Quantitation of human cytomegalovirus DNA in bone marrow transplant recipients

Summary. HCMV DNA was retrospectively quantitated in the early post-transplant period in 36 paediatric bone marrow transplant (BMT) recipients prospectively monitored for human cytomegalovirus (HCMV) infection on the basis of antigenaemia and viraemia assays. Viral DNA was quantitated in peripheral blood leucocytes (PBL) by PCR using an internal control of amplification and a series of external standards. Densitometric analysis of hybridization results obtained on PCR products enabled construction of a standard curve from which DNA amounts of clinical samples, expressed in terms of genome equivalents (GE), were interpolated. Of the 36 BMT recipients, three had clinically symptomatic HCMV infection with mean peak levels of viral DNA > 5000 GE (antigenaemia and viraemia mean peak levels were 873 and 35, respectively), whereas 19 with HCMV reactivation were asymptomatic (five of them had abortive HCMV infection) showing mean peak DNA levels of 131 GE (and of 6-8 and 13 for antigenaemia and viraemia, respectively) (P≤0.01). Single or multiple courses of pre-emptive therapy with ganciclovir or foscarnet were given to 14/19 asymptomatic children in whom antigenaemia levels were > 2 or lower yet persisting. Overall, in the 14 asymptomatic treated patients the mean antigenaemia level was 9-3 (range 1-22), and the mean DNA level was 184-6 (range 20-710) GE. Antiviral drugs were also administered to the three symptomatic patients who, due to late diagnosis of HCMV infection, escaped preemptive therapy. Antiviral treatment caused marked decrease or disappearance of viral DNA, antigenaemia and viraemia in both symptomatic and asymptomatic patients. In conclusion, our study suggests that: (i) starting therapy in the presence of a mean antigenaemia level of 9′3 (range 1-22) corresponding to a mean DNA level of 184′6 (range 20-710) GE avoided occurrence of any major HCMV-related clinical complication; (ii) clinical symptoms were associated with antigenaemia levels > 100 and DNA levels > 1000 GE; (iii) the effect of antiviral treatment could be more carefully monitored by quantitation of viral DNA.     

Cytomegalovirus infection during immunosuppressive therapy for diffuse parenchymal lung disease

Background and objective: Cytomegalovirus (CMV) infection is a life‐threatening condition in patients with diffuse parenchymal lung diseases (DPLDs), who are receiving immunosuppressive therapy. The aim of this study was to describe the clinical features of CMV infection and to propose a strategy for managing CMV infection in patients with DPLD who are receiving immunosuppressive therapy. Methods: A retrospective longitudinal observational study was performed on 69 patients with DPLDs (39 with acute/subacute onset, 30 with chronic onset) who were receiving immunosuppressive therapy and were positive for CMV pp65 antigen (CMV‐pp65Ag) in peripheral blood leukocytes (PBLs). Results: Clinical CMV disease and subclinical CMV antigenaemia developed in 23 and 46 patients, respectively. The cut‐off level of CMV‐pp65Ag indicating clinical CMV disease, as determined by receiver operator characteristic curve analysis, was 7.5 cells per 5 × 10⁴ PBLs. Multivariate analysis revealed that early CMV infection was associated with acute/subacute onset of underlying DPLD and with respiratory dysfunction at the commencement of immunosuppressive therapy. Multivariate analysis also suggested that the acute/subacute onset of underlying DPLD, a CMV‐pp65Ag titre of >7.5 cells per 5 × 10⁴ PBLs, and C‐reactive protein levels ≥10 mg/L indicated a poor prognosis. Conclusions: We recommend that CMV‐pp65Ag antigenaemia of >7.5 cells per 5 × 10⁴ PBLs in patients with DPLD should be treated with ganciclovir. Patients with lower levels of CMV‐pp65Ag antigenaemia should be closely monitored or treated with ganciclovir if the clinical findings suggest a poor prognosis.     

