further testing was completed for 14 of the 22 patients with false-positive screening tests. 13 had negative tests for HIV RNA and 1 had a second HIV Ag/Ab test with negative findings. 8 (36.3%) screening test false-positive patients could not be located after their departure from the ED.

Conclusion

If patients were disclosed of their HIV-positive status because of the screening test result, approximately 10% of these individuals would have been incorrectly categorized generating significant personal and social disruption while waiting for the confirmatory result.

Disclosures

All authors: No reported disclosures.

Aseptic meningitis in adults and children: Diagnostic and management challenges

BACKGROUND

Aseptic meningitis represents a common diagnostic and management dilemma to clinicians.

OBJECTIVES

To compare the clinical epidemiology, diagnostic evaluations, management, and outcomes between adults and children with aseptic meningitis.

STUDY DESIGN

We conducted a retrospective study from January 2005 through September 2010 at 9 Memorial Hermann Hospitals in Houston, TX. Patients age≥2months who presented with community-acquired aseptic meningitis with a CSF white blood cell count >5cells/mm³ and a negative Gram stain and cultures were enrolled. Patients with a positive cryptococcal antigen, positive blood cultures, intracranial masses, brain abscesses, or encephalitis were excluded.

RESULTS

A total of 509 patients were included; 404 were adults and 105 were children. Adults were most likely to be female, Caucasian, immunosuppressed, have meningeal symptoms (headache, nausea, stiff neck, photophobia) and have a higher CSF protein (P <0.05). In contrast, children were more likely to have respiratory symptoms, fever, and leukocytosis (P <0.05). In 410 (81%) patients, the etiologies remained unknown. Adults were more likely to be tested for and to have Herpes simplex virus and West Nile virus while children were more likely to be tested for and to have Enterovirus (P <0.001). The majority of patients were admitted (96.5%) with children receiving antibiotic therapy more frequently (P <0.001) and adults receiving more antiviral therapy (P=0.001). A total of 384 patients (75%) underwent head CT scans and 125 (25%) MRI scans; all were normal except for meningeal enhancement. All patients had a good clinical outcome at discharge.

DISCUSSION

Aseptic meningitis in adults and children represent a management challenge as etiologies remained unknown for the majority of patients due to underutilization of currently available diagnostic techniques.

Characteristics and outcome of respiratory syncytial virus infection in patients with leukemia

BACKGROUND AND OBJECTIVES

Little is known about respiratory syncytial virus (RSV) infection in patients with leukemia. The aim of this study was to determine the characteristics, and the outcome of RSV infection with or without therapy with aerosolized ribavirin in leukemia patients.

DESIGN AND METHODS

We reviewed the records of 52 leukemia patients with RSV infection seen at our institution between October 2000 and March 2005.

RESULTS

The median age of the patients was 47 years (range, 1-83 years). Most patients were male (65%) and had acute leukemia (65%); 46% had received salvage chemotherapy and 62% corticosteroids before RSV infection. Compared to the 25 patients with upper respiratory tract infection (URI), the 27 patients with pneumonia had a higher median APACHE II score at the time of the first assessment at the hospital for respiratory symptoms (11 vs 16), and a higher rate of corticosteroid treatment in the month preceding the infection (48% vs 74%) (all p < or =0.05). Twenty-four (46%) patients received aerosolized ribavirin. Patients who presented with URI and were treated with ribavirin were less likely than non-treated patients to develop pneumonia (68% vs 96%, p<0.01) and possibly die of pneumonia (6% vs 36%, p=0.1). Multiple logistic regression analysis identified high APACHE II score and lack of ribavirin treatment as independent predictors of progression to pneumonia (p=0.01). Five patients (10%) died within 30 days of RSV infection; all had pneumonia.

INTERPRETATION AND CONCLUSIONS

RSV infection is associated with significant morbidity and mortality in leukemia patients; treatment with aerosolized ribavirin at the stage of URI may prevent pneumonia in some subsets of patients.

