key: cord-014965-efmozngq
authors: nan
title: Infectious diseases other than CMV (1st Section)
date: 2001-06-11
journal: Bone Marrow Transplant
DOI: 10.1038/sj.bmt.1702942
sha: 
doc_id: 14965
cord_uid: efmozngq

nan

performed after culturing CD34+ cells for 3 days, we observed the same effect as described above. However, when CD34+ cells were cultured for 7 days prior to infection, a comparable suppression of cell expansion could be found for both HHV-6 variants A and B. Our results suggest, that HHV-6A may influence the expansion of more immature progenitor cells, whereas HHV-6B displays a suppressive effect only on more mature, differentiated cells in vitro.

W.H. Krü ger, N. Krö ger, M. Abromeit, H. Renges, F. Tö gel, J. Schrum, P. Schafhausen, R. Erttmann, H. Kabisch, A.R. Zander (Hamburg, D) Patients with a positive history of systemic fungal infection undergoing allogeneic SCT are highly endangered by reactivation of their infection. For such patients some attempts of antimycotic prophylaxis with low dose conventional amphotericin-B (Am-B) have been reported. However, the major side effect of conventional Am-B is nephrotoxicity. Here, we report data of patients grafted under the protection of liposomal (lip) Am-B. 37 patients (w/m: 14/23) with a median age of 37 (2-65) years underwent allogeneic mrd (n=19), mud (n=14), syngeneic (n=2) or autologous SCT (n=2) for treatment of AL (n=24), CML (n=7), MDS (n=4), SAA (n=1), and granulomatosis (n=1). All patients had a history of fungal pneumonia with evidence for Aspergillus spp. as infectious agent in 17 cases. Three patients had suffered from Aspergillus sinusitis (n=2) and aspergillosis of the bone, respectively. Fungal infection was culture-documented in 8 cases. X-ray examination or clinical parameters led to the diagnosis in 29 cases. Therapy with Lip-AmB was started either primarily (n=18) or after a short course of conventional Am-B (n=15) or itraconazole (n=4). Lip-AmB was initiated on day +3 (-10-69) for a median duration of 19 days (2-63). The start dose of 2,7 (0,6-5) mg/kg was increased to 2,9 (1,0-8,2) mg/kg in some patients. Lip-AmB was excellently tolerated, fever and chills occurred in two patients. Creatinine showed a slight increase to 137% (85%-667%) of the base line probably not related to Lip-AmB. After a median follow-up of 28 (8-78) days 22 (60%) patients were discharged without evidence for fungal infection. 3/8 (38%) of patients with history of culture-documented mycosis died from relapse of C. krusei septicaemia (n=1), from CNS bleeding probably related to relapsed aspergillosis and from multi-organ failure without culture-proven mycosis. 5 patients have died from aspergillosis (n=2) or candidosis. One of these patients had to be grafted during active aspergillosis of the lung for disease-specific reasons. The remaining seven patients have died from multi-organ failure (n=4), GvHD and septicaemia (n=1) and pneumonia (n=2) related to bacterial infection in two cases. Patients with a history of preceding mycotic infection are at high risk to acquire potentially fatal infections under SCT. However, our data clearly show that only 7/37 (19%) of our patients developed culture-positive fungal infection during severe immunosuppression. We conclude that a history of preceding fungal infection is no contraindication for stem cell transplantation. Between 1/96 and 9/98, 17 out of 270 pts manifested proven or possible TXO after allogeneic SCT. During this period 4/17 patients died from TXO as primary cause of death. Since 10/98 we started a prospective randomized monocentric study comparing TMP/SMX with PYM/DPS to prevent reactivation in patients at risk. Risk was defined as a positive serology for TXO in recipients or donors. Additionally, immunosuppression with a daily dose of more than 50 mg prednisolone was requested for inclusion. Randomization was executed when hematopoiesis appeared stable at the end of hospitalization. Arm A received TMP/SMX 2 x 160 / 800 mg twice a week (A). Arm B was treated with PYM 50 mg once a week and DPS 50 mg once a day (B). Folinic acid was given 2 x 30 mg twice a week to all pts. 111/199 pts were at risk, 67/111 were randomized and evaluable. Patients with drug related side effects discontinued prophylaxis and switched to the alternative arm after resolution. During the study, 1 pt developed lethal cerebral TXO prior to randomization. The principal reason for exclusion was cytopenia (18/44 pts), immunosuppression with PDN Ͻ50mg/d (n=25), and non signed informed consent (n=1). Prophylaxis associated side effects were equally distributed in the two study arms (Fisher exact test p=0,2). Main reason for discontinuation was cytopenia. Interestingly, the covered interval by prophylaxis was significantly longer for arm A: 160 versus 67 days, respectively (t-test: p=0.001). At a first glance, arm A seems to be better tolerated in view of the longer covered period of prophylaxis. However, longer follow up and further analysis will show whether this is due to side effects itself or to the practice of the physician to take arm B side effects more serious than those of arm A. To evaluate the influence of the helicobacter pylori (h.p.) infection on gastrointestinal complications after high-dose chemotherapy and stem cell transplantation (STX) we tested 114 patients (54 female, 60 male) by the 13C-urea breath test prior to initiation of conditioning therapy. At the initial testing 92 patients (solid tumors: 24pts., hematological malignancies: 68 pts.) showed a negative result and 22 patients (solid tumors: 9 pts., hematological malignancies: 13 pts.) a positive result without any gastrointestinal complaints. Compared to the overall incidence of h.p. infection of 19% in these patients, the subpopulation of breast cancer-patients had a higher infection rate (41%). These 114 patients with a median age of 46 years (17-60) underwent an autologous (n=95) or allogeneic transplantation (n=19). Beside gut decontamination they all received prophylaxis with intravenous ranitidin (150mg/d) which was replaced by a proton pump inhibitor (PPI) at a dose of 40mg/d i.v. if clinical symptoms of gastritis appeared. No main differences between both groups according to the occurrence of nausea/ vomitus, enteritis and mucositis could be seen. However, the incidence of severe mucositis WHOIII/IV as well as enteritis WHO III/IV was higher in h.p. positive patients (41% and 23%) in comparison with h.p. negative patients (29% and 10%). Especially in breast cancer patients (n=22) mucositis WHOIII/IV was more pronounced in the h.p. positive group (55% vs. 15% respectively). Furthermore, the occurrence of clinical signs of gastritis could not be related to the helicobacter infection: 36% of the h.p. positive vs. 45% of the h.p. negative patients felt epigastrical pain. 68% vs.71% needed treatment with a proton pump inhibitor. In conclusion helicobacter pylori infection seems not to influence the incidence of gastrointestinal complications but possibly the severity of mucositis and enteritis.

