SEARCH:   Advanced

Prepublished online as a Blood First Edition Paper on August 22, 2002; DOI 10.1182/blood-2002-07-1982. This Article Abstract Full Text (PDF) All Versions of this Article: 2002-07-1982v1 101/2/463    most recent Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Rights and Permissions Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Wolf, D. G. Articles by Kra-Oz, Z. Search for Related Content PubMed PubMed Citation Articles by Wolf, D. G. Articles by Kra-Oz, Z. Related Collections Brief Reports Clinical Trials and Observations Social Bookmarking                   What's this?  Previous Article  |  Table of Contents  |  Next Article  Blood, 15 January 2003, Vol. 101, No. 2, pp. 463-465 CLINICAL OBSERVATIONS, INTERVENTIONS, AND THERAPEUTIC TRIALS Brief report Emergence of late cytomegalovirus central nervous system disease in hematopoietic stem cell transplant recipients Dana G. Wolf, Nell S. Lurain, Tsila Zuckerman, Ron Hoffman, Judith Satinger, Alik Honigman, Niveen Saleh, Emanuel S. Robert, Jacob M. Rowe, and Zipora Kra-Oz From the Hadassah University Hospital, Jerusalem, Israel; Rush-Presbyterian-St Luke's Medical Center, Chicago, IL; Rambam Medical Center, Haifa, Israel.     Abstract Top Abstract Introduction Study design Results and discussion References Preemptive ganciclovir therapy has reduced the occurrence of early cytomegalovirus (CMV) disease after hematopoietic stem cell (HSC) transplantation. However, late disease is increasingly reported. We describe 2 patients who developed late CMV central nervous system (CNS) disease after haploidentical HSC transplantation. Direct genotypic analysis was used to examine the presence of ganciclovir resistance. One patient had a mixed viral population in the cerebrospinal fluid (CSF), with coexistent wild-type and mutant UL97 sequences. The presence of 2 different strains was confirmed by subclone sequencing of the UL54 gene. One of the strains was different from the concurrent blood strain. The second patient had resistant variant in the lungs. These cases raise concern about the changing natural history of CMV disease in HSC transplantation, with emergence of previously uncommon manifestations following prolonged prophylaxis. Under these circumstances the CNS may be a sanctuary site, where viral persistence and antiviral drug resistance could result from limited drug penetration. (Blood. 2003;101:463-465) © 2003 by The American Society of Hematology.     Introduction Top Abstract Introduction Study design Results and discussion References Despite the availability of potent antiviral drugs, cytomegalovirus (CMV) remains a significant complication after hematopoietic stem cell (HSC) transplantation.1 The widespread use of prophylactic and preemptive ganciclovir therapy has reduced the occurrence of early CMV disease; however the development of late disease is increasingly recognized.2,3 Prolonged ganciclovir exposure may also lead to the selection of ganciclovir-resistant strains.4,5 Ganciclovir resistance results mainly from impaired phosphorylation of the drug, caused by mutations in the CMV UL97 phosphotransferase.5-8 Less frequently, resistance is caused by mutations in the UL54 (DNA polymerase) gene.9,10 Until recently, ganciclovir resistance has been described mainly among AIDS patients receiving prolonged maintenance therapy.4,7,11 Over the past few years, ganciclovir resistance has been increasingly reported among solid-organ transplant recipients, especially those with high viral load and lengthened antiviral exposure.12,13 Thus far, there have been only anecdotal reports of ganciclovir resistance among hematopoietic stem cell transplant (HSCT) recipients.14 We and others have described the emergence of ganciclovir resistance in children after HSC transplantation.15,16 Studies in adult HSCT recipients, however, demonstrated the absence of resistance after up to 56 days of cumulative ganciclovir exposure.17 Yet, with improved survival after HSC transplantation, change in immunosuppressive regimens, and longer duration of ganciclovir exposure, drug resistance in association with late disease is expected to become a growing problem in this setting. Here, we report 2 cases of late-onset CMV central nervous system (CNS) disease, which developed during preemptive antiviral therapy after HSC transplantation. Direct genotypic analysis was used to examine the role of drug resistance and compartmental differences among infecting strains in the development of this unusual manifestation.     