Cytomegalovirus pneumonia in patients with lymphoma

Case Report: Fatal cytomegalovirus pneumonia after CAR-T cell therapy in the long-term follow-up

Introduction

The rapidly developed CAR-T cell therapy has a unique profile of side effects, which perhaps has not been totally realized and understood, especially the late-phase toxicity. CMV is prevalent world-wide and establishes a life-long latency infection. It can lead to life-threatening complications in immunocompromised host, and little is known about CMV disease in patients after CAR-T cell therapy. Here, we report a patient who developed possible CMV-pneumonia three months after anti-CD19 and anti-CD22 CAR-T cell therapy for relapsed B-ALL, contributing to the understanding of severe side-effects mediated by virus infection or reactivation in patients receiving CAR-T cell infusion.

Case presentation

A 21-year old male patient with relapsed B-ALL received anti-CD19/22 CAR-T cell therapy, and achieved complete remission 2 weeks after the infusion. However, three months later, the patient was hospitalized again with a 10-day history of fever and cough and a 3-day history of palpitations and chest tightness. He was diagnosed with possible CMV pneumonia. Under treatment with antiviral medicine (ganciclovir/penciclovir), intravenous gamma globulin and methylprednisolone and the use of BiPAP ventilator, his symptoms improved, but after removing penciclovir his symptoms went out of control, and the patient died of respiratory failure 22 days after admission.

Conclusion

CMV infection/reactivation can occur in patients long after receiving anti-CD19/22 CAR-T cell therapy, and induce fatal pneumonia, which reminds us of the late side effects associated with immunosuppression after CAR-T cell infusion.

A Prospective Study of Plasma and Bronchoalveolar Lavage Fluid CMV DNA Load Quantification for the Diagnosis and Outcome of CMV Pneumonitis in Immunocompromised Hosts

BACKGROUND

Molecular testing has been utilized for cytomegalovirus (CMV) pneumonitis (CMVP) diagnosis, although its validity and optimal cut-off values remain limited.

METHODS

A prospective study of CMVP diagnosis among immunocompromised patients was conducted by measuring quantitative CMV DNA polymerase chain reaction in plasma and bronchoalveolar lavage fluid (BALF).

RESULTS

Forty-five adult immunocompromised patients were investigated. Thirty-two patients (71%) received immunosuppressive therapy. Eleven patients (24%) were confirmed to have CMVP. Of those, three and eight patients were classified as proven and probable CMVP, respectively. Median (IQR) plasma CMV DNA loads in CMVP and non-CMVP were 41,939 (4,424-122,608) and 0 (0-44) IU/mL, respectively (p<0.001). Median (IQR) BALF CMV DNA loads in CMVP and non-CMVP were 379,652 (163,800-1,254,000) and 0 (0-1,348) IU/mL, respectively (p<0.001). A significant correlation was observed between plasma and BALF CMV DNA loads (r=0.887, p<0.001). Plasma CMV DNA load of 831 IU/mL was established as a cut-off value for diagnosing CMVP (AUC 0.9987, sensitivity 100%, specificity 94.1%, positive predictive value 84.5%, negative predictive value 100%).

CONCLUSIONS

A strongly positive correlation was observed between CMV DNA loads measured in plasma and BALF. CMV DNA load quantification could potentially assist in diagnosing CMVP in immunocompromised patients, although bronchoscopy remains encouraged for a definitive diagnosis.

Age-Related Disease Risks in Younger versus Older B-Cell Non-Hodgkin's Lymphoma Survivors

BACKGROUND

Younger cancer survivors may develop age-related diseases due to the cancer treatment that they undergo. The aim of this population-based study is to estimate incidence of age-related diseases besides cardiovascular disease among younger versus older B-cell non-Hodgkin's lymphoma (B-NHL) survivors compared with their respective general population cohorts.

METHODS

Survivors of B-NHL were diagnosed between 1997 and 2015 from the Utah Cancer Registry. Using the Utah Population Database, up to 5 cancer-free individuals from the general population were matched with a B-NHL survivor on sex, birth year, and state of birth. Hazard ratios (HR) for age-related disease outcomes, which were identified from medical records and statewide health care facility data, were estimated using Cox Proportional Hazards models for B-NHL survivors diagnosed at <65 years versus ≥65 years at least 5 years since B-NHL diagnosis.