Low-dose Amphotericin B Lipid Complex (ABLC) is safe and effective as empiric anti-fungal therapy in immunocompromised patients with hematologic malignancies R. Powles, B. Sirohi, J. Mehta, S. Kulkarni, K. Murphy, B. Cheung, A. Conway, R. Saso, A. Riggs, S. Singhal, D. Cunningham, J. Treleaven (Sutton, UK) ABLC (Abelcet, The Liposome Company) is a ribbon-shaped liposomal formulation of amphotericin B consisting of dimyristoylphosphatidylcholine and dimyristoyl-phosphatidylglycerol in a 7:3 molar ratio which is especially concentrated in pulmonary tissue. It is known to be safe and effective in presumed and confirmed fungal infections in immunocompromised patients at the dose of 5 mg/kg. There are limited data on its use at lower doses. We explored low-dose ABLC in immunocompromised patients with hematologic malignancies who had fever of unknown origin which had failed to respond to combination antimicrobials, and were presumed to have fungal sepsis. 26 immunocompromised patients (15-70 y, median 44; 17 leukemia, 7 myeloma, 2 lymphoma) received 32 courses of ABLC at the median daily dose of 2 mg/kg rounded off to the nearest vial size (range, 1.3-2.7 mg/kg) after autologous (n=7) or allogeneic (n=8) stem cell transplantation or chemotherapy (n=17). The median neutrophil count at start of ABLC therapy was 0.1 x 109/L (range, 0-8.6). 14 courses of ABLC had been preceded by conventional amphotericin B and 11 by fluconazole without response. The median days of therapy with ABLC was 6 (range, 1-35). Courses of 4 doses (n=23) were considered evaluable for efficacy and all courses were evaluable for toxicity. 18 courses resulted in complete response, 3 in partial response, and 2 in failure (overall response rate 91%). The 2 failures were switched after 5 and 6 days of ABLC to 3 and 2.5 mg/kg AmBisome for 10 and 6 days respectively, grew candida and aspergillus from the sputum respectively, and died without responding. The change in serum creatinine from the beginning to the end of therapy was -56 to +54 micromol/L (median -1). 23 treatment courses had been premedicated with chlorpheniramine/hydrocortisone for the first few days. Infusion-related toxicities comprised rigors (n=9), pyrexia (n=5), hypertension (n=1), and hypotension (n=1); at least one of these toxicities was seen in 9 (28%). These data suggest that low-dose ABLC is very effective empiric anti-fungal therapy in immunocompromised patients with hematologic malignancies. Viral pneumonia is an important cause of morbidity and mortality in patients undergoing allogeneic stem cell transplantation. A previous study from the USA has found viral pathogens such as respiratory syncytial virus (RSV), influenza A and B (Flu A & B), parainfluenza (Paraflu) and adenovirus emerging as significant causes of upper and lower respiratory tract infections (Clin Inf Dis 1996; 22:778-82) . A retrospective analysis of the incidence of community respiratory viral infections in our population was carried out for the 72 allogeneic BM and PBSC transplants performed on 70 patients between January 1997 and December 1999. RSV, Flu A & B, Paraflu, adenovirus and picornavirus were detected using direct immunofluorescence testing of nasopharyngeal aspirate or bronchoalveolar lavage fluid as clinically indicated. The overall incidence of proven community respiratory viral infection was 26% in the first year post allograft (19 of 72 transplants). These consisted of 9 cases of RSV (48%), 4 of Flu A (21%), 1 of Flu B (5%), 3 of Paraflu III (16%), 1 of adenovirus (5%) and 1 of picornavirus (5%). These results are comparable to previous US studies. Six of these 19 patients (32%) had upper respiratory signs only, 3 received specific anti-viral therapy with nebulised ribavirin for RSV (1), Paraflu III (1) and Flu A (1). The other 13 patients (68%) had lower respiratory tract signs on examination and 7 had chest X-ray changes. Of this group, 9 were treated with nebulised ribavirin for RSV (7), Paraflu III (1) and Flu A (1) and 4 went on to receive IV ribavirin for RSV, one received zanamivir and amantidine for Flu A and 3 had no specific antiviral therapy for Flu A (1), Paraflu III (1) and picornavirus (1). Overall of the 19 proven infections, 12 patients made a full recovery, 2 died of RSV pneumonitis, two patients with Paraflu III died of superimposed infection, one bacterial and one fungal; neither received specific antiviral therapy and three died of unrelated causes. To conclude, prompt treatment of community respiratory viral infections may reduce morbidity and mortality in adult allogeneic BMT and PBSCT patients but respiratory viral infection was still the primary cause of death in 3% of our patients and probably contributed significantly in a further 3%.