Management of human cytomegalovirus infection and disease after allogeneic bone marrow transplantation

BACKGROUND AND OBJECTIVE: Human cytomegalovirus (HCMV) infection and disease remain a major cause of morbidity and mortality after bone marrow transplantation. HCMV disease, especially pneumonitis, may be treated with ganciclovir and immunoglobulin but even so the outcome is poor with mortality rates of 30-70%. It is therefore imperative to treat HCMV infection before it develops into disease. The aim of this article is to describe the main strategies used to prevent HCMV infection and to improve the survival after CMV disease in bone marrow transplant recipients. INFORMATION SOURCES: In the present review, we examined personal papers in this field and articles published in journals covered by the Science Citation Index and Medline. STATE OF THE ART: Major advances have been made in preventing HCMV infection and disease through two different approaches, both of which reduce HCMV induced morbidity and mortality: In pre-emptive therapy, patients are given ganciclovir when HCMV infection is first identified and this is continued 3-4 months after transplantation; in prophylactic therapy ganciclovir is given to all patients at risk of HCMV disease from engraftment up to 3-4 months post transplantation. Each strategy has advantages and disadvantages and there is no evidence for the superiority of one over the other since the overall survival is the same and the incidence of death from HCMV disease is similar. PERSPECTIVES: The use of more sensitive tests such as HCMV PCR or antigenemia may improve the outcome but probably will not eradicate all HCMV disease. Future possible strategies could include adoptive transfer of CD8+ HCMV-specific cytotoxic T lymphocytes clones derived from the donor marrow or boosting donor or patient immunity using subunit anti-HCMV vaccines such as gB or pp65.     

Abortive human cytomegalovirus infection in patients after allogeneic bone marrow transplantation.

Infection with human cytomegalovirus (HCMV) after allogeneic bone marrow transplantation (BMT) was studied in 12 HCMV seronegative recipients of marrow from seropositive donors by weekly monitoring of cultures, expression of HCMV antigenemia (pp65) in granulocytes, polymerase chain reaction (PCR) on HCMV-DNA in granulocytes and IgM and IgG anti-HCMV antibodies. Eight patients remained negative in all tests as did 33 HCMV seronegative recipients of marrow from seronegative donors. In four patients, a transient expression of HCMV antigen pp65 in granulocytes from peripheral blood, together with a positive PCR on HCMV-DNA from the same samples were found without positive cultures, seroconversion or expression of other HCMV antigens in granulocytes. The data indicate the presence of an abortive HCMV infection in these four patients.     

The immunosuppressive effect of human cytomegalovirus infection in recipients of allogeneic hematopoietic stem cell transplantation

In immune-competent individuals, human cytomegalovirus (HCMV) infection is associated with impairment of T-cell function. Our goal was to evaluate prospectively whether clinically asymptomatic HCMV infection in allogeneic hematopoietic stem cell transplantation (alloHSCT) recipients, treated pre emptively with ganciclovir, influences T-cell function as well. Mitogen-stimulated T-cell proliferative activity, together with cell surface markers, was tested in 49 patients on days + 30, + 45, + 60, and + 90 after alloHSCT and, additionally, in cases of positive HCMV pp65-antigenemia. HCMV infection was diagnosed in 19 patients. None of them developed HCMV disease. T-cell proliferative activity was significantly decreased on days when HCMV antigenemia was positive as compared to days without antigenemia. The number of pp65-positive cells negatively correlated with proliferative response. Comparison of patients who did experience HCMV infection with those who did not reveals significant decrease of T-cell proliferative activity observed on days + 30 and + 45, a time period when antigenemia was most frequently found to be positive, whereas no difference was detected on days + 60 and + 90. We conclude that, even clinically asymptomatic, HCMV infection has negative impact on T-cell proliferation capacity in alloHSCT recipients. However, pre emptive therapy with ganciclovir makes this immunosuppressive effect transient and restricted to the time of infection duration.     

Mechanisms of human cytomegalovirus (HCMV) (re)activation and its impact on organ transplant patients