RESULTS

Comparing 2,129 B-NHL survivors with 8,969 individuals from the general population, younger B-NHL survivors had higher relative risks of acute renal failure [HR, 2.24; 99% confidence interval (CI), 1.48-3.39; P _{heterogeneity} = 0.017), pneumonia (HR, 2.42; 99% CI, 1.68-3.49; P _{heterogeneity} = 0.055), and nutritional deficiencies (HR, 2.08; 99% CI, 1.48-2.92; P _{heterogeneity} = 0.051) ≥5 years after cancer diagnosis.

CONCLUSION

Younger B-NHL survivors had higher relative risks of acute renal failure, pneumonia, and nutritional deficiencies than older B-NHL survivors compared with their respective general population cohorts, ≥5 years after cancer diagnosis.

Prevalence and Recurrence Rates of Cytomegalovirus Infection Among Patients With Hematological Diseases in the Western Brazilian Amazon: A Cross-Sectional Study

Cytomegalovirus (CMV) is a worldwide distributed pathogen that may cause serious complications in patients with hematological diseases. This study aimed to serologically characterize CMV infection in patients suffering from hematological diseases in Amazonas state, Brazil. Serum samples from 323 patients were tested for the presence of anti-CMV IgM or IgG antibodies using an enzyme-linked immunosorbent assay. Positive samples for IgM were submitted to the IgG avidity test to differentiate primary infection from recurrent infection. An epidemiological questionnaire was administered to collect the sociodemographic information of the study population. The overall prevalence of CMV infection verified in this study was 91.3%. The highest rates were found in patients suffering from platelet disorders (94.5%), anemia (93.3%), or leukemia (91%). The study population was predominantly composed of individuals with low socioeconomic status. Blood transfusions were more common in patients with anemia or leukemia, but this variable was not correlated with the seropositivity for CMV infection. Measurement of IgG avidity in patients positive for anti-CMV IgM demonstrated a recurrent infection rate of 5.2% (17/323). Over 80% of recurrent infections occurred in patients with acute lymphocytic leukemia (ALL) or anemia. Our findings indicated that CMV infection is highly prevalent in patients from the western Brazilian Amazon who have hematological diseases. The prevalence observed progressively rose with increasing age, whereas anemia or ALL figured as risk factors for the recurrence of CMV infection.

Infectious Disease Complications in Patients with Cancer

Critically ill patients with cancer are vulnerable to infections because of the underlying malignancy, tumor-directed therapy, immunosuppression, breaches in mucosa or skin, malnutrition, and other factors. Neutropenia remains the most important risk factor for infection. Infectious complications occurring in critically ill patients with cancer can affect the bloodstream, lungs, gastrointestinal tract, central nervous system, urinary tract, and the skin. Pneumonias are the leading cause of infection in patients with cancer admitted to the intensive care unit. Consideration of opportunistic pathogens in the differential diagnosis is important in patients with impaired cellular and/or humoral immunity or compromised splenic function.

Acute and Chronic Respiratory Failure in Cancer Patients

In 2016, there was an estimated 1.8 million new cases of cancer diagnosed in the United States. Remarkable advances have been made in cancer therapy and the 5-year survival has increased for most patients affected by malignancy. There are growing numbers of patients admitted to intensive care units (ICU) and up to 20% of all patients admitted to an ICU carry a diagnosis of malignancy. Respiratory failure remains the most common reason for ICU admission and remains the leading causes of death in oncology patients. There are many causes of respiratory failure in this population. Pneumonia is the most common cause of respiratory failure, yet there are many causes of respiratory insufficiency unique to the cancer patient. These causes are often a result of immunosuppression, chemotherapy, radiation treatment, or hematopoietic stem cell transplant (HCT). Treatment is focused on supportive care and specific therapy for the underlying cause of respiratory failure. Noninvasive modalities of respiratory support are available; however, careful patient selection is paramount as indiscriminate use of noninvasive positive pressure ventilation is associated with a higher mortality if mechanical ventilation is later required. Historically, respiratory failure in the cancer patient had a grim prognosis. Outcomes have improved over the past 20 years. Survivors are often left with significant disability.