Study design Top Abstract Introduction Study design Results and discussion References Patients The 2 patients were treated at the Rambam Medical Center, Haifa, Israel, where a total of 138 patients received allogeneic HSCT (28 of which were haploidentical) between January 1999 and January 2002. After transplantation, the patients received antiviral therapy with acyclovir and were monitored for CMV infection by weekly pp65 antigenemia assay. Preemptive ganciclovir therapy was instituted on positive antigenemia result. Treatment was switched to foscarnet when clinical resistance was suspected or when adverse effects necessitated discontinuation of ganciclovir. Approval was obtained from the Rambam institutional review board for these studies. Informed consent was provided according to the Declaration of Helsinki. Patient 1. A 30-year-old woman with acute myeloid leukemia (AML) diagnosed 1.5 year previously (M2 t(6;9), second complete remission) received haploidentical T-cell-depleted HSCT from her sister. Both patient and donor were CMV seropositive (D+/R+). Conditioning regimen included total body irradiation, thiotepa, fludarabine, and antithymocytic globulin. Her initial transplantation course was unremarkable. Starting from day 19, recurrent episodes of CMV reactivation were noted, which were treated by preemptive therapy (Figure 1A). Her subsequent course was further complicated by chronic graft-versus-host disease (GVHD) treated with steroids and lymphopenia (CD4 30 cells/mm3). On day 285, the patient presented with acute confusional state. Cerebrospinal fluid (CSF) polymerase chain reaction (PCR) was positive for CMV, and brain magnetic resonance imaging (MRI) showed diffuse white matter changes. The patient subsequently developed disseminated disease with CMV pneumonitis and died despite combined treatment with ganciclovir, foscarnet, and anti-CMV immunoglobulins. View larger version (17K): [in this window] [in a new window]   Figure 1. Recurrent CMV reactivation in patients who developed late-onset CMV disease following preemptive therapy. (A, patient 1; B, patient 2) Thick line, induction treatment; dotted line, maintenance treatment; arrow, time of diagnosis of disease. Patient 2. A 54-year-old man with AML diagnosed 3 months previously (M2; monosomy 7, first complete remission) received haploidentical T-cell-depleted HSCT from his daughter. CMV serostatus was D/R. Conditioning regimen included thiotepa, fludarabine, and melphalan. During the neutropenic period, the patient received granulocyte infusion from CMV-seropositive donor because of severe life-threatening perianal abscess. His subsequent course was characterized by recurrent episodes of CMV infection, starting from day 45 (Figure 1B). Severe GVHD developed from day 140. On day 201, low-grade fever developed with confusion and disorientation. CSF PCR was positive for CMV. CMV pneumonitis was also evident. The patient was treated with ganciclovir and foscarnet but died shortly thereafter. Amplification and sequencing of the CMV UL97 and UL54 genes Direct PCR sequencing was performed as described7,10,15 by using overlapping primer pairs encompassing nucleotides 1207 to 1979 (UL97) and 900 to 3000 (UL54). These regions include all of the known resistance mutations. For subclone sequencing, PCR products were inserted into p-Gem-T vector, transformed into Escherichia coli DH-5, and both strands of the inserts were sequenced.     Results and discussion Top Abstract Introduction Study design Results and discussion References CMV CNS disease had been exceedingly rare in HSCT recipients in the era that predated the use of preventive antiviral therapy. In patients with advanced AIDS, CMV CNS disease often develops during therapy for human CMV (HCMV) retinitis and can result from ganciclovir-resistant strains.18,19 The development of late disease after cumulative ganciclovir therapy of 252 and 103 days suggested the presence of resistant virus. Indeed, direct genotypic analysis revealed the presence of viral strains with UL97 ganciclovir-resistance mutations in the blood and CNS in patient 1 and in the lungs in patient 2 (Table 1). The amino acid substitutions found in the UL54 gene were not associated with resistance.                                