Human cytomegalovirus (HCMV) infection plays an important role in transplant patients. Its impact is both direct and indirect. This review focuses on new aspects of HCMV (re)activation and HCMV related pathology, particularly HCMV-associated renal allograft injury. During the last two years we have learned that HCMV is more frequently (re)activated, even in healthy people, than previously expected. Inflammatory as well as stress mediators and some drugs may (re)activate the virus by using distinct intracellular pathways. Commonly, HCMV (re)activation is accompanied by HCMV antigenemia/DNAemia, suggesting that precursor cells in the bone marrow play an important role as a reservoir of latent virus. However, local HCMV (re)activation (colon, lung) without detection of active HCMV infection in the peripheral blood is possible. In healthy people a sufficient type 1 T-cell response controls the active HCMV infection, while in patients with severe immune deficiency (AIDS, high-dose immunosuppression) the virus can spread in an uncontrolled fashion and induce ‘classic’ HCMV disease. In patients with moderate immune deficiency (e.g. long-term transplant patients on low-dose immunosuppression) virus spreading is controlled but the elimination of cells harboring the active virus may be insufficient. The resulting persistent HCMV antigenemia may induce chronic inflammatory processes leading to tissue injury, particularly in the allograft. Therefore, antiviral therapy may be useful in patients suffering from graft deterioration with otherwise clinically symptomless HCMV infection. HCMV-related immune deficiency with an increased risk of developing bacterial/fungal superinfections is frequently seen in patients with symptomatic HCMV disease but not in asymptomatic CMV antigenemia. The risk of developing superinfections can be predicted by flow-cytometric monitoring of peripheral blood monocytes.     

Evaluation of the COBAS Amplicor HCMV Monitor for early detection and monitoring of human cytomegalovirus infection after allogeneic stem cell transplantation

Early diagnosis of human cytomegalovirus (HCMV) infection and the introduction of preemptive antiviral therapy have reduced HCMV-related mortality after allogeneic stem cell transplantation. A critical goal remains stratifying risk profiles and minimizing potential harm owing to antiviral overtreatment. We compared the commercially available standardized COBAS Amplicor CMV Monitor (CACM) to an in-house PCR assay, for the monitoring of HCMV infection. Seventy-two patients were surveyed by an in-house PCR of whole blood, quantitative viral load assessment by CACM and virus culture assays in a prospective and a retrospective study. A high concordance between CACM and PCR was documented. The viral load at onset correlated with the peak viral load (Spearman rank correlation R=0.634, P=0.0004). In patients developing HCMV disease, both viral loads were in trend higher (P=0.823, respectively P=0.053), and the viremic episodes longer (P=0.015), as compared to asymptomatically HCMV-infected patients. The serological pre-transplant status was the major risk factor for the development of HCMV disease, showing highest risk for seropositive patients receiving a seronegative graft, whereas donor type (related or unrelated) and graft type (bone marrow or peripheral blood mobilized stem cells) did not have an influence. HCMV infection proved to be a risk factor for the development of non-viral opportunistic infections (P=0.002).     

High-dose acyclovir and pre-emptive ganciclovir in prevention of cytomegalovirus disease in pediatric patients following peripheral blood stem cell transplantation

Cytomegalovirus (CMV) disease remains an important cause of morbidity and mortality in patients undergoing hematopoietic stem cell transplantation (HSCT). We evaluated high-dose acyclovir (HDACV) and pre-emptive ganciclovir to prevent CMV disease in 76 children who underwent peripheral blood stem cell transplantation (PBSCT) and were at risk for CMV reactivation and disease (both recipient and donor seropositive) from May 1998 to April 2003. All received HDACV from day -9 to 6 months post transplant in conjunction with weekly CMV pp65 antigenemia monitoring. The incidence of antigenemia in this cohort was 19.7%, at a median of 22 days post-PBSCT. The frequencies were 26.4 and 4.4% in allogeneic and autologous groups, respectively (P=0.03). Patients with nonmalignant disease had higher CMV antigenemia than those with malignant disease (30.8 vs 8.1%, P=0.02). Age at PBSCT, sex, graft-versus-host disease (GVHD) prophylaxis regimen and presence of acute GVHD did not affect the risk of CMV antigenemia. None of the patients who had positive pp65 antigenemia developed CMV disease during the study period. We conclude that pp65 antigenemia-guided HDACV and pre-emptive ganciclovir may prevent CMV disease in children undergoing PBSCT.     