A.J. Ullmann, K. Weise, P. Brandt, C. Huber (Mainz, D)

Objective: Patients post stem cell transplantation are at very high risk for reactivating Varicella-zoster virus [VZV] . Herpes zoster infection is frequent and has the potential to disseminate. Atypical generalized zoster is associated with an increased mortality rate. Methods: Retrospective analysis of 1282 blood samples originally collected from 53 patients for CMV-monitoring was performed. Period of analysis was approximately one year with a minimum of 5 months. Thirty-seven of the patients received an allogeneic transplantation and 16 underwent a CD34-selected autologous transplantation. PCR-primers were selected from the ORF63 of the VZV-genome. Confirmation of the positive results was performed by southern blot analysis. The patients' histories were available from their medical record and/or telephone interview. Results: None of the patients with negative blood PCR-results developed VZV-disease. Seven of the 12 allogeneic transplanted patients with at least one positive PCR-result had a VZV-disease. Three of the positive patients developed a disseminated disease. Four of the 5 patients with a positive result and no VZV-disease received at that time point polyvalent immunoglobulins. None of the five received antiviral medications. All (n=2) of the autologous transplanted patients with a positive PCR-result developed a VZV-disease. Conclusion: This retrospective analysis reveals that the PCR testing of the blood for VZV has a high sensitivity and suggests that a VZV-viremia occurs even during localized disease. A prospective study to evaluate the possibility to predict a disseminated VZV-disease is warranted.

Antimicrobial prophylaxis in EBMT centers: a report from the EBMT infectious diseases working party H. Akan, C. Cordonnier for the Infectious Diseases Working Party of the EBMT (Ankara, TR; Creteil, F)

In order to know about the anti-infectious prophylactic policies used in the EBMT centers, the IDWP run a mail-in survey regarding antibacterial, antifungal, antiviral, and immunoglobulin (IVIG) prophylaxis. The survey consisted of questions on indications and modalities (drugs, doses, duration) of prophylaxis in autologous and allogeneic SCT. Seventy-four centers from 18 countries responded. 1. Allogeneic transplant centers 67/71 centers give antibacterial prophylaxis during neutropenia, mostly by quinolones (58%) and 8/67 centers (12%) continue prophylaxis after the neutropenic phase, mostly until discharge. 69/73 (94%) centers give antifungals, at least during neutropenia, with fluconazole (48%), oral Ampho B (20.4%) or itraconazole (11.1%). Three centers give prophylaxis until discharge. Prolonging prophylaxis in case of GVHD is a common approach. The main selection criteria for antifungal prophylaxis are secondary prophylaxis (60%) and unrelated transplants (20%). 77/83 (93%) centers give antiviral prophylaxis during a mean duration of 90 days. 10 centers use Ganciclovir and 5 use Valaciclovir instead of Aciclovir for selected pts (unrelated SCT, CMV positivity). 25/73 (34%) centers give IVIG to all allogeneic pts and half of them give 0.2-0.5 g/kg/w. 20/73 (27%) centers restrict IVIG prophylaxis to selected pts (unrelated transplants, hypogammaglobulinemia, CMV positivity). 2. Autologous transplant centers 33/37 (89%) centers give prophylactic antibacterials, mainly quinolones (67%) during neutropenia, and 6 centers continue prophylaxis after the first month. 38/42 (90%) centers give prophylactic antifungals mainly fluconazole (62%), itraconazole (14%) and oral Ampho B (12%). 45/53 (85%) centers give antiviral prophylaxis mainly Aciclovir (82%) during a mean duration of 60 days. 9/48 (18%) centers give IVIG to all pts and 11/48 (23%) only to selected pts. Our survey indicate that although antimicrobial prophylaxis is common in SCT centers, there are great discrepancies in the policies used in the EBMT centers, with different regimens, selection criteria, and durations of prophylaxis. These findings indicate the need for guidelines. This survey will serve as a basis for future discussions and proposals of recommendations from the IDWP.

Radiologically guided fine needle lung biopsies in the evaluation of focal pulmonary lesions in allogeneic stem cell transplant recipients E. Jantunen, A. Piilonen, L. Volin, P. Ruutu, T. Parkkali, P. Koukila-Kahkola, T. Ruutu (Kuopio, Helsinki, FIN) Lung problems are common in allogeneic stem cell transplant (SCT) recipients. We have retrospectively evaluated feasibility and usefulness of radiologically guided fine needle lung biopsies(FNLB) in the evaluation of focal pulmonary lesions in this patient population. During a 10-year period, altogether 30 FNLBs in 21 patients were performed (1-3 biopsies/patient) guided by either ultrasound (N=17) or computed tomography (N=13). The median time from SCT to the first FNLB was 131 days (20-343 d). In addition to complications of FNLB, also biopsy findings in relation to the final diagnosis were assessed. Prophylactic platelet transfusions were given in 19 procedures (66 %). Complications of FNLB included clinically insignificant pneumothorax in four procedures (13 %) and hemoptysis in one case. The first FNLB was suggestive of invasive pulmonary aspergillosis (IPA) in six patients (29 %). Additional clinically useful findings of FNLB included Pseudomonas aeruginosa (two patients) and Nocardia (one patient). The final diagnosis was IPA in 14 patients, immunological lung problems in three patients and other in four patients. FNLB is feasible in allogeneic SCT recipients with a low complication rate. The diagnostic yield is relatively high especially in suspicion of IPA. However, re-biopsy or other diagnostic methods are often needed in patients with non-confirmatory findings on FNLB. Among chronic carriers of hepatitis B virus receiving CHT for NHL, a reactivation of virus replication has been often observed and this may give rise to hepatitis, hepatic failure and death, and may prevent from performing further therapy including trasplantation procedures. Herein we present our experience in four patients with NHL where a hepatitis flare-up was observed after 2 (in three patients) and 6 (in one patient) cycles of standard-dose chemotherapy.