View this table: [in this window] [in a new window]   Table 1. CMV UL97 and UL54 amino acid substitutions in HSCT recipients with late-onset CMV disease Potential risk factors for late disease with ganciclovir resistance were haploidentical T-cell-depleted HSCT with myeloablative conditioning. Delayed immune reconstitution together with GVHD in these patients could allow for continuous high-rate virus replication (as reflected by the antigenemia) with emergence of resistant strains under drug pressure. Notably, similar underlying factors were identified in a recent series of HSCT recipients who developed HCMV retinitisanother uncommon manifestation.20 Thus, the shift in the epidemiology of CMV in HSCT recipients to late-onset disease may be associated with the emergence of unusual manifestations, previously considered characteristic of AIDS patients. The pathogenesis of late CMV CNS disease after HSC transplantation is not clear. The virus may have migrated to the brain during preceding episodes of viremia. Interestingly, direct sequencing revealed the presence of mixed viral sequences in the CSF of patient 1, with different resistance mutations in the blood and CSF. To determine the number of strains represented, we subcloned the UL54 product (nucleotides 2400 to 3000). The results showed the presence of at least 2 different strains in the CNS, one of which was different from the concurrent blood strain by 16 nucleotides. The CMV serostatus of patient 1 was D+/R+. Thus, there are 2 identifiable sources for multiple circulating strains. The serostatus of patient 2 was D/R, which points to a single source of virus from granulocyte infusion. The finding of different strains in the blood and CNS raises the possibility of a unique mechanism for CNS disease in HSCT recipients: recent studies of gene delivery to the brain have shown that after bone marrow (BM) transplantation, donor-derived BM cells repopulate the CNS with subsequent differentiation into microglia, neurons, and astrocytes.21-23 Because BM progenitor cells are a major reservoir of latent CMV,24 the CNS could potentially become an acquired site of CMV latency in HSCT recipients. Low penetration of antiviral drugs to the CNS, along with impaired local immune surveillance, may favor persistent replication with possible emergence of resistant strains. As demonstrated in AIDS patients, the presence of multiple strains may be associated with more severe disease.25 Compartmental differences among infecting strains, found in the 2 patients, suggest that direct genotypic analysis in the blood may not always predict the resistance profile in the tissues. In conclusion, the cases described herein raise concern about the changing natural history of HCMV disease in HSC transplantation. Under these circumstances, the CNS may become a viral sanctuary site. New antiviral agents with different mechanisms and better penetration are needed to deal with the emergence of late-onset drug-resistant CMV in HSCT recipients.     Acknowledgments The work was carried out in the Straus Molecular Diagnostics Core Facility, Hadassah University Hospital, Jerusalem, Israel.     Footnotes Submitted July 3, 2002; accepted August 9, 2002. Prepublished online as Blood First Edition Paper, August 22, 2002; DOI 10.1182/blood-2002-07-1982. Supported by grants from the Israel Science Foundation and Israel Cancer Association, and a grant from the Samuel and Dora Straus Foundation, New York, NY. The publication costs of this article were defrayed in part by page charge payment. Therefore, and solely to indicate this fact, this article is hereby marked "advertisement" in accordance with 18 U.S.C. section 1734. Reprints: Dana G. Wolf, Department of Clinical Microbiology & Infectious Diseases, Hadassah University Hospital, POB 12000, Jerusalem, Israel 91120; e-mail: wolfd{at}md2.huji.ac.il.     