Comparative clinical manifestations and immune effects of cytomegalovirus infections following distinct types of immunosuppression

Epidemiology and Clinical Features of Epstein-Barr Virus and Cytomegalovirus Infections in Japanese Infants and Young Children

The recent clinical features of Epstein-Barr virus (EBV) and cytomegalovirus (CMV) infections in young children in developed countries remain unclear. This study investigated the clinical features of EBV and CMV infections and the latest seroepidemiology in Japan. Seroprevalence was analyzed 303 stored serum samples using commercial Enzyme Immunosorbent Assay kits, and viral infections were investigated in a cohort of febrile children under 5 years of age. After maternal antibody levels declined, the seroprevalences of EBV and CMV gradually increased by adolescence to 42.9% and 57.1%, respectively. Among 2,732 febrile children, serum EBV and CMV DNAs were detected in 1.76% and 1.24%, respectively. Of 25 primary EBV-infected patients, 15 (60.0%) had infectious mononucleosis (IM) with significantly higher IM frequency, WBC, atypical lymphocyte ratios, AST, ALT, LDH, and EBV DNA load compared to EBV-reactivated patients. No CMV DNA-positive patients had IM. Among primary EBV-infected patients, those with IM were older and had more atypical lymphocytes and higher EBV DNA load than those without IM. The age of primary EBV infection appears to have decreased compared to reports from Western countries in the 1990s. Even among children under 5 years of age, 60.0% of those with primary EBV infection developed IM.

Risk of cytomegalovirus infection in solid organ transplant recipients: A population-based cross-sectional study

BACKGROUND

Relative to healthy individuals, in severely immunocompromised transplant recipients, the presentation of cytomegalovirus (CMV) is characterized by delayed clearance, more recurrent episodes, and faster changes in their condition over time. This study investigates CMV occurrence in solid organ transplantation (SOT) recipients, addressing a gap in epidemiological research.

METHODS

Using National Health Insurance Research Database data, a cross-sectional study observed SOT recipients (2003-2019) with propensity score matching. The case group was 11,028 SOT recipients and 44,112 patients with chronic kidney disease (CKD) as the comparison. Logistic regression, adjusting for sex, age, insured salary, urbanization, and comorbidities, estimated CMV risk in a 3-year follow-up. Sensitivity analysis was performed to compare the risk of CMV at different follow-up periods (6-month, 1-year, and 2-year follow-up).

RESULTS

At 3-year follow-up, SOT recipients exhibited a higher CMV risk (aOR: 57.14, 95 % CI: 39.51-82.63) than CKD patients. Risks persisted at 6 months (aOR: 89.53, 95 % CI: 47.24-169.68), 1 year (aOR: 54.11, 95 % CI: 48.94-144.54), and 2 years (aOR: 62.82, 95 % CI: 41.71-94.61). In subgroup analysis, lung transplant recipients had the highest risk (aOR: 177.98, 95 % CI: 79.41-399.75), followed by kidney (aOR: 75.97, 95 % CI: 52.33-110.27) and liver transplant recipients (aOR: 31.44, 95 % CI: 20.78-47.50).

CONCLUSION

CMV risk persists post-SOT, peaking at 6 months. Lung transplant recipients face the highest risk, trailed by kidney and liver recipients.

The adverse impact of cytomegalovirus infection on intensive care units outcomes in critically ill COVID-19 patients: a single-center prospective observational study

PURPOSE

To assess the incidence and clinical impact of CMV infection in critically ill COVID-19 patients, examining ICU and hospital mortality, and length of hospital stay.

METHODS

In this single-center, prospective observational study (March 2020 - September 2022), 431 patients with COVID-19 pneumonia and moderate to severe ARDS were included. An active CMV surveillance protocol was implemented, analyzing CMV DNA in plasma and bronchoalveolar lavage (BAL). Clinical characteristics and outcomes were compared between CMV-COVID co-infected patients and those without CMV reactivation.