The patients were affected by mantle cell, follicle centre grade III, peripheral T-cell unspecified and diffuse large B-cell lymhoma respectively, were male aged 39, 47, 52 and 62 years respectively, HCV and HIV negative. In all patients, pretreatment HBV serology was as follow: HbsAg positive, HbeAg negative, total anti-c Ab positive, IgM anti-c negative, anti-e Ab positive and anti-s Ab negative. Three of them were treated with F-MACHOP regimen, the oldest was treated with the CHOP regimen. HBV-DNA, was negative before starting chemotherapy and became positive in all four patients. After spontaneous recovery they were treated with Lamivudine 100 mg once daily and this allowed resuming and completing the chemotherapy program without another reactivation of hepatitis B. In two patients high-dose chemotherapy and autologous stem cell tranplantation was also performed under Lamivudine as a part of our program for high-risk NHL. Antiviral treatment was stopped 4 to 6 months after the last chemotherapy given. During the follow-up period they were monitored with twice-monthly blood counts, transaminases'levels and HBV-DNA: all these parameters remained normal/negative all throughout the period. Currently, patient B.S. is in CR 19 months from diagnosis and 13 months from the end of chemotherapy; patient D.F.A. is in CR 22 months from diagnosis and 12 months from the end of chemotherapy, patient V.E is in CR 34 months from diagnosis and 26 months from trasplantation; patient C.G. is in CR 23 months from diagnosis and 6 months from transplantation. This data suggests a possible role of Lamivudine in preventing hepatitis B reactivation during administration of chemotherapy and ASCT to chronic carriers of hepatitis B virus. Background: Severe acute graft-versus-host-disease (aGvHD) of the gut is still a major complication after allogeneic stem-cell transplantation (SCT) as response rates to treatment (tx) of intestinal GvHD (iGvHD) are lower than those observed for GvHD of the skin. Since TNF-alpha (TNFa) is one of the key cytokines in aGvHD, murine monoclonal antibodies (mab) against TNFa were used in GvHD-prophylaxis and also in the therapy of severe iGvHD. Infliximab, a chimeric human and mouse mab against TNFa has been introduced recently as a new tx option for pts with progressive Crohn's disease. This antibody showed also promising results in the tx of steroid-resistant (sr) aGvHD achieving response rates up to 80% in pts with iGvHD. In previous studies of our own, the combination of OKT3 and a murine mab against TNFa (MAK 195) showed potent synergistic effects without major side effects in the tx of pts with sr iGvHD. Thus it seemed reasonable to combine OKT3 and infliximab in the tx of severe sr aGvHD of the gut. Results: We report the results of a pilot study using the combination of OKT3 and infliximab as second or third-line-tx in 3 pts who developed sr aGvHD grade III to IV with severe involvement of the gut after allogeneic SCT. Infliximab was given in a dose of 5 mg/kg weekly for two weeks (i.e. three doses) combined with OKT3 5mg daily for seven days. All three pts responded well showing marked improvement of diarrhea and abdominal pain. But several days to weeks after the tx all three pts died due to severe infectious complications. One patient developed histologically proven aspergillosis of the liver, in another patient invasive aspergillosis of the gut was demonstrated at autopsy and finally the third patient developed hepatic dysfunction and pneumonia which clinically presented as fungal pneumonia and of which he died despite of antibacterial and antifungal tx. Conclusions: T cell-depletion and blocking of TNFa is an effective tx of refractory intestinal aGvHD but provokes life-threatening fungal infections. Inhibiting the inflammatory T cell response by T cell depletion and blocking the effector functions of neutrophils and macrophages by TNFa-suppression gives way to breakthrough-infections of aspergilli as could be dramatically demonstrated in our small series of three pts. We therefore conclude that pts who are really at need to receive both, T cell depleting and TNFa blocking antibodies should receive antifungal tx with substances effective against aspergilli not only in prophylactic but in full therapeutic doses. Objective: Toxoplasmosis is a rare but serious infectious complication after allogeneic BMT. By PCR, parasitemia can be detected in the peripheral blood before symptomatic disease develops. The risk factors for reactivation of toxoplasmosis, however, are unknown. Methods: We prospectively studied 28 consecutive patients seropositive for T. gondii with PCR at least fortnightly for the presence of T. gondii DNA in the peripheral blood. The following potential risk factors were evaluated: gender, age, type of preparative regimen (myeloablative or non-myeloablative), presence or absence of GVHD before parasitemia, receiving methylprednisolone before parasitemia, underlying disease (CML versus other malignancies), CMV reactivation, amount of specific IgG against T. gondii before BMT, and donor (family donor versus matched unrelated donor). Results: 8 of the 28 patients (29%) showed T. gondii DNA in the peripheral blood at a mean of 102 days after BMT (95% CI, 30 to 173 days). Of those 8 patients, four had a persistent parasitemia which could be treated successfully in two patients. The other two patients died of fulminant toxoplasmosis despite treatment. 4 of the 8 patients demonstrated only a transient parasitemia on one or two occasions. 20 patients without parasitemia were compared to the parasitemic patients. There was no statistically significant difference between the two groups with respect to age, gender, length of follow-up, amount of specific IgG against T. gondii before BMT, preparative regimen (myeloablative versus non-myeloablative), underlying disease (CML versus other malignancies), presence of GVHD, occurrence of CMV reactivation, or donor (family donor versus MUD). Only the use of methylprednisolone was observed more frequently in patients with T. gondii parasitemia (7 of 8 patients) versus the control group (10 of 20 patients); this, however, just missed statistical significance (p = 0.07 by the Fisher exact test). Conclusions: In this series of patients, no risk factor for T. gondii parasitemia could be detected. Until a population at risk can be identified in larger series, regularly monitoring allogeneic BMT patients seropositive for T. gondii may be justified for the presence of T. gondii DNA, especially if the patients receive steroid medication. ABCD consists of amphotericin and sodium cholesteryl sulfate in a 1:1 molar ratio. Between 7/99 and 7/00, 58 immunocompromised/neutropenic patients (2-71 y, median 48) with hematologic malignancies (31 acute leukemia, 16 myeloma, 4 lymphoma, 7 other) received 65 courses of ABCD at daily dose of 1 mg/kg for presumed (n=55) and 3-4 mg/kg for proven/strongly suspected (n=9; 3 microbiologic, 6 radiologic) fungal infections. ABCD administration followed allogeneic (n=14), autologous (n=17), or syngeneic (n=2) stem cell transplantation, or chemotherapy (n=32). The major indications for the use of ABCD were renal dysfunction or potassium requirements Ͼ3 mmol/kg/d on conventional amphotericin. In view of known problems with infusion-related toxicity of ABCD, each dose was administered over 4-6 h after premedication comprising 1 g paracetamol, 10 mg chlorpheniramine, 25-50 mg pethidine, 100 mg hydrocortisone and 20 mg nefopam in various combinations. Courses comprising 4 doses were evaluable for efficacy, and all courses were evaluable for toxicity. The median neutrophil count at initiation of treatment was 0 and the median baseline creatinine was 141 micromol/L (18-460). 46 courses in 43 patients (4-26 doses, median 9) were evaluable for efficacy. 9 courses in proven infections resulted in 2 complete and 4 partial responses, and 3 failures (67% response). 37 courses in presumed infections resulted in 23 complete and 4 partial responses, and 10 failures (73% response). The overall response rate was 72%. The change in serum creatinine from the beginning to the end of therapy was -145 to +331micromol/L (median -27). Despite premedication, significant infusion-related toxicity was seen: 30 (46%) rigors, 26 (40%) pyrexia, 6 (9%) bronchospasm, 6 (9%) rash, and 4 (6%) anaphylaxis. At least 1 of these toxicities was seen in 37 (57%). Tachyphylaxis developed to infusion-related reactions with subsequent doses. 12 (18%) patients experienced hepatotoxicity which could not be definitely attributed to ABCD. The underlying intervention (type of transplant or chemotherapy) did not affect efficacy or toxicity. We conclude that despite its efficacy, the high incidence of infusion-related side effects seen in ABCD-treated patients despite extensive premedication is likely to be a limiting factor in the usefulness of this drug. The frequent use of corticosteroids mandated by ABCD may be detrimental in patients who are already immunocompromised and/or neutropenic. Human Herpes Virus 6 (HHV-6) is ubiquitous through the human population, with more than 80% of adults being seropositive. The incidence of HHV-6 reactivation and its impact on morbidity in allografted recipients is poorly known. We have conducted in the last six months a prospective PCR screening of HHV-6 in 2O consecutive patients allografted in our institution (6 CML, 1 CLL, 1 HD, 4 AML, 7 ALL, 1 MDS) with 14 HLA-identical (10 related and 4 unrelated) and 6 haplo-identical donors. Acyclovir was used in all as prophylaxis. PCR screening for HHV-6 was performed twice a week on peripheral blood (PB) and on bone marrow or organs biopsies (liver, gut or skin) when available. A nested PCR using primers recognizing type A and B HHV-6 early antigen gene was used. Out of the 20 patients, five became PCR-positive, four of which displayed clinical symptoms. P1 (matched unrelated T-cell depleted transplant) engrafted normally, with grade II skin GVHD after the second DLI. HHV-6 was initially detected in a liver biopsy (day 23) performed for hepatitis associated with viral encephalopathy. He was first successfully treated with foscavir but reactivated 7 months later with the same clinical pattern. P2 (T-cell depleted haploi-identical transplant) engrafted normally without aGVHD. He was successfully treated with foscavir after detection of HHV-6 in PB at month 1 associated with encephalopathy confirmed by MRI. At month3, PCR became positive again in PB and marrow without clinical symptoms and it was decided not to treat. P3 (matched related transplant) engrafted normally, and developed limited cGVHD after early cyclosporin withdrawal for lack of molecular response. He presented with mild hepatitis at month 4. A liver biopsy was performed and revealed positive for HHV-6, with marrow and PB screening remaining negative throughout the follow-up. Foscavir treatment led to resolution of hepatitis. P4 (matched related transplant), engrafted normally without GVHD. He then became PCR positive for both CMV and HHV-6 in PB and marrow and was treated with ganciclovir with negativation of both PCR tests. We conclude that HHV-6 reactivation may be an underestimated factor of morbidity in allogeneic transplant and should therefore monitored carefully. However, PCR screening in PB does not appear as a sensitive marker as in CMV reactivation, some patients showing positivity only in the involved organ tissue and the role of PB PCR screening remains to be better defined.