Neuraminidase Inhibitors Improve Outcome of Patients with Leukemia and Influenza: An Observational Study

We reviewed the records of 33 patients with leukemia who experienced influenza during the period from October 2000 to March 2004. Three (38%) of the 8 patients who did not receive neuraminidase inhibitor therapy and none of the 25 patients who received it died of influenza pneumonia (P=.001). The use of neuraminidase inhibitor therapy seems to improve the outcome of influenza in patients with leukemia.

Respiratory viral infections in adults with hematologic malignancies and human stem cell transplantation recipients: a retrospective study at a major cancer center

Community respiratory viruses (CRVs) have been recognized as a potential cause of pneumonia and death among hematopoietic stem cell transplantation (HSCT) recipients and patients with hematologic malignancies. We reviewed the Microbiology Laboratory records dated from July 1, 2000, to June 30, 2002, to identify patients who had respiratory specimens positive for influenza, parainfluenza, respiratory syncytial virus, or picornavirus. We identified 343 infections among patients with underlying hematologic malignancies and HSCT. We collected data on type of disease, age, sex, type of infection, neutrophil and lymphocyte counts, therapy, and outcome. Influenza, parainfluenza, and respiratory syncytial virus accounted for most cases and were approximately equal in frequency. Most infections occurred predominantly among recipients of allogeneic transplants. Infection progressed to pneumonia in 119 patients (35%) and occurred with similar frequency for the 3 viruses. Patients at greatest risk for developing pneumonia included those with leukemia, those aged more than 65 years, and those with severe neutropenia or lymphopenia. Lack of respiratory syncytial virus-directed antiviral therapy (p=0.025) and age (p=0.042) were associated with development of respiratory syncytial virus pneumonia, and an absolute lymphocyte count<or=200 cells/mL (p=0.049) was associated with development of influenza pneumonia. The overall mortality rate for CRV pneumonia was 15%. The only independent predictor of fatal outcome was an absolute lymphocyte count<or=200 cells/mL (p=0.03) in patients with influenza pneumonia.HSCT recipients and patients with hematologic malignancies who develop upper respiratory infection due to CRVs should be considered for antiviral therapy of proven efficacy to reduce the risk of pneumonia and death.

Influence of type of cancer and hematopoietic stem cell transplantation on clinical presentation of Pneumocystis jiroveci pneumonia in cancer patients

Pneumocystis jiroveci pneumonia is a common infection in patients with AIDS but an infrequent cause of pneumonia in cancer patients. Little is known about the impact of cancer type and hematopoietic stem cell transplantation on the presentation and outcome of P. jiroveci pneumonia in cancer patients. A retrospective cohort study of all patients with cancer and P. jiroveci pneumonia cared for at The M.D. Anderson Cancer Center during 1990-2003 was conducted. Eighty episodes of P. jiroveci pneumonia in 79 patients were identified. In most (67%) episodes, patients had a hematologic malignancy. In 23 (29%) episodes, patients had undergone hematopoietic stem cell transplantation. Twenty-seven percent of patients with histopathologically confirmed P. jiroveci pneumonia had nodular infiltrates on the radiographic study. Pleural effusion and pneumothorax were more common in patients with hematopoietic stem cell transplantation than in those with solid tumors. Clinical suspicion of P. jiroveci pneumonia was less common in patients with nodular infiltrates than in those without such a radiographic finding (7 vs. 39%; p=0.002). Twenty-six of 76 (34%) patients with data available died of P. jiroveci pneumonia. Predictors of death by univariate analysis included older age, tachypnea, high APACHE II score, use of mechanical ventilation or vasopressors, lower arterial pH level, absence of interstitial component, pneumothorax, and comorbid conditions (all p<0.05). Multivariate analysis identified the use of mechanical ventilation as an independent predictor of death. Death attributable to P. jiroveci pneumonia appeared to be higher in patients with hematopoietic stem cell transplantation. The clinical presentation of P. jiroveci pneumonia in cancer patients may be affected by the category of cancer and the history of hematopoietic stem cell transplantation. P. jiroveci pneumonia remains a rare yet severe infection in cancer patients.