RESULTS

CMV-COVID co-infection was detected in 14.8% (64/431) of the cohort. Patients with CMV-COVID co-infection exhibited significantly higher ICU mortality (43.8% vs. 13.6%; p < 0.001) and hospital mortality (48.4% vs. 13.6%; p < 0.001) compared to patients without CMV. CMV infection was an independent predictor of hospital mortality (OR 4.91; 95% CI 2.76-8.75; p = 0.019). Earlier CMV reactivation was associated with an increased risk of hospital mortality (HR = 0.94; 95% CI: 0.90-0.98; p = 0.003). Additionally, CMV-COVID patients had a higher incidence of ICU-acquired infections and a prolonged hospital stay.

CONCLUSIONS

In critically ill patients with SARS-CoV-2 pneumonia, CMV infection was frequently observed, and associated with increased ICU and hospital mortality. CMV co-infection correlated with a higher incidence of ICU-acquired bacterial and fungal infections and prolonged hospital stays. This emphasizes the importance of early CMV monitoring upon ICU admission, as timely detection and intervention could potentially mitigate its impact on patient outcomes.

Human Cytomegalovirus Infection Induces Long-Term Changes in the Cytokine Milieu of Kidney Transplant Recipients

The impact of human cytomegalovirus (HCMV) infection on the mid- and long-term balance between pro-inflammatory and anti-inflammatory cytokines among kidney transplant recipients (KTRs) remains unclear. We measured plasma levels of 12 Th1/Th2-type cytokines (granulocyte-macrophage colony-stimulating factor, interferon-γ, interleukin [IL]-1β, IL-2, IL-4, IL-5, IL-6, IL-10, IL-12p70, IL-13, IL-18 and tumor necrosis factor-α) in a cohort of 290 KTRs at four time points through month 12 after transplantation. Cytokine levels at each point were compared according to the previous documentation of HCMV replication by two approaches: "cumulative exposure" from the time of transplantation and "recent exposure" within the 2-3 months preceding cytokine assessment. Significance levels were Bonferroni-corrected for multiple pairwise comparisons. Plasma levels of IL-6, IL-10, and IL-12p70 at month 1 were significantly increased in KTRs that had experienced HCMV infection during the first 30 days. By month 3, IL-6 and IL-10 remained increased in KTRs with cumulative exposure through day 90. Cumulative exposure to HCMV replication through day 180 was also associated to increased IL-10 levels at month 6. In addition, KTRs with recent HCMV exposure had increased IL-10 levels at months 3 and 6. After multivariable adjustment, cumulative exposure to HCMV infection and/or the area under curve of HCMV DNAemia during the corresponding period were associated to IL-10 levels within the highest quartile at months 1, 3, and 6. Preceding HCMV infection induces sustained changes in the plasma cytokine milieu of KTRs, with elevated IL-6 and IL-10 levels throughout the first 6 months after transplantation.

Active cytomegalovirus infection in mechanically ventilated patients with sepsis

BACKGROUND

Active cytomegalovirus (CMV) infection is associated with poor prognosis in septic patients with critical illness. Patients of septic category are highly likely to benefit from prophylactic antiviral therapy. Nevertheless, the clinical characteristics for CMV reactivation are lacking among septic patients requiring mechanical ventilation. The aim of this study was to investigate the incidence, risk factors, and clinical outcomes regarding active CMV infection in mechanically ventilated patients with sepsis.

METHODS

A single-center, retrospective cohort study conducted from January 2021 to December 2023 that included septic patients on mechanical ventilation at the intensive care unit (ICU) of a national hospital. Study participants were divided into active and non-active CMV infection groups based on CMV DNAemia within a 28-day hospitalization period in ICU. Clinical features, laboratory findings, treatment measures, and clinical outcomes were compared between the two groups.

RESULTS

Among 118 septic patients, 21 (17.8%) exhibited active CMV infection within 28-day ICU admission. Hemoglobin served as an independent risk factor and predictor for active CMV infection (P < 0.05). Moreover, the duration of mechanical ventilation and ICU stay in active CMV infection patients were significantly higher than in the comparison group (P < 0.05).

CONCLUSIONS

Active CMV infection is common and associated with adverse clinical outcomes in mechanically ventilated patients with sepsis. A low level of hemoglobin is an independent risk factor for active CMV infection. Further prospective studies are warranted to assess the efficacy of initiating prophylactic and preemptive antiviral therapies among patients with sepsis disorders.