J. Olson, J. Adler-Moore (Pomona, USA) Systemic candidiasis is difficult to completely eradicate using conventional treatment regimens, especially in continuously suppressed animals. It was hypothesized that with the unique pharmacokinetics of AmBi (i.e., sustained bioavailability in tissues and reduced toxicity at high doses), an intermittent, high dose treatment regimen could be designed that would be effective in clearing the infection from the kidneys of both IC and IS Candida albicans infected mice. By monitoring the kidneys for clearance at various times during treatment, it could also be determined if the immune status of the animals effected the length of treatment needed. Groups of IC or IS mice (cyclophosphamide 75 mg/kg IP, 2X/wk throughout study)(n=20/group), were challenged IV with 5.9 Log CFU (IC) or 4.8 Log CFU (IS). Beginning d2 post-challenge, IC or IS mice received IV, either 20 mg/kg AmBi or 5% dextrose, 3X/wk. After 1, 3 or 5 weeks of treatment, the amount of Candida in the kidney tissue was assessed 48h post-treatment. An additional five IC and IS mice received no further treatment after wk 5. At the end of wk 9, their kidneys were examined for the presence of fungi. Both IS and IC mice had a dose dependent, significant (pϽ0.05) reduction in median Introduction Viral respiratory infections are thought to complicate treatment of hematological malignancies frequently, but current techniques do not always yield a causative agent. Therefore, we evaluated the additional value of PCR in the detection of viral infections in haematologic cancer patients with pulmonary abnormalities on X-ray, of whom broncho-alveolair lavage (BAL) samples had been stored. Methods Between October 1997 and June 2000, we collected BAL sample from 43 patients (M/F: 28/15; median age:46). In 17 of these patients nose/troat (NT) swabs were collected within 1 week as well. After initial examination of these samples by virus culture, they were stored at -70 degrees C. PCR was done on both BAL and NT samples for the following respiratory viruses: parainfluenza virus 1,2, and 3, respiratory syncytial virus (RSV), rhinovirus, influenzavirus A and B, enterovirus and coronavirus. We compared the results of PCR detection with those of virus culture and paired serology specimens (n=29). Results Twenty-eight patients had been treated with stem cell transplantation (SCT) for their underlying diseases (allo-SCT: 24, auto-SCT: 4), and 15 patients had been treated with cytotoxic agents for leukaemia (n=11) or NHL (n=4). On presentation with respiratory symptoms 17 patients were neutropenic and 27 patients were on immunosuppressive medication. Virus cultures of BAL showed 9 respiratory viruses in 8 patients, that were also detected by PCR. In addition, PCR was able to detect 8 respiratory viruses in another 7 patients. Interestingly, when from a patient both BAL and NT samples were available (n=7) PCR on NT swabs yielded the same results as PCR on BAL samples. Serological examination only detected a RSV infection in 4 patients, and had no additional value over PCR. Two of 17 viral infections were acquired nosocomially. Four of 15 (27%) of patients treated with cytotoxic therapy and 11 of 28 (40%) SCT recipients developed respiratory diseases related to respiratory viruses. Six patients had a respiratory illness related to both respiratory virus and other cause (bacterial and fungal pneumonia: n=4, bronchiolitis: n=2). Conclusion PCR is more sensitive compared to direct culture and serology for the detection of respiratory viruses in patients with haematologic malignancies. Examination of NT swabs by PCR appears as sensitive as on BAL samples. Introduction : the diagnosis of Invasive Aspergillosis (IA) in neutropenic patients affected by hematological neoplasms is cumbersome, due to the difficulty of obtaining adeguate bioptic and cultural specimens, very scarce results of radiological detection of early lesions, inadeguate results of serologic tests. RT-PCR detection of DNA is still under study, and detection of galactomannan by ELISA is sensible, but not particularly specific. Patients and methods : we performed 263 seriated ELISA assays twice a week in 37 auto/alloBMT and neutropenic patients at risk for invasive mycoses (neutropenia, GVHD, high-dose chemotherapy, immunosuppressive treatment): 6 alloBMT (3 ANLL, 2 MM, 1 BC CML), 16 autoBMT (8 MM,6 NHL,2 HD), 8 ANLL, 2 SAA, 2 BC/AP CML, 1 CLL, 1 HD,1 NHL. Antifungal prophylaxis included fluconazole, itraconazole or i.v. low-dose amphotericin B (Am-B). The results of ELISA assay was considered positive in a single patient, if at least two consecutive positive tests were obtained. All febrile patients entered a program of radiological survey by weekly chest CT scan. Results : 241 assays out of 263 were negative. There were 19 positive results for 9 affected (positive) patients, developing IA as follows : 2 proven cases, and 7 probable according the revised EORTC Mycoses Study Group criteria; in all the patients positivity of ELISA assay was sustained and durable, and decreased with the efficacy of antifungal treatment. At the onset of ELISA assay positivity the chest RX was negative; while the chest CT scan detected only subtle pulmonary changes, suggestive of fungal lesions, and thereafter became diagnostic of IA. The remaining 28 patients (including 2 with borderline single positive assay and one with only a single positive test) never developed IA. Sensitivity and specificity of ELISA assay (considering proven and probable IA diagnoses) were 100%. At onset of ELISA assay positivity the patients were given 1-1.5 mg/kg/day Am-B, eventually changed to 3-5 mg/kg/day liposomal Am-B. In 2 ANLL patients, refractory to liposomal Am-B, voriconazole determined improvement of pulmonary cavitations in 1 and regression in the other patient, enabling him to undergo alloBMT. Mortality was high, reaching 50% in alloBMT and 12.5% in autoBMT recipients. Conclusion : we suggest that combination of routinary, twice a week, ELISA assay and weekly chest CT scan could enable an early diagnosis of pulmonary IA, for targeted antifungal treatment.

