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Loucif Y, Mackenzie C, Tselikmann O, Rump LC. Infectious Diarrhea in Kidney Transplant Recipients. Cureus 2025; 17:e82194. [PMID: 40370893 PMCID: PMC12076263 DOI: 10.7759/cureus.82194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2025] [Indexed: 05/16/2025] Open
Abstract
Introduction Infectious diarrhea represents a significant and frequent complication among kidney transplant recipients, primarily due to the immunosuppressive therapy required to prevent graft rejection. This condition poses substantial risks to both graft function and patient survival, driven by increased susceptibility to opportunistic pathogens and potential medication-related gastrointestinal effects. This study aims to characterize the pathogen spectrum and associated risk factors of infectious diarrhea in a German cohort of kidney transplant recipients, providing insights into regional patterns and clinical implications. Methods A retrospective cohort study was conducted, analyzing 604 patients, including 436 kidney transplant recipients, who were hospitalized with infectious diarrhea (ICD-10 codes A00-A09) at the Universitätsklinikum Düsseldorf (UKD) between January 2019 and December 2023. Nontransplant patients (n = 168) were included as a comparison group to evaluate pathogen distribution and infection risk specific to immunosuppressive therapy in transplant recipients. Pathogen identification was performed focusing on stool samples. Data collected included transplantation status, dates of admission and transplantation, recurrence rates, and detailed immunosuppressive regimens. Statistical analyses were applied to evaluate pathogen distribution, temporal patterns, and the influence of immunosuppression on infection risk. Results The most prevalent pathogens identified among kidney transplant recipients were Clostridioides difficile (26.3%), cytomegalovirus (CMV, 12.3%), enteropathogenic Escherichia coli (EPEC, 8.6%), and norovirus (4.8%). Immunosuppression significantly heightened infection susceptibility, with Clostridioides difficile infections occurring notably more frequently and CMV-related diarrhea observed exclusively in the transplant cohort. Recurrence rates were elevated for both CMV and Clostridioides difficile, underscoring their clinical persistence. Temporal analysis revealed a median onset of CMV infections at approximately 13 months post-transplantation, with no significant seasonal variation. Conclusions The predominance of opportunistic pathogens such as Clostridioides difficile and CMV in kidney transplant recipients reflects the profound impact of immunosuppression on infection risk and pathogen profiles. These findings emphasize the necessity for enhanced diagnostic approaches in kidney transplant recipients, including early and comprehensive pathogen screening, and targeted prevention strategies, such as optimized and maybe prolonged CMV prophylaxis and stringent hygiene protocols for Clostridioides difficile. It emphasizes close monitoring of a potential viral load in blood samples, especially after cessation of the routine CMV prophylaxis after kidney transplantation. This study contributes to a better understanding of infectious diarrhea in this vulnerable population and lays the groundwork for improved clinical management, overall cost reduction, and future prospective research.
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Affiliation(s)
- Yassin Loucif
- Nephrology, Universitätsklinikum Düsseldorf, Düsseldorf, DEU
| | - Collin Mackenzie
- Infectious Disease, Universitätsklinikum Düsseldorf, Düsseldorf, DEU
| | - Olga Tselikmann
- Nephrology, Universitätsklinikum Düsseldorf, Düsseldorf, DEU
| | - Lars C Rump
- Nephrology, Universitätsklinikum Düsseldorf, Düsseldorf, DEU
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Durkee-Shock J, Cohen A, Maghzian N, Pezzella G, Jensen-Wachspress M, Hostal A, Barton K, Gangler K, Dávila Saldaña BJ, Chaimongkol N, Bollard CM, Sosnovtsev SV, Cohen J, Nagata BM, Alves DA, Ghosh R, Seifert BA, Freeman A, Gonzalez C, Notarangelo LD, Green KY, Keller MD. Reconstitution of Norovirus-Specific T-Cell Responses Following Hematopoietic Stem Cell Transplantation in Patients With Inborn Errors of Immunity and Chronic Norovirus Infection. J Infect Dis 2025; 231:773-783. [PMID: 39140311 PMCID: PMC11911796 DOI: 10.1093/infdis/jiae398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 05/25/2024] [Accepted: 08/13/2024] [Indexed: 08/15/2024] Open
Abstract
BACKGROUND Chronic norovirus infection (CNI) causes significant morbidity in immunocompromised patients. No effective prevention or treatment currently exists. METHODS Two patients with inborn errors of immunity, X-linked severe combined immunodeficiency (X-SCID) and DOCK8 deficiency, were followed longitudinally for clinical course, immune reconstitution, norovirus-specific T-cell (NST) response, B-cell reconstitution, and norovirus-specific antibody production. Samples were obtained in the peri-hematopoietic stem cell transplant (HSCT) setting before and after CNI clearance. The norovirus strain causing CNI was followed longitudinally for norovirus stool viral loads and sequencing. RESULTS The noroviruses were identified as GII.4 Sydney[P4 New Orleans] in 1 patient and GII.17[P17] in the other. An exacerbation of diarrhea post-HSCT in the patient with X-SCID was consistent with norovirus infection but not with graft-versus-host disease on pathologic samples. Both patients recovered polyfunctional NSTs in the CD4 and CD8 T-cell compartments that recognized multiple norovirus structural and nonstructural viral antigens. T-cell responses were minimal during active CNI but detectable after resolution. Mapping of NST responses between the patient with DOCK8 deficiency and his matched sibling donor were nearly identical. B-cell reconstitution or new endogenous antibody production for immunoglobulin A or immunoglobulin G was not observed. CONCLUSIONS This report is the first to demonstrate reconstitution of NST immunity after HSCT closely temporally aligned with clearance of CNI, suggesting that cellular immunity is sufficient for norovirus clearance.
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Affiliation(s)
- Jessica Durkee-Shock
- Laboratory of Infectious Diseases, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Ariella Cohen
- Center for Cancer and Immunology Research, Children’s National Hospital, Washington, District of Columbia
| | - Naseem Maghzian
- Center for Cancer and Immunology Research, Children’s National Hospital, Washington, District of Columbia
| | - Gloria Pezzella
- Center for Cancer and Immunology Research, Children’s National Hospital, Washington, District of Columbia
| | - Mariah Jensen-Wachspress
- Center for Cancer and Immunology Research, Children’s National Hospital, Washington, District of Columbia
| | - Anna Hostal
- Laboratory of Infectious Diseases, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Karenna Barton
- Laboratory of Infectious Diseases, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Krista Gangler
- Laboratory of Infectious Diseases, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Blachy J Dávila Saldaña
- Center for Cancer and Immunology Research, Children’s National Hospital, Washington, District of Columbia
- Division of Blood and Marrow Transplantation, Children’s National Hospital, Washington, District of Columbia
| | - Natthawan Chaimongkol
- Laboratory of Infectious Diseases, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Catherine M Bollard
- Center for Cancer and Immunology Research, Children’s National Hospital, Washington, District of Columbia
- Division of Blood and Marrow Transplantation, Children’s National Hospital, Washington, District of Columbia
| | - Stanislav V Sosnovtsev
- Laboratory of Infectious