Drug-resistant human cytomegalovirus infection in children after allogeneic stem cell transplantation may have different clinical outcomes

Three seropositive pediatric recipients of allogeneic stem cell transplantation out of a group of 42 patients receiving T-cell-depleted, unrelated transplants and 37 patients receiving T-cell-depleted, haploidentical transplants were monitored longitudinally for human cytomegalovirus (HCMV) infection and the emergence of antiviral drug resistance. Early in the posttransplant course, all 3 patients developed HCMV mutations conferring drug resistance to ganciclovir. One child additionally developed multidrug resistance to foscarnet and cidofovir, with mutations in the viral phosphotransferase gene (UL97) and the DNA-polymerase gene (UL54) being found. These data show that resistant HCMV infection does not necessarily correlate with a severe clinical outcome. The early detection of genotypic resistance up to 129 days before the emergence of phenotypic resistance and the dissociation of resistance patterns among different body sites emphasize the importance of genotypic analyses of different DNA specimens for an efficient antiviral therapy. T-cell-depleted children having transplantation might be at an increased risk for the development of drug resistance.     

High-dose acyclovir and pre-emptive ganciclovir to prevent cytomegalovirus disease in myeloablative and non-myeloablative allogeneic stem cell transplantation

We evaluated high-dose acyclovir and pre-emptive ganciclovir to prevent cytomegalovirus disease in myeloablative and non-myeloablative allogeneic stem cell transplantation. One hundred and seventy-four consecutive patients who were at risk for CMV infection (either recipient or donor seropositive) and received either intensive chemoradiotherapy and a T cell-depleted stem cell transplant followed by delayed add-back of donor T cells (TCDT: n = 98), or a non-myeloablative preparative regimen followed by an unmanipulated peripheral blood stem cell transplant (NMT: n = 76) from an HLA-identical sibling donor were studied. All received high-dose acyclovir (HDACV) from day - 7 for 3 months post-transplant in conjunction with weekly CMV pp65 antigenemia monitoring and pre-emptive treatment with intravenous immunoglobulin (not CMV-specific) and ganciclovir. The actuarial probabilities of developing pp65 antigenemia were 83 +/- 4% after TCDT and 41 +/- 6% after NMT (P < 0.00001) with reactivation occurring earlier in the TCDT group (the median 36 days vs 55 days). We observed no reactivation of CMV in seronegative recipients with a seropositive donor (n = 23). A total of 11 patients (5 in TCDT, 6 in NMT) developed CMV disease within 400 days after transplantation, and one death was clearly attributable to CMV interstitial pneumonitis (IP). This strategy was associated with effective control of CMV antigenemia in the majority of patients and near-complete eradication of fatal CMV IP.     

Systemic nocardiosis following allogeneic bone marrow transplantation

Abstract: Five cases of systemic Nocardia infection were diagnosed among 301 allogeneic bone marrow transplant recipients. A sixth case included in this report received her transplant at another institution. The cumulative annual incidence rate of this infection was 1.75%. All patients had been treated previously for acute graft-versus-host disease (GVHD). At the time of diagnosis of systemic Nocardia infection, a median of 198 (range 148–1121) days after transplantation, all patients had extensive chronic GVHD and were taking 2 to 3 immunosuppressive medications. Prior to diagnosis of Nocardia infection patients had experienced multiple opportunistic infections, including infections with Mycobacterium avium-intracellulare, Pneumocystis carinii , and cytomegalovirus antigenemia. Treatment with trimethoprim-sulfamethoxazole (TMP-SMX), ceftriaxone, or carbapenem antibiotics resulted in a median survival of 219 days from the time of diagnosis and an actuarial 1-year survival of 40%. All patients who received more than 2 weeks of therapy were cured of their infections. Notably, 5/6 patients in this cohort were unable to take TMP-SMX because of myelosuppression. In comparison with randomly selected control patients, the use of pentamidine for prevention of P. carinii infection was associated with a marginal increase in the risk of Nocardia infection. We postulate that the use of TMP-SMX may be of benefit in the prophylaxis of infections other than P. carinii in patients with chronic GVHD.     