Pneumocystis jirovecii pneumonia in HIV-uninfected, rituximab treated non-Hodgkin lymphoma patients

Rituximab is associated with a higher incidence of Pneumocystis jirovecii pneumonia infection. Pneumocystis prophylaxis is advised in many immunocompromised populations treated with rituximab. However, the beneficial effect of pneumocystis prophylaxis in HIV-uninfected, rituximab-treated non-Hodgkin lymphoma (NHL) patients has not been assessed. Thus, we conducted this retrospective study to explore pneumocystis infection in HIV-uninfected NHL patients who received at least three courses of chemotherapy without haematopoietic stem cell transplantation using the Taiwan National Health Insurance Research Database. Patients who had rituximab-based chemotherapy were included in the experimental (rituximab) group, while the rest of the patients who did not receive any rituximab-based chemotherapy throughout the study period formed the control group. The prevalence rate of pneumocystis infection in the rituximab group (N = 7,554) was significantly higher than that in the control group (N = 4,604) (2.95% vs. 1.32%). The onset of pneumocystis infection occurred between 6 and 16 weeks after chemotherapy. Patients who had pneumocystis prophylaxis, whether or not they had a pneumocystis infection later in their treatment course, had significantly better first-year survival rates (73% vs. 38%). Regular pneumocystis prophylaxis should be considered in this group of patients.

Diagnosis of cytomegalovirus pneumonia by quantitative polymerase chain reaction using bronchial washing fluid from patients with hematologic malignancies

Background

The incidence of cytomegalovirus (CMV) pneumonia is increasing in patients diagnosed with hematologic malignancies. The utility of CMV-DNA viral load measurement has not been standardized, and viral cut-off values have not been established. This study was designed to investigate the utility of CMV quantitative real-time PCR (qRT-PCR) using bronchial washing fluid.

Methods

We retrospectively reviewed the microbiologic and pathologic results of bronchial washing fluid and biopsy specimens in addition to the patients' clinical characteristics.

Results

A total of 565 CMV qRT-PCR assays were performed using bronchial washing fluid from patients with hematologic malignancies. Among them, 101 were positive for CMV by qRT-PCR; of these, 24 were diagnosed with CMV pneumonia and 70 with CMV infection, and 7 were excluded due to a diagnosis of invasive pulmonary aspergillosis rather than viral pneumonia. The median CMV load determined by qPCR was 1.8 × 10⁵ copies/mL (3.6 10³-1.5 × 10⁸) in CMV pneumonia patients and 3.0 × 10³ copies/mL (5.0 × 10²-1.1 × 10⁵) in those diagnosed with CMV infection (P < 0.01). Using the ROC curve, the optimal inflection points were 18,900 copies/mL (137,970 IU/mL) in post-bone marrow transplantation (BMT) patients, 316,415 copies/mL (2,309,825 IU/mL) in no-BMT patients and 28,774 copies/mL (210,054 IU/mL) in all patients.

Conclusions

The CMV titers in bronchial washing fluid determined by qRT-PCR differed significantly between patients diagnosed with CMV pneumonia and those with CMV infection. The viral cut-off values in bronchial washing fluid were suggested for the diagnosis of CMV pneumonia, which were different depending on the BMT status.

Pharmacokinetics and Safety of Letermovir Coadministered With Cyclosporine A or Tacrolimus in Healthy Subjects

Letermovir is being developed for human cytomegalovirus infection treatment and prophylaxis. In patients receiving transplants, antivirals are coadministered with cyclosporine A (CsA) or tacrolimus (TAC) immunosuppressants. Therefore, we investigated the potential for letermovir-immunosuppressant interactions. In 2 phase 1 clinical trials either CsA 50 mg or TAC 5 mg was administered to healthy males. Following washout, letermovir 80 mg was dosed twice daily for 7 and 11 days in the CsA and TAC trials, respectively, with a second dose of immunosuppressant coadministered with letermovir at steady state. In addition, letermovir 40 mg twice daily was administered for 14 days, and either CsA 50 or 200 mg administered on days 7 and 14. Pharmacokinetics and tolerability were assessed. Letermovir increased CsA and TAC C_max by 37% and 70%, respectively, and exposure by 70% and 78%, respectively, compared with immunosuppressant alone; t_½ was also increased from 10.7 to 17.9 hours for CsA. CsA (50/200 mg) increased letermovir C_max,ss (109%/167%) and AUC_ss,τ (126%/237%) and decreased t_½ (4.33 to 3.68/3.04 hours) versus letermovir alone. TAC did not significantly affect letermovir pharmacokinetics. All treatments were well tolerated. Concomitant letermovir increased TAC and CsA exposure. CsA altered letermovir pharmacokinetics, whereas TAC did not.