References Top Abstract Introduction Study design Results and discussion References 1. Hebart H, Kanz L, Jahn G, Einsele H. Management of cytomegalovirus infection after solid-organ or stem-cell transplantation: current guidelines and future prospects. Drugs. 1998;55:59-72[Medline] [Order article via Infotrieve]. 2. Boeckh M. Current antiviral strategies for controlling cytomegalovirus in hematopoietic stem cell transplant recipients: prevention and therapy. Transpl Infect Dis. 1999;1:165-178[CrossRef][Medline] [Order article via Infotrieve]. 3. Nguyen Q, Champlin R, Giralt S, et al. Late cytomegalovirus pneumonia in adult allogeneic blood and marrow transplant recipients. Clin Infect Dis. 1999;28:618-623[Medline] [Order article via Infotrieve]. 4. Drew WL, Miner RC, Busch DF, et al. Prevalence of resistance in patients receiving ganciclovir for serious cytomegalovirus infection. J Infect Dis. 1991;163:716-719[Medline] [Order article via Infotrieve]. 5. Chou S. Antiviral drug resistance in human cytomegalovirus. Transpl Infect Dis. 1999;1:105-114[CrossRef][Medline] [Order article via Infotrieve]. 6. Sullivan V, Talarico CL, Stanat SC, Davis M, Coen DM, Biron KK. A protein kinase homologue controls phosphorylation of ganciclovir in human cytomegalovirus-infected cells. Nature. 1992;358:162-164[CrossRef][Medline] [Order article via Infotrieve]. 7. Wolf DG, Smith IL, Lee DJ, Freeman WR, Flores-Aguilar M, Spector SA. Mutations in human cytomegalovirus UL97 gene confer clinical resistance to ganciclovir and can be detected directly in patient plasma. J Clin Invest. 1995;95:257-263[Medline] [Order article via Infotrieve]. 8. Chou S, Waldemer RH, Senters AE, et al. Cytomegalovirus UL97 phosphotransferase mutations that affect susceptibility to ganciclovir. J Infect Dis. 2002;185:162-169[CrossRef][Medline] [Order article via Infotrieve]. 9. Smith IL, Cherrington JM, Jiles RE, Fuller MD, Freeman WR, Spector SA. High-level resistance of cytomegalovirus to ganciclovir is associated with alterations in both the UL97 and DNA polymerase genes. J Infect Dis. 1997;176:69-77[Medline] [Order article via Infotrieve]. 10. Chou S, Lurain NS, Weinberg A, Cai GY, Sharma PL, Crumpacker CS. Interstrain variation in the human cytomegalovirus DNA polymerase sequence and its effect on genotypic diagnosis of antiviral drug resistance. Adult AIDS Clinical Trials Group CMV Laboratories. Antimicrob Agents Chemother. 1999;43:1500-1502[Abstract/Free Full Text]. 11. Jabs DA, Martin BK, Forman MS, et al. Longitudinal observations on mutations conferring ganciclovir resistance in patients with acquired immunodeficiency syndrome and cytomegalovirus retinitis: The Cytomegalovirus and Viral Resistance Study Group Report Number 8. Am J Ophthalmol. 2001;132:700-710[CrossRef][Medline] [Order article via Infotrieve]. 12. Limaye AP, Corey L, Koelle DM, Davis CL, Boeckh M. Emergence of ganciclovir-resistant cytomegalovirus disease among recipients of solid-organ transplants. Lancet. 2000;356:645-649[CrossRef][Medline] [Order article via Infotrieve]. 13. Limaye AP, Raghu G, Koelle DM, Ferrenberg J, Huang ML, Boeckh M. High incidence of ganciclovir-resistant cytomegalovirus infection among lung transplant recipients receiving preemptive therapy. J Infect Dis. 2002;185:20-27[CrossRef][Medline] [Order article via Infotrieve]. 14. Erice A. Resistance of human cytomegalovirus to antiviral drugs. Clin Microbiol Rev. 1999;12:286-297[Abstract/Free Full Text]. 15. Wolf DG, Yaniv I, Honigman A, Kassis I, Schonfeld T, Ashkenazi S. Early emergence of ganciclovir-resistant human cytomegalovirus strains in children with primary combined immunodeficiency. J Infect Dis. 1998;178:535-538[Medline] [Order article via Infotrieve]. 16. Eckle T, Prix L, Jahn G, et al. Drug-resistant human cytomegalovirus infection in children after allogeneic stem cell transplantation may have different clinical outcomes. Blood. 2000;96:3286-3289[Abstract/Free Full Text]. 17. Gilbert C, Roy J, Belanger R, et al. Lack of emergence of cytomegalovirus UL97 mutations conferring ganciclovir (GCV) resistance following preemptive GCV therapy in allogeneic stem cell transplant recipients. Antimicrob Agents Chemother. 