Listeriosis in recipients of allogeneic blood and marrow transplantation: thirteen year review of disease characteristics,treatment outcomes and a new association with human cytomegalovirus infection

Listeriosis is uncommon in recipients of allogeneic blood, marrow and organ transplantation. Six patients with systemic Listeria monocytogenes infection during 1985-1997 at Bone Marrow Transplantation Service, Memorial Sloan-Kettering Cancer Center are described. In two male and four female patients, the median duration from transplantation to isolation of L. monocytogenes was 62.5 (range 29 to 821) days. Among five allogeneic marrow transplant recipients, four (80%) received HLA antigen matched, T cell-depleted grafts from three unrelated and a single related donor. One patient underwent mismatched-related marrow graft transplant. Cord stem cell transplantation was performed in a single patient. Two required therapy for graft-versus-host disease (GVHD). The 13 year incidence of systemic Listeria infections was 0.47 percent. All six presented with fever (>39 degrees C), and L. monocytogenes bloodstream invasion. Mental status changes and meningioencephalitis were observed in two (33.3%). A concurrent primary opportunistic infection was present in five individuals (83.3%), and four (80%) were being treated for acute human cytomegalovirus (HCMV) viremia. Sixty-six percent responded to therapy and two died from unrelated, non-listeric causes. Systemic listeriosis was uncommon in our high-risk allogeneic blood and marrow transplantation population, and response to therapy with parenteral ampicillin and gentamicin was excellent. The association between primary HCMV reactivation and subsequent listeric infection emphasizes the significance of HCMV-related dysfunction in hosts' cellular immune responses, especially in the setting of allogeneic transplantation.     

CMV infections following allogeneic BMT: risk factors, early treatment and correlation with transplant related mortality.

BACKGROUND. The impact of early detection of CMV infections in allogeneic bone marrow transplantation (BMT) and of early treatment with ganciclovir is still uncertain. METHODS. 98 patients undergoing allogeneic BMT for hematologic malignancies (n = 91) or aplastic anemia (n = 7) were monitored weekly for the expression of the lower matrix protein pp65 of cytomegalovirus (CMV) on peripheral blood cells (PB) and urine sediments (U) as detected by C10 and C11 monoclonal antibodies (Clonab, Biotest) and immunoperoxidase. Bronchoalveolar lavage (BAL) cytospin preparations were also studied in patients with clinically documented interstitial pneumonia. Patients were considered to be infected with CMV if pp65 was detected in PB (n = 15) or BAL cells (n = 6), or in the presence of serum CMV-IgM with (n = 7) or without (n = 3) pp65-positive cells in urine sediments. RESULTS. The overall actuarial risk at 300 days of developing a CMV infection was 35%. CMV serum/status (IgG) pre-BMT of donor and/or recipient predicted the occurrence of CMV infections post-BMT: in neg/neg donor/recipient pairs (n = 17) the actuarial risk at 300 days was 0%, compared to 41% in pairs in which donor and/or recipient were CMV seropositive (n = 81) (p = 0.001). 24/31 patients were treated with ganciclovir (DHPG), and 17 survive. Mortality of patients treated early with DHPG on the basis of CMV antigenemia was 18% compared to 42% for untreated patients (p = 0.9). Pretransplant donor/recipient seropositivity accurately predicted transplant related mortality (TBM): 6% in neg/neg pairs vs 41% in all other combinations (p = 0.008). CONCLUSIONS. The risk of developing CMV infections post-BMT can be predicted by pre-transplant serostatus, diagnosed by monitoring the expression of pp65-protein and correlates with transplant related mortality. The latter appears to be reduced by early treatment with DHPG.     

Oral versus intravenous ganciclovir for the prophylaxis of cytomegalovirus disease after allogeneic bone marrow transplantation

Abstract
Background:  Prophylactic low dose i.v. ganciclovir in patients at risk after allogeneic bone marrow transplantation (BMT) is highly effective in the prevention of cytomegalovirus (CMV) disease and infection.
Aim:  In this study, we sought to assess the tolerability of oral ganciclovir in patients after allogeneic BMT.
Methods:  CMV seropositive patients or those with CMV seropositive donors were randomised to be treated with i.v. ganciclovir 5 mg/kg three times weekly or oral ganci­clovir 3 g daily from engraftment to day 84. The period of accrual was from May 1997 to October 1998. Patients were monitored for CMV infection by weekly serology. Thirty-one patients received oral ganciclovir and 27 patients received i.v. ganciclovir, the treatment groups being balanced for clinical characteristics and prognostic factors.
Results:  Renal dysfunction, transfusion requirements and significant nausea and vomiting were not different. There were no documented cases of CMV disease during the study period although three patients developed CMV polymerase chain reaction positivity at various times. One patient treated with i.v. ganciclovir developed non-fatal gastrointestinal CMV disease after the study period on day 108. Eight patients in the oral group failed to complete planned therapy, whereas two patients failed to complete the i.v. course.
Conclusion:  We conclude that oral ganciclovir is a reasonable, well-tolerated alternative to i.v. ganciclovir for the prophylaxis of CMV disease after allogeneic BMT. (Intern Med J 2004; 34: 98−101)     