Cytomegalovirus infection in patients with haematological diseases and after autologous stem cell transplantation as consolidation: a single-centre study

Because of the widespread use of immunosuppressive drugs, CMV infection is one of the most important causes of morbidity and mortality in patients with haematological malignancies worldwide. The aim of the study was to retrospectively analyse the epidemiology of CMV infection in haematological patients. Between 2008 and 2014, 1238 quantitative CMV DNA detections from plasma specimens were performed. These specimens were collected from 271 patients with haematological malignancy. Patients were grouped on the basis of underlying diseases (lymphoid and myeloid malignancies and other haematological diseases). In the lymphoid and myeloid groups, we distinguished ASCT and non-ASCT groups. During the studied period, the majority of examined patients (82.6 %) were treated with lymphoproliferative disease. A total of 126 (46.5 %) patients underwent ASCT, while 145 (53.5 %) did not have stem cell transplantation. A total of 118 (9.5 %) of 1238 plasma specimens proved to be positive for CMV DNA; these specimens were collected from 66 (24.4 %) patients. Twenty-four (16.6 %) of 145 non-ASCT patients had CMV PCR positive specimens. Among non-ASCT patients with positive CMV PCR results, 10 patients were asymptomatic, 14 had symptomatic reactivation, while 2 had CMV disease. In the ASCT group, 42 (33.3 %) patients had CMV PCR positive samples. CMV reactivation was asymptomatic in 34 (81 %) cases, and 8 (19 %) patients had symptomatic reactivation. In the non-ASCT group, the rate of CMV infection is low. In the ASCT group, the prevalence of CMV infection was higher than in the non-ASCT group, but the majority of CMV infection was asymptomatic and only small number of patients had symptomatic reactivation. Thus, our results also showed that the use of routine CMV DNA monitoring is not necessary in patients with haematological malignancies not receiving fludarabine-containing regimen or alemtuzumab, in spite of this to decrease the mortality we have to consider the use of molecular tests in case of suspected infectious conditions.

Cytomegalovirus disease in children with acute lymphoblastic leukemia

Viral infections are an underrecognized problem in children on standard chemotherapy for acute lymphoblastic leukemia (ALL). In countries with high baseline seroprevalence of cytomegalovirus (CMV) such as India, it may be an important pathogen leading to fever, end-organ damage, and cytopenia. Data regarding the incidence and manifestations of CMV disease in pediatric ALL patients are scanty. The authors prospectively assessed all children on chemotherapy for ALL with prolonged febrile neutropenia (FN) for CMV disease over a 3-year period. Children with end-organ damage, including pneumonia, retinitis, and colitis, were also evaluated. Quantitative and qualitative polymerase chain reaction (PCR) from blood, body fluids, or tissue was done along with ophthalmologic evaluation. CMV disease was detected in 10% of the children with prolonged FN. In addition, other children were identified due to end-organ damage, lung and eye being the common organs of involvement. Time of CMV reactivation was essentially during nonintense phase of chemotherapy. Lymphopenia was present in most children, and prolonged lymphopenia was associated with relapse of CMV infection after therapy. The authors conclude that CMV is an important pathogen in children on standard chemotherapy for ALL. It has a good outcome with early detection and directed therapy. Parenteral ganciclovir is needed for a period of 14-21 days to prevent recurrence.

Cytomegalovirus Pneumonia after Anti-CC-chemokine Receptor 4 Monoclonal Antibody (Mogamulizumab) Therapy in an Angioimmunoblastic T-cell Lymphoma Patient

Angioimmunoblastic T-cell lymphoma (AITL) is an aggressive T-cell lymphoma. A 63-year-old man was diagnosed with AITL. He received 6 cycles of CHOP therapy, but showed progressive disease. Subsequently, he received ESHAP chemotherapy; however, it was not effective. He received mogamulizumab (an anti-CCR4 monoclonal antibody). After 4 cycles, his respiratory condition worsened and he was diagnosed with cytomegalovirus (CMV) pneumonia. Despite antiviral and antibiotic therapy, he died. We speculate that the combination of progressive lymphoma with mogamulizumab and chemotherapy likely caused CMV pneumonia. Because mogamulizumab therapy causes immunosuppression, if CMV pneumonia is suspected, then rapid treatment should be initiated.