Respiratory virus infections in adult T-Cell depleted allograft recipients: risk factors and response to anti-viral therapy S. Chakrabarti, K. Collingham, K. Holder, C. Fegan, T. Gentle, D. Milligan (Birmingham, UK) We prospectively evaluated respiratory virus infections in 40 allograft recipients conditioned with conventional myeloablative (n=23) or non-myeloablative treatment and T-cell depleted with Campath antibodies. Throat samples were obtained weekly for 180 days. Upper and lower respiratory symptoms were evaluated by naso-pharyngeal aspirates and BAL. Parainfluenza (PIV), RSV, Influenza (IF)B and adenovirus infections were treated with ribavirin (oral, inhaled or IV) in a dose escalation regimen. IFA infections were treated with amantadine or zanamivir if unresponsive. 16 episodes of respiratory virus infection were detected in 9 patients (22%). All infections were associated with upper respiratory illness and 5 had lower respiratory involvement. PIV3 (PIV3; 5, PIV1; 1), and RSV(5) were the commonest isolates. There were four episodes of influenza (IFA 3; IFB 1) and 2 episodes of rhinovirus and a single episode of adenovirus. Six patients had infection with multiple viruses and the median number of respiratory virus isolated was 2 (range 1-4). The median time to the onset of the infection was 95 days (range 0 to 700). The duration of treatment ranged from 7 to 46 days (median 23 days). Two episodes of rhinovirus and one of IFB were self-limited and were not treated with antivirals. The adenovirus infection responded to donor lymphocytes. Two patients each with PIV and RSV required oral or iv ribavirin at 60 mg/kg/day. The 3 other episodes of PIV and 2 episodes of RSV responded to inhaled ribavirin. IFA infection responded to amantadine in one patient and another patient needed zanamivir. There was one death (11%) related to respiratory virus infection (RSV and IFA). On analysis of the risk factors, the dose of Campath antibody was the only significant factor (7 infections in 18 patients receiving 100mg Campath versus 2/22 in patients receiving a lower dose p=0.03, OR 4.5 (1.1-26). On comparing the immunological recovery, the median CD4 cell count at 3-6 months was lower in the infected group (72±45/mm3), compared to the non-infected group (186±72/mm3); p=0.003. In conclusion, multiple respiratory virus infections are frequent after T-cell depleted transplants, the dose of T-cell antibody being a significant risk factor. Infection correlated with a poor CD4 recovery at 3-6 months post-transplant. Although mortality was low, prolonged antiviral therapy added to the morbidity and cost.