Fatal cytomegalovirus necrotising enteritis in a small bowel transplantation adult recipient with low pp65 antigenaemia levels

Although advances in immunosuppressive therapy have led to increased survival of solid organ transplantation recipients, it is well established that current protocols have been associated with an increased risk of developing tissue-invasive infections. In particular, cytomegalovirus still represents an important cause of morbidity. We report a case of cytomegalovirus infection involving the graft ileum with documented necrotising enteritis that developed after small bowel transplantation. The patient, a 56-year-old Caucasian female with a postsurgery short bowel syndrome, underwent a small bowel transplantation. Immunosuppression was maintained by combination of tacrolimus, steroids and daclizumab. Both the donor and the recipient were serologically negative for cytomegalovirus IgG. Nevertheless, ganciclovir prophylaxis was given for 21 days after surgery, as standard procedure. On hospital day 174, routine pp65 antigenaemia resulted positive (14/200,000 peripheral blood leukocytes). The patient was asymptomatic and preemptive ganciclovir therapy was instituted. In the following 3 days, due to a cytomegalovirus antigenaemia increase, ganciclovir was changed to foscarnet with subsequent virological response (7/200,000 peripheral blood leukocytes, on day 181). Two days later, the patient complained of acute abdominal pain and she underwent surgery for the diagnosis. Since the intraoperative findings consisted of a diffuse acute purulent peritonitis, the intestinal graft, together with native rectum, was removed. Biopsy specimens showed evidence of tissue-invasive cytomegalovirus infection. Postsurgery, the patient developed septic shock and died on day 198 as a consequence of multiple organ failure.     

Cytomegalovirus infection after autologous bone marrow transplantation with comparison to infection after allogeneic bone marrow transplantation

Cytomegalovirus (CMV) infection was detected in 65 of 143 (45%) autologous bone marrow transplant (BMT) patients. CMV pneumonitis occurred in only 2% of the patients and CMV retinitis occurred in none. Infection occurred in half of the 40 initially seronegative patients and 47% of the 94 initially seropositive patients. Among initially seropositive patients, platelet recovery was slower in infected patients than in those not infected (97 v 35 days median, P = .003), and neutrophil recovery was slightly delayed in infected patients (31 days v 24 days, P = .02). Although the incidence of CMV infection was comparable in autologous and allogeneic BMT patients, CMV pneumonitis was less frequent in autologous BMT patients (2% v 12%, P less than .001). The risk for CMV pneumonitis in autologous BMT patients was comparable with that in allogeneic BMT patients without graft-v-host disease (GVHD) (2% v 6%), but significantly lower than the risk in allogeneic BMT patients with GVHD (2% v 23%, P less than .001).     

人巨细胞病毒 pp65基因重组蛋白在昆虫细胞中的表达与分析

目的为了制备人巨细胞病毒(HCMV)pp65基因疫苗,应用BacToBac系统对HCMVpp65基因进行表达,并对重组蛋白质的特异性及生物活性进行确定。方法通过脂质体法用HCMVpp65基因重组病毒感染Sf9昆虫细胞,并在感染的不同时期收集细胞,用特异性的HCMVpp65MAb对重组蛋白进行Westernblot,并选择HCMVIgG阳性及阴性的孕妇血清与重组蛋白进行免疫印迹反应。结果重组Bacmid大分子DNA直接转染昆虫细胞可得到100%的阳性重组病毒,病毒滴度为3×107pfu/ml,重组病毒组在感染后48h开始出现一相对分子质量为65000大小的特异带,感染后72h量明显增加,持续至感染后96h,在野生型AcNPV感染细胞及正常昆虫细胞的空白对照中未见该蛋白带。Westernblot显示目的蛋白条带与HCMVpp65MAb发生特异反应。6例阳性血清中有5例与重组pp65发生特异性反应,而阴性对照组未见特异性反应带。结论HCMVpp65基因可在Sf9昆虫细胞中有效表达,且所表达的重组蛋白pp65与人体中感染的野生型HCMVpp65具有相同的抗原性。因此有望为疫苗的制备打下基础。     