Serological and viraemic status of human cytomegalovirus infection in patients with colorectal cancer is not correlated with viral replication and transcription in tumours

Colorectal cancer (CRC) is amongst the leading causes of cancer-related mortality worldwide. Emerging evidence suggests that human cytomegalovirus (HCMV) exists in the tumour tissue of CRC and is associated with disease outcome. To study whether tumoral HCMV is related to viral reactivation in blood, tumour specimens and pre- and post-operative blood samples from CRC patients were collected prospectively. PCR and quantitative PCR were performed to detect HCMV DNA. HCMV IgG and IgM antibodies were measured using a microparticle enzyme immunoassay. Transcription of a spliced HCMV UL73 gene transcript was analysed by quantitative reverse transcription PCR. HCMV was detected in 42.2% (35/83) of the tumour samples, with a low median viral load (30.08, range 2.33-5704 copies per 500  ng genomic DNA). The vast majority (80/81, 98.8%) of the CRC patients were seropositive for HCMV IgG. HCMV DNA was positive in 11.3% (22/194) of the pre-operative and 8.9% (15/168) of the post-operative blood samples. However, presence of HCMV and its viral load in tumours were not associated with the detection or viral loads in blood samples. About 26.67% (8/30) of the HCMV-positive tumours with available RNA had detectable viral UL73 transcripts, whilst none of the blood samples were positive for viral RNA (P < 0.0001). Therefore, presence of HCMV in tumours does not correlate with the serological or viraemic status of CRC patients. Active viral gene transcription occurred in the tumour but not in the blood of CRC patients. HCMV reactivation in CRC patients is possibly due to virus-cancer interactions in the CRC tumour microenvironment.

Reduced Mortality of Cytomegalovirus Pneumonia After Hematopoietic Cell Transplantation Due to Antiviral Therapy and Changes in Transplantation Practices

BACKGROUND

Despite major advances in the prevention of cytomegalovirus (CMV) disease, the treatment of CMV pneumonia in recipients of hematopoietic cell transplant remains a significant challenge.

METHODS

We examined recipient, donor, transplant, viral, and treatment factors associated with overall and attributable mortality using Cox regression models.

RESULTS

Four hundred twenty-one cases were identified between 1986 and 2011. Overall survival at 6 months was 30% (95% confidence interval [CI], 25%-34%). Outcome improved after the year 2000 (all-cause mortality: adjusted hazard ratio [aHR], 0.7 [95% CI, .5-1.0]; P = .06; attributable mortality: aHR, 0.6 [95% CI, .4-.9]; P = .01). Factors independently associated with an increased risk of all-cause and attributable mortality included female sex, elevated bilirubin, lymphopenia, and mechanical ventilation; grade 3/4 acute graft-vs-host disease was associated with all-cause mortality only. An analysis of patients who received transplants in the current preemptive therapy era (n = 233) showed only lymphopenia and mechanical ventilation as significant risk factors for overall and attributable mortality. Antiviral treatment with ganciclovir or foscarnet was associated with improved outcome compared with no antiviral treatment. However, the addition of intravenous pooled or CMV-specific immunoglobulin to antiviral treatment did not seem to improve overall or attributable mortality.

CONCLUSIONS

Outcome of CMV pneumonia showed a modest improvement over the past 25 years. However, advances seem to be due to antiviral treatment and changes in transplant practices rather than immunoglobulin-based treatments. Novel treatment strategies for CMV pneumonia are needed.

Cytomegalovirus colitis following azacitidine therapy

The present report describes the first recognized case of cytomegalovirus (CMV) colitis following azacitidine therapy. A 66-year-old woman with myelodysplastic syndrome developed CMV colitis, which responded to treatment with ganciclovir. Currently, patients receiving azacitidine do not undergo CMV testing, or receive prophylaxis or CMV-free blood products; however, this policy needs to be revised.

Risk factors and outcomes of cytomegalovirus viremia in cancer patients: a study from a medical center in northern Taiwan

BACKGROUND

Cytomegalovirus (CMV) is a pathogen and can cause life-threatening infection in the patients with malignancies. This study was conducted to investigate the risk factors and outcomes of CMV viremia in patients with malignancies.

METHODS

Data were collected with retrospective analysis from adults suffering from CMV viremia with underlying malignancies. A total of 107 patients were enrolled in a tertiary medical center in northern Taiwan from March 2008 to December 2009.