Screening for Aspergillus spp. by a PCR of whole blood samples from patients with haematological disorders C. Lass-Flö rl, E. Gunsilius, D. Nachbaur, H. Einsele, M. Dierich (Austria, Germany)

We performed a screening for Aspergillus spp. by polymerase chain reaction of whole blood samples in patients with haematological disorders. In a two-year study, 121 patients admitted to the University Hospital of Innsbruck for cancer chemotherapy without clinical signs of fungal infection were prospectively screened for Aspergillus spp. In 28 of 121 (23%) patients Aspergillus DNAemia was detected. Of these patients 16 (57%) were positive only once for Aspergillus DNA but positivity was never associated with invasive aspergillosis. PCR positive episodes were short and resolved without antifungal treatment. Five patients (18%) had intermittent PCR positive results. Seven (25%) patients presented at least two consecutive positive PCR results, one of these patients developed invasive aspergillosis and another two were highly suspected of having aspergillosis. Based on the criteria of EORTC case definitions sensitivity and specificity of serial PCR monitoring were 75% and 96%. Positive PCR results became negative shortly after commencement of antifungal treatment but the changes did not correlate with clinical responsiveness to treatment in three patients. Our results indicate the potential usefullness of PCR for screening for Aspergillus spp. in patients at risk yet without antifungal treatment.

R. Herbrecht, A. Thiebaut, A. Vekhoff, F. Isnard-Grivaud, P. Moreau, G. Michel, S. Dupuis, F. Bastides, A. Datry, O. Lortholary (Strasbourg, Lyon, Paris, Nantes, Marseille, Tours, Bobigy, F) A pharmaco-epidemiology study to evaluate current therapeutic practice in treating invasive fungal infections (IFI) was carried out in 27 haematology departments between November 1998 and October 1999. Two hundred fifty two IFI were recorded, leading to an incidence of 0.92%. Therapeutic practice was analysed in the 5 last patients treated in each center for a total of 122 cases. The average age of patients was 41 years (range 1 week -78 years). One hundred and nine (89%) had a haematological malignancy. Eighty one (66%) had aspergillosis, 35 (29%) candidiasis and 6 (5%) another IFI. According to the criteria of the EORTC/MSG, aspergillosis was retrospectively graded as "proven" in 17% of the cases, as "probable" in 62% and as "possible" in 21%. Factors associated with IFI were antibiotherapy (93%), chemotherapy (74%), presence of a central veinous catheter (82%), neutropenia Ͻ 1000 ANC/µl (78% of which 42 % were severe Ͻ 100 ANC/µl), haematopoetic stem cells transplant (29% with two thirds of allografts), corticosteroid therapy (51%), immunosuppressive therapy (22%), radiotherapy (11.5%), prior IFI (9%) and diabetes (8%). Eighty eight percent of patients received nephrotoxic agents and 62% prophylactic antifungal therapy. Fifty six percent of the aspergillosis and 70% of the candidiasis were treated with more than 2 lines of antifungal treatment. First line treatments were amphotericin B (44%), azoles (16%), amphotericin B mixed in Intralipid (16%), liposomal amphotericin B (11.5%), lipid complex of amphotericin B (5%) with a cure rate of 42%, 43%, 25%, 44% and 15% respectively. In haematopoietic stem cells transplant recipients, antifungal first line treatments were 31%, 22%, 8%, 22% and 6% respectively. The overall mortality rate was 52 % and was higher in aspergillosis (56%) than in candidiasis (45%). Death was attributed to the IFI in 67% of the aspergillosis and in 28% of the candidiasis. In transplant patients, cure rate was 41 % and an overall mortality was 58 %. In conclusion, this first pharmaco-epidemiological study evaluates the incidence of IFI in haematology departments in France and reflects the variety of treatments used as first line antifungal therapy. The overall incidence of adenovirus infection following bone marrow transplant (BMT) has been reported in two comprehensive studies at 5% and 21%, with rates of disease of 1% and 6.5%, respectively. The clinical manifestations of adenovirus infection in BMT recipients range from fever with gastroenteritis or cystitis to disseminated disease with multi-organ involvement and high mortality. Although there are several case-reports which support either the use of ribavirin with or without immunoglobulins, or ganciclovir, no conclusive evidence of benefit or clear treatment recommendations has been defined. The antiviral drug cidofovir ((S)-1-(3-hydroxy-2-phosphonylmethoxypropyl) cytosine, HPMPC) is an acyclic nucleoside phosphonate with broadspectrum activity in vitro against several DNA viruses, including adenovirus. We report the use of intravenous (iv) cidofovir for the treatment of adenovirus infection from June 1999 to October 2000 in five haematology patients: four children and one adult (age range: 3 years -29 years). In four patients, the infection occurred post-allogeneic transplantation (3 HLA-identical related; 1 haplotype mismatched) between days +22 and days +123; one patient had adenovirus infection before transplantation. In three patients, adenovirus was isolated only from faeces, but two patients had disseminated infection with isolates from multiple sites (oropharynx, urine, faeces, and conjunctiva). All patients received iv cidofovir at a dose of 5 mg/kg once a week (and thereafter every fortnight) for at least 2 weeks or until negative for adenovirus by viral culture. Four patients cleared adenovirus within one month after commencing treatment and one patient died because of a fungal infection while still on cidofovir, and no follow-up sample was available. Cidofovir was well tolerated, and no severe side effects were observed. Conclusion: Cidofovir has been used for the treatment of adenovirus infection in pre-/post-BMT patients. Based on these preliminary results further randomised/multicentre studies are warranted to establish the efficacy of cidofovir in the treatment of adenovirus infection.