Cytomegalovirus Infection in Patients with Lymphoma: An Important Cause of Morbidity and Mortality

BACKGROUND

Cytomegalovirus (CMV) antigenemia (CMV-A) and CMV disease (CMV-D), known causes of morbidity and mortality among patients with leukemia and recipients of hematopoietic stem cell transplantations, are described sporadically in patients with lymphoma. We sought to determine the risk factors and outcome of CMV-A and CMV-D among patients with lymphoma.

PATIENTS AND METHODS

We conducted a retrospective cohort study with such patients identified between 1997 and 2003 at The University of Texas M. D. Anderson Cancer Center. Seventy-one patients with 82 episodes of CMV-A and/or CMV-D (CMV-A in 38 episodes and CMV-D in 44 episodes) were studied.

RESULTS

Cytomegalovirus antigenemia and/or CMV-D were more common among patients with non-Hodgkin's lymphoma than among those with Hodgkin's disease (P = 0.01). Most CMV infectious episodes occurred in patients who had active (88%) and stage III/IV lymphoma (84%). Eleven of 65 patients (17%) with outcome data died with CMV-A and/or CMV-D. Death with CMV infection was more common among patients with CMV-D than among those with CMV-A (29% vs. 3%, respectively, P = 0.005). Predictors of death by univariate analysis included intensive care unit admission, mechanical ventilation, high antigenemia burden, relapse of CMV-A and/or CMV-D, and antiviral-associated toxicity (all P < 0.05). Multivariate analysis identified antiviral toxicity as the only independent predictor of death (P = 0.01).

CONCLUSION

In an era of intense and pleiotropic immunosuppressive therapy in patients with lymphoma, CMV-A and CMV-D are significant infections. Preventive strategies might be warranted for patients at risk.

Cytomegalovirus pneumonia in patients with lymphoma

BACKGROUND

Even when treated with antiviral therapy, cytomegalovirus pneumonia (CMVp) is associated with high morbidity and mortality in immunocompromised patients. CMVp has been rarely reported in patients with lymphoma.

METHODS

The authors reviewed the records of patients treated at The University of Texas M. D. Anderson Cancer Center (Houston, TX) between 1997 and 2003. Collected information included demographics, use of chemotherapy, or corticosteroids, concomitant infections, and outcome.

RESULTS

Thirty-one patients with lymphoma with 36 episodes of CMVp were identified. The incidence of CMVp increased between 1997 and 2003 (0 of 1000 treated patients vs. 9 of 1000 treated patients; P = 0.07). Most episodes occurred in patients with non-Hodgkin lymphoma (89%). Most of the patients (92%) had received chemotherapy and corticosteroids (89%) before the onset of CMVp. Concomitant CMV antigenemia was detected in 11 (41%) of the 27 episodes in which testing was performed. In 19 episodes (53%), patients had coinfections within 90 days of the episode of CMVp. Coinfections were present at the onset of CMVp in 11 episodes (31%). The yield for CMV in bronchoalveolar lavage (BAL) specimens was higher with culture methods than with cytologic evaluation or immunohistochemical staining (P < 0.001). The number of CMV antigenemia tests performed increased fourfold over the study period. The CMV-attributed mortality rate was 30% (9 of 30 patients). Independent predictors of death by multivariate Cox regression analysis were high APACHE II score (> 16) at onset of CMVp (P = 0.02, hazards ratio [HR] = 15.5, 95% confidence interval [CI], 1.5-163.7), and development of toxicity to antivirals (P = 0.04, HR = 14.03, 95% CI, 1.2-169.1).

CONCLUSIONS

The incidence of CMVp in patients with lymphoma is increasing. CMV detection in BAL specimens was better with culture methods than with cytologic or immunohistochemical methods. High APACHE II score and development of antiviral toxicity were associated with a fatal outcome.