RESULTS

Among the 107 patients who suffered with CMV viremia with an overall mortality rate of 56.1% (60/107), 75 patients (70.1%) had solid organ malignancies and 32 (29.9%) had hematological malignancies. Mechanical ventilation (p=0.048), leukocytosis (p=0.004), and lack of appropriate early treatment (p=0.011) were independent predisposing factors associated with higher mortality rate.

CONCLUSIONS

CMV viremia predicts high mortality rate in cancer patients, especially in those with mechanical ventilation, leukocytosis, and lack of appropriate early treatment. Appropriate early antiviral therapy is recommended to improve outcomes.

Presence of human herpes virus 6 (HHV6) in pediatric lymphomas: impact on clinical course and association with cytomegalovirus infection

Background

Activation of herpes virus 6 (HHV6) has seen in Hodgkin's and non-Hodgkin's Lymphoma (HL&NHL) as a result of lymphoma associated immunosuppression. Multiple studies have suggested an association between both HHV6 and cytomegalovirus CMV for development of CMV disease affecting the pathogenesis of lymphoma. Therefore, this study investigated the frequency of HHV6, its impact on clinical manifestations of lymphoma and its possible association with risk for development of CMV infection in pediatric lymphoma patients.

Methods

Presence of HHV6 DNA and CMV DNA was investigated by PCR assay in both WBC's and plasma samples from 50 patients diagnosed with HL or NHL. CMV antibody titer was also determined in sera obtained from each patient. Twenty apparently healthy siblings were used as a control group.

Results

In a study group of 50 patients diagnosed with HL or NHL, 23/50 (46%) were found to be positive for herpes virus DNA (HHV6 or CMV) in WBC's or plasma by PCR assay and this was significantly higher than its presence in the pediatric control group 2/20 (10%) (p = 0.005). Ten out of these 23 (43%) were found to have active CMV infection. Fifty six percent of patients with CMV infection were found among NHL cases with B- subtype. The presence of both herpes viruses DNA was significantly associated with more frequent episodes of febrile neutropenia (median 3 episodes), absolute neutrophil count (< 0.8), lymphocytes (< 0.5), and low hemoglobin level (< 9.1), (p < 0.05).

Conclusion

The presence of HHV6 can be considered as a predicting indicator of cellular immunosuppression preceding the onset of CMV infection which may result in a severe outcome among pediatric lymphoma patients.

Viral pneumonias in immunocompromised adult hosts

Viral infections have always been considered pediatric diseases. However, viral pneumonia has become an important cause of morbidity and mortality in immuncompromised adults. Improved diagnostic techniques, such as the introduction of highly sensitive nucleic acid amplification tests, have not only allowed us to discover new viruses but also to determine the etiology of viral pneumonia in immunocompromised adult hosts. Unfortunately, only a few antiviral agents are available. Thus, early diagnosis and treatment are crucial to patient outcome. In this article, we review the most common viruses that have been implicated as etiologic agents of viral pneumonia in immunocompromised adults. We discuss the epidemiologic characteristics and clinical presentation of these viral infections and the most appropriate diagnostic approaches and therapies when available.

Drug-induced pneumonitis detected earlier by 18F-FDG-PET than by high-resolution CT: a case report with non-Hodgkin's lymphoma

Drug-induced pneumonitis is a serious and an unpredictable side effect of chemotherapy in patients with malignant lymphoma. We present the case of a 51-year-old man who developed drug-induced pneumonitis during chemotherapy for non-Hodgkin's lymphoma in which pneumonitis was detected earlier by 18F-fluorodeoxyglucose positron emission tomography (18F-FDG-PET) than by high-resolution computed tomography (HRCT). After five courses of chemotherapy, 18F-FDG-PET was performed for assessing residual lesions, and diffuse lung uptake was incidentally observed. No symptoms were present, and HRCT performed immediately following PET revealed no abnormalities. Mild dyspnea appeared 3 days after PET, and additional HRCT revealed patchy ground-glass opacities disseminated with the appearance of interlobular septum thickening. Drug-induced pneumonitis was finally diagnosed, and treatment was initiated. 18F-FDG-PET can be an imaging modality for detecting drug-induced pneumonitis at an extremely early stage in which HRCT is incapable of revealing any abnormal changes.

Epidemiologic analysis of reactivated cytomegalovirus antigenemia in patients with cancer

The epidemiologic features of reactivated cytomegalovirus (CMV) antigenemia were studied among 4,382 cancer patients who were cared for and tested at the University of Texas M. D. Anderson Cancer Center from 2001 to 2004. The effects of stem cell transplant (SCT) status, underlying disease, age, sex, ethnicity, and antibody status (prior to CMV exposure) on the incidence of CMV antigenemia were determined; and the CMV burdens were quantified. Antigenemia occurred in 9.3% of patients with non-SCT (n = 2511), 12.0% with autologous SCT (n = 582), and 39.1% with allogeneic SCT (n = 1289). Non-SCT patients with lymphoid tumors had a significantly higher rate of antigenemia than those with myeloid tumors (13.6% versus 3.9%) (P < 0.001); however, after allogeneic SCT, the underlying diseases had little effect, except for multiple myeloma (56.8%) (P = 0.014). Among the allogeneic SCT recipients, higher CMV antigenemia rates were also associated with female sex, older age, and positivity for pre-SCT CMV antibody. Depending on the underlying disease and its associated initial CMV risk, allogeneic SCT increased the risk by 2.6- to 29.6-fold (overall, 4.0-fold). With or without SCT, Asians had the highest CMV antigenemia rates and burdens, followed by blacks, Hispanics, and whites, and these partially correlated with antibody prevalence. Among the 808 patients with antigenemia, the circulating peak CMV burden was significantly higher among non-SCT patients (geometric mean, 18.7 positive cells per 10(6) leukocytes) than among allogeneic SCT patients (geometric mean, 7.7 positive cells per 10(6) leukocytes) or autologous SCT patients (geometric mean, 7.0 positive cells per 10(6) leukocytes) who underwent monitoring for CMV. Together, these results allow stratification of CMV risks and suggest a substantial CMV reactivation among non-SCT cancer patients and, thus, the need for better diagnosis and control.

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Viral Infections in Patients with Hematological Malignancies

Viral infections are important causes of morbidity and mortality for patients with a hematological malignancy. However, the true incidence and consequences of viral infections for these patients who undergo conventional nontransplant therapy are poorly defined. The difference in incidence and outcome of viral infections among patient groups is wide, but dependent upon the intensity and duration of T-cell–mediated immune suppression. Infections caused by cytomegalovirus (CMV), herpes simplex virus (HSV), varicella-zoster virus (VZV), respiratory syncytial virus (RSV), parainfluenza viruses and influenza viruses have been intensely studied, yet newly recognized aspects of these viral infections including late CMV infection; the emergence of new viral pathogens (human herpesvirus-6, BK virus, adenovirus, and human metapneumovirus); the development of molecular diagnostic techniques, and the potential of new agents for viral prophylaxis (maribavir), or preemptive therapy (valganciclovir) form the basis of this review. Well-designed prospective studies are needed to better clarify the spectrum of these viral infections and develop effective prevention and treatment strategies. Yet the increased use of agents like alemtuzumab that induce profound T-cell depletion demands that we develop a better understanding of viral infections that occur in patients with hematological malignancy who receive nontransplant therapy.

Gastrointestinal cytomegalovirus disease in patients with cancer: a two decade experience in a tertiary care cancer center

Although gastrointestinal cytomegalovirus disease (GI-CMVd) is not common in cancer patients, it is associated with high morbidity and mortality. Herein, we review our 2-decade experience with GI-CMVd in such patient population at The University of Texas M.D. Anderson Cancer Center. Forty-seven patients were identified. Thirty-four patients (72%) had an underlying haematological malignancy, and 18 patients (38%) developed GI-CMVd following hematopoietic stem cell transplantation (HSCT). Nine (25%) of the 36 cancer patients with data available had AIDS. Upper-GI tract involvement was more common in patients with haematological malignancies than in those with solid tumours (P=0.02). Patients with AIDS were more likely to have colonic involvement than were those without AIDS (67% vs. 15%, P=0.006), and patients without AIDS were more likely to have gastric involvement (59% vs. 11%, P=0.01). The CMV-attributable mortality rate was 42%. Independent predictors of death by multivariate analysis included disseminated CMV and AIDS (P<0.01). The presentation of GI-CMVd varies according to the type of cancer, and AIDS. GI-CMVd is associated with a high mortality among cancer patients, particularly those with disseminated CMV disease or AIDS.