Prevalence of hepatitis C after bone marrow transplantation for solid tumours in children included in a randomised study from 1985 to 1987 comparing prophylactic versus therapeutic transfusion of platelet concentrates

there was still no recoverable fungus in the IS mice, and only one IC mouse had 1.31 Log CFU/g. In conclusion, both IS and IC mice responded similarly to 3X/wk treatment with 20 mg/kg AmBi. There was a significant

As the risk of post-transfusion hepatitis C was high during this period, we tested in 1999, post-BMT sera of 66 children (30 in PPT and 36 in TPT group) to determine whether either of these two strategies was associated with a higher risk of hepatitis C. Children were screened for anti-HCV using a 3rd generation Enzym Linked Immunosorbent Assay (ELISA)(Elysis, Ortho Diagnostic) and we investigated the presence of viral RNA by PCR (Test Cobas Amplicor HCV V2.0, Roche Diagnostic). The median interval between the last blood products transfusion and the serum sample was 3 months (range: 1-18). PCR analysis of RNA was positive in 28 children (42%): 12/30 in group PPT versus 16/36 in group TPT (p=NS). The mean total number of PC units transfused during the trial was not significantly different between the PPT and TPT groups: 65.5+/-82.2 versus 46.2+/-83.2 respectively. This mean total number of transfused PC units in relation to the weight and the total duration of neutropenia was 1.8 in PPT group versus 1.3 units in TPT group (p=0.07). Anti-HCV antibodies were detected by the ELISA assay in 12/28 PCR-positive serum RNA samples (ELISA sensitivity=0.43). All the 38 PCR-negative serum RNA samples were negative by the ELISA assay (ELISA specificity=1). The interval between the last blood product transfusion and the serum sample

One of 18 pre-BMT serum RNA samples was PCR-positive and 17/18 were PCR negative. In conclusion, the prevalence of hepatitis C after BMT in children transfused with pooled random PC between 1985 and 1987 was 47% in our study. The ELISA test used has a poor sensitivity in this population and PCR analysis of RNA must be preferred to test hepatitis C after BMT

One other patient treated with immunosuppressive therapy for SAA has developed EBV-LPD at the same period. Diagnosis of EBV-LPD was confirmed by PCR and several immunological studies at the time of first clinical symptoms in three. Cause of death in one was not clear until autopsy. Diagnosis of EBV-LPD was confirmed on autopsy in all three patients who died 6, 7, and 43 days after first clinical symptoms. LPD as a cause of death still cannot be excluded in one other patient. First signs of LPD appeared 64, 64 and 67 days after last dose of ATG (16mg/kg) in transplant patients, 30 days after last dose of ATG (30mg/kg) in patient treated with ATG+CsA for relapsing SAA. Signs of EBV-LPD included fever, pancytopenia, lymphadenopathy, splenomegaly, lymphocytosis, elevated IgG. Serological studies done prior exposure to ATG were positive for latent EBV infection in all of them. All affected patients got same batch of rabbit-ATG as a GVHD prophylaxis pre-transplant in three, as an IS therapy in one. Thirteen other transplanted patients got the same dose and batch of r-ATG, which was followed with other unusual and otherwise less frequent complications (encephalitis in two, severe and relapsing BKV hemorrhagic cystitis in one, autoimmune cytopenia in two and unexplained anemia in two). Transplant related mortality 180 days after transplant in our cohort of 16 patients who got the same batch of r-ATG was extremely high (50%) compare to 24% TRM over last two years in fully comparable cohort of 25 patients receiving r-ATG (84% alternative donors) transplanted at the same center

Gonzá lez-Fraile, M.C. del Cañ izo

166 women with a median age of 46 years (21-60) diagnosed of breast cancer were treated with autologous peripheral stem-cell support using two different conditioning regimens: in 147 cases STAMP-V regimen and, in 19 patients STAMP-I. The median number of MNC infused was 5.6 x 108/kg and a median of 2.06 x 106/kg CD 34+ cells. Granulocyte colony-stimulating factors were used in all patients

Febrile episodes were classified: 1) microbiologically confirmed with bacteriemia in 33 cases (21%), (gram-positive infections in 22 cases (66.6%), and only 11 (33.4%) gram-negative, 2) microbiologically confirmed infections without bacteriemia in 42 cases (26.2%), with a similar proportion of gram-positive and gram-negative agents, 3) clinically documented infections in 46 cases (29.4%), 10 of which were pneumoniae, 4) fever of unknown origin in 35 (23%), 56% responded to first-line antimicrobial therapy

Aim:To present a fungal PCR assay for detection and identification of fungal pathogens in blood and bronchoalveolar lavage (=BAL)

Number of patients analysed were six, (2 males and 4 females, ages ranged between 4 months and 40 years). All had received allogeneic stem cell transplantation because of ALL (n=2),SCID (n=1), CML (n=1), NHL (n=1) and AML (n=1)

Ultrasound confirmed with typical hepato-splenic Candida lesions. Blood cultures were negative.One patient was positive for C.parapsilosis in PCR (we get our samples after first blood culture was positive). Nine blood cultures were positive for C.parapsilosis. One patient was positive in BAL for C.albicans in PCR. Culture of BAL confirmed C.albicans. One patient was positive for fungi in PCR (detected by electrophoresis only ,negative for Candida and Aspergillus spp. in ELISA) 3 days after blood culture revealed Phichia Etchellsii. Conclusion: Fungal PCR performed in blood and BAL for detection and identification of fungal pathogens is a rapid and sensitive method

EBV-infection/disease in allogeneic stem cell transplantation and Cidofovir (CDF) treatment

This study was a retrospective survey among EBV-infection/disease and the efficacy of CDF. 36 CDF applications were evaluated. 5 of 32 CDF-treated pts tested concommitantely positive for CMV, 6 for HHV6 and 1 for VZV reactivation/infection. 1 pt received previous antiviral therapy with Ganciclovir and Foscarnet, 2 pts received Cidofovir combined with Foscarnet and Ganciclovir. 29 pts. received CDF as first line therapy. The dosage of CDF was 1-5 mg/Kg/week. The duration was from 1 application to 7 times. All patients received probenecid and prehydratation. 4 pts suffered from presumed side effects of CDF (vomiting and nausea)