急性冠状动脉综合征患者巨细胞病毒检测及临床意义

目的：探讨人巨细胞病毒（ｈｕｍａｎ ｃｙｔｏｍｅｇａｌｏｖｉｒｕｓ,ＨＣＭＶ）感染与急性冠状动脉综合征（ａｃｕｔｅ ｃｏｒｏｎａｒｙ ｓｙｎｄｒｏｍｅ,ＡＣＳ）的关系。方法：利用人巨细胞病毒磷酸化蛋白ｐｐ７１基因引物,采用聚合酶链反应（ｐｏｌｙｍｅｒａｓｅ ｃｈａｉｎ ｒｅａｃｔｉｏｎ,ＰＣＲ）检测２２例急性冠状动脉综合征患者和３８例健康对照者外周血ＨＣＭＶ基因的表达。同时应用琼脂扩散法检测血清Ｉ     

Risk-Adapted Preemptive Therapy for Cytomegalovirus Disease after Allogeneic Stem Cell Transplantation: A Single-Center Experience in Korea

Cytomegalovirus (CMV) remains a major cause of infection in recipients of hematopoietic stem cell transplants (HSCT) and results in significant mortality and morbidity. We present the results of CMV pp65 antigenemia-guided, risk-adapted preemptive therapy aimed at preventing CMV disease in allogeneic HSCT. Preemptive ganciclovir treatment was started when more than 5 CMV antigen-positive cells were detected in the low-risk group (with grade 0-I acute GVHD and matched related HSCT) and when any antigen-positive cells were seen in the high-risk group (with grade II-IV acute GVHD or matched unrelated HSCT). At least 1 episode of antigenemia was observed in 53 (59.6%) of 89 patients before day 100, and preemptive therapy was performed in 33 patients. CMV disease occurred in 6 patients (5 in the high-risk group and 1 in the low-risk group), and late CMV disease developed in 4 patients. Only 1 patient died of CMV pneumonitis before day 100. Neutropenia was observed in 51.5% of ganciclovir-treated patients, and coinfection/superinfection was observed in 42.4%. A strategy of ganciclovir treatment focusing on patients at higher risk could reduce the toxicity from the antiviral drug and be cost-effective. Extended surveillance for CMV disease using more sensitive diagnostic methods is necessary in high-risk patients.     

Evaluation of the NucliSens CMV pp67 assay for detection and monitoring of human cytomegalovirus infection after allogeneic stem cell transplantation

Preemptive treatment based on the sensitive detection of CMV-DNA has helped to reduce HCMV-related mortality after allogeneic stem cell transplantation (SCT). Detection of active viral replication might help to better predict HCMV disease. In this study, 33 recipients at risk for HCMV infection after allogeneic SCT were prospectively monitored 1x/week for active HCMV infection by NASBA, whole blood DNA-PCR and virus culture assays. Preemptive antiviral therapy was initiated after the second positive PCR result, while NASBA results were not considered for clinical decision-making. Overall, a high agreement between PCR and NASBA on a per sample (85.3%) and per patient (87.9%) level was demonstrated. HCMV DNA titers in the blood were found to be higher in PCR(+)/NASBA(+) compared to PCR(+)/NASBA(-) samples (P < 0.01). None of the NASBA-negative patients developed HCMV disease. Sixteen of 18 patients receiving PCR-based preemptive therapy were also found NASBA positive. There was no difference between the assays for the time to the first positive test result. However, the time to the first negative test result upon initiation of antiviral therapy was significantly shorter for the NASBA assay (P = 0.002), indicating a high positive predictive value to assess the efficacy of antiviral therapy. Three patients developed late-onset HCMV disease, all of whom were found to be PCR and NASBA positive. In conclusion, the data presented clearly demonstrate the value of patient monitoring using the NASBA assay to early diagnose active HCMV infection and to assess the efficacy of antiviral therapy in high risk patients after allogeneic SCT. A prospective comparison of PCR-based vs NASBA-based preemptive therapy is ongoing.