Iron deficiency anemia: an early clinical presentation of cytomegalovirus-induced hemorrhagic colitis in chronic myeloid leukemia patients under dasatinib treatment

Dasatinib is a second-generation tyrosine kinase inhibitor employed for chronic myeloid leukemia (CML) treatment that achieves high rates of prolonged and complete molecular responses (MR). Among the adverse effects reported, it has been associated with hemorrhagic complications, mainly due to its inhibiting effects on platelet functions. In addition, immune alterations induced by dasatinib may elevate the risk of bleeding and cytomegalovirus (CMV) infection, particularly in the gastrointestinal tract, thus contributing to the development of hemorrhagic colitis. In this case report, we highlight three cases of CML receiving treatment with dasatinib where CMV hemorrhagic colitis occurred. All of them exhibited iron deficiency anemia as a premature clinical manifestation in the absence of intestinal symptoms, unlike cases previously reported in the literature. CMV infection was confirmed with stool samples or tissue quantitative polymerase chain reaction and/or immunohistochemistry staining in colon biopsies. All three cases could be managed with valganciclovir and iron supplements in an outpatient setting. Management strategies of dasatinib during and after CMV infection varied, as they are not yet established and need to be individualized based on the gravity of symptoms and disease state. Iron deficiency anemia during dasatinib treatment should raise suspicion for the potential presence of CMV colitis, prompting endoscopic studies to rule out this complication, even if intestinal symptoms are not present.

Prognostic significance of plasma cytomegalovirus (CMV) DNA load in immunocompetent patients with CMV pneumonia: A retrospective cohort study

Cytomegalovirus (CMV) pneumonia, often presented as pneumonitis, is characterized by respiratory failure and large interstitial infiltrates visible on chest radiographs. This retrospective cohort study investigates the predictive significance of plasma CMV DNA load on the short- and long-term mortality among immunocompetent patients diagnosed with CMV pneumonia. The study included 61 immunocompetent patients suspected of having CMV pneumonia, treated with intravenous ganciclovir after positive CMV DNA results from bronchoalveolar lavage or plasma. Our multivariate Cox regression analysis identified several independent predictors of mortality. Having idiopathic pulmonary fibrosis (IPF) significantly increased the risk of in-hospital mortality (HR: 7.27, 95% CI: 1.62-32.52, p = 0.009), as did shorter durations of antiviral therapy (HR: 0.90, 95% CI: 0.84-0.97, p = 0.005) and higher CMV DNA levels (>3870 IU/mL; HR: 9.63, 95% CI: 2.32-39.98, p = 0.002). High CMV DNA levels (>5154 IU/mL) were also predictors of 30-day mortality (HR: 9.39, 95% CI: 2.20-40.01, p = 0.002). For 1-year mortality, the presence of IPF (HR: 2.96, 95% CI: 1.08-8.06, p = 0.034), hypersensitivity pneumonia (HP) (HR: 4.30, 95% CI: 1.57-11.78, p = 0.005), shorter duration of total antiviral therapy (HR: 0.95, 95% CI: 0.93-0.99, p = 0.010), and higher CMV DNA levels (>327 IU/mL) (HR: 3.36, 95% CI: 1.33-8.47, p = 0.010) were identified as independent determinants. The study reveals that IPF increases short and long-term mortality risks, while HP increases long-term mortality. Extended antiviral treatment duration results in a 10% reduction in in-hospital mortality for each additional day of treatment. Furthermore, elevated viral loads are associated with higher mortality rates, highlighting the necessity for careful monitoring.