2001;45:3669-3671[Abstract/Free Full Text]. 18. Wolf DG, Spector SA. Diagnosis of human cytomegalovirus central nervous system disease in AIDS patients by DNA amplification from cerebrospinal fluid. J Infect Dis. 1992;166:1412-1415[Medline] [Order article via Infotrieve]. 19. Wolf DG, Lee DJ, Spector SA. Detection of human cytomegalovirus mutations associated with ganciclovir resistance in cerebrospinal fluid of AIDS patients with central nervous system disease. Antimicrob Agents Chemother. 1995;39:2552-2554[Abstract]. 20. Crippa F, Corey L, Chuang EL, Sale G, Boeckh M. Virological, clinical, and ophthalmologic features of cytomegalovirus retinitis after hematopoietic stem cell transplantation. Clin Infect Dis. 2001;32:214-219[CrossRef][Medline] [Order article via Infotrieve]. 21. Priller J, Flugel A, Wehner T, et al. Targeting gene-modified hematopoietic cells to the central nervous system: use of green fluorescent protein uncovers microglial engraftment. Nat Med. 2001;7:1356-1361[CrossRef][Medline] [Order article via Infotrieve]. 22. Brazelton TR, Rossi FM, Keshet GI, Blau HM. From marrow to brain: expression of neuronal phenotypes in adult mice. Science. 2000;290:1775-1779[Abstract/Free Full Text]. 23. Mezey E, Chandross KJ, Harta G, Maki RA, McKercher SR. Turning blood into brain: cells bearing neuronal antigens generated in vivo from bone marrow. Science. 2000;290:1779-1782[Abstract/Free Full Text]. 24. Kondo K, Xu J, Mocarski ES. Human cytomegalovirus latent gene expression in granulocyte-macrophage progenitors in culture and in seropositive individuals. Proc Natl Acad Sci U S A. 1996;93:11137-11142[Abstract/Free Full Text]. 25. Leach CT, Detels R, Hennessey K, et al. A longitudinal study of cytomegalovirus infection in human immunodeficiency virus type 1-seropositive homosexual men: molecular epidemiology and association with disease progression. J Infect Dis. 1994;170:293-298[Medline] [Order article via Infotrieve]. © 2003 by The American Society of Hematology.   CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this? This article has been cited by other articles: N. Stern-Ginossar, N. Saleh, M. D. Goldberg, M. Prichard, D. G. Wolf, and O. Mandelboim Analysis of Human Cytomegalovirus-Encoded MicroRNA Activity during Infection J. Virol., October 15, 2009; 83(20): 10684 - 10693. [Abstract] [Full Text] [PDF] C. Bressollette-Bodin, A. Claver, D. Boutolleau, P. Chevallier, T. Guillaume, T. Gastinne, P. Moreau, J-L. Harousseau, B.M. Imbert-Marcille, and S. Le Gouill Surgical treatment of a foscavir-resistant atypical Cytomegalovirus pneumonia in an allogeneic stem cell transplant recipient Haematologica, May 1, 2008; 93(5): e39 - e41. [Full Text] [PDF] C. Gilbert and G. Boivin Human Cytomegalovirus Resistance to Antiviral Drugs Antimicrob. Agents Chemother., March 1, 2005; 49(3): 873 - 883. [Full Text] [PDF] K. L. Springer, S. Chou, S. Li, R. H. Giller, R. Quinones, J. E. Shira, and A. Weinberg How Evolution of Mutations Conferring Drug Resistance Affects Viral Dynamics and Clinical Outcomes of Cytomegalovirus-Infected Hematopoietic Cell Transplant Recipients J. Clin. Microbiol., January 1, 2005; 43(1): 208 - 213. [Abstract] [Full Text] [PDF] A.-M. Fillet, L. Auray, S. Alain, K. Gourlain, B. M. Imbert, F. Najioullah, G. Champier, S. Gouarin, J. Carquin, N. Houhou, et al. Natural Polymorphism of Cytomegalovirus DNA Polymerase Lies in Two Nonconserved Regions Located between Domains Delta-C and II and between Domains III and I Antimicrob. Agents Chemother., May 1, 2004; 48(5): 1865 - 1868. [Abstract] [Full Text] [PDF] This Article Abstract Full Text (PDF) All Versions of this Article: 2002-07-1982v1 101/2/463    most recent Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Rights and Permissions Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Wolf, D. G. Articles by Kra-Oz, Z. Search for Related Content PubMed PubMed Citation Articles by Wolf, D. G. Articles by Kra-Oz, Z. Related Collections Brief Reports Clinical Trials and Observations Social Bookmarking                   What's this?

	Copyright © 2003 by American Society of Hematology         Online ISSN: 1528-0020