Mcl-1 Protein and Viral Infections: A Narrative Review

MCL-1 is the prosurvival member of the Bcl-2 family. It prevents the induction of mitochondria-dependent apoptosis. The molecular mechanisms dictating the host cell viability gain importance in the context of viral infections. The premature apoptosis of infected cells could interrupt the pathogen replication cycle. On the other hand, cell death following the effective assembly of progeny particles may facilitate virus dissemination. Thus, various viruses can interfere with the apoptosis regulation network to their advantage. Research has shown that viral infections affect the intracellular amount of MCL-1 to modify the apoptotic potential of infected cells, fitting it to the "schedule" of the replication cycle. A growing body of evidence suggests that the virus-dependent deregulation of the MCL-1 level may contribute to several virus-driven diseases. In this work, we have described the role of MCL-1 in infections caused by various viruses. We have also presented a list of promising antiviral agents targeting the MCL-1 protein. The discussed results indicate targeted interventions addressing anti-apoptotic MCL1 as a new therapeutic strategy for cancers as well as other diseases. The investigation of the cellular and molecular mechanisms involved in viral infections engaging MCL1 may contribute to a better understanding of the regulation of cell death and survival balance.

Alzheimer's disease as a viral disease: Revisiting the infectious hypothesis

Alzheimer's disease (AD) represents the most frequent type of dementia in elderly people. Two major forms of the disease exist: sporadic - the causes of which have not yet been fully understood - and familial - inherited within families from generation to generation, with a clear autosomal dominant transmission of mutations in Presenilin 1 (PSEN1), 2 (PSEN2) or Amyloid Precursors Protein (APP) genes. The main hallmark of AD consists of extracellular deposits of amyloid-beta (Aβ) peptide and intracellular deposits of the hyperphosphorylated form of the tau protein. An ever-growing body of research supports the viral infectious hypothesis of sporadic forms of AD. In particular, it has been shown that several herpes viruses (i.e., HHV-1, HHV-2, HHV-3 or varicella zoster virus, HHV-4 or Epstein Barr virus, HHV-5 or cytomegalovirus, HHV-6A and B, HHV-7), flaviviruses (i.e., Zika virus, Dengue fever virus, Japanese encephalitis virus) as well as Human Immunodeficiency Virus (HIV), hepatitis viruses (HAV, HBV, HCV, HDV, HEV), SARS-CoV2, Ljungan virus (LV), Influenza A virus and Borna disease virus, could increase the risk of AD. Here, we summarized and discussed these results. Based on these findings, significant issues for future studies are also put forward.

Targeting CMV Reactivation to Optimize Care for Critically Ill COVID-19 Patients: A Review on the Therapeutic Potential of Antiviral Treatment

Cytomegalovirus (CMV) reactivation has been linked to adverse clinical outcomes in critically ill patients, with emerging evidence suggesting a potential connection with severe COVID-19. Mechanisms driving this association may include primary lung injury, amplification of systemic inflammation, and secondary immunosuppression. Diagnostic challenges in detecting and assessing CMV reactivation necessitate a comprehensive approach to improve accuracy and inform treatment decisions. Currently, there is limited evidence on the efficacy and safety of CMV pharmacotherapy in critically ill COVID-19 patients. Although insights from non-COVID-19 critical illness studies suggest a potential role for antiviral treatment or prophylaxis, the risks and benefits must be carefully balanced in this vulnerable patient population. Understanding the pathophysiological role of CMV in the context of COVID-19 and exploring the advantages of antiviral treatment are crucial for optimizing care in critically ill patients. This review provides a comprehensive synthesis of available evidence, emphasizing the need for additional investigation to establish the role of CMV treatment or prophylaxis in the management of severe COVID-19 and to develop a framework for future research on this topic.

Current management of CMV infection in cancer patients (solid tumors). Epidemiology and therapeutic strategies

Little evidence is available regarding the incidence of CMV disease in patients with solid cancers. Latest data show that approximately 50 % of these patients with CMV PCR positivity developed clinically relevant CMV-viremia, and would require specific therapy. In the clinical arena, CMV reactivation is an important differential diagnosis in the infectological work up of these patients, but guidelines of management on this subject are not yet available. CMV reactivation should be considered during differential diagnosis for patients with a severe decline in lymphocyte counts when receiving chemoradiotherapy or immunochemotherapy with lymphocyte-depleting or blocking agents. Monitoring of CMV reactivation followed by the implementation of preemptive strategies or the establishment of early antiviral treatment improves the prognosis and reduces the morbidity and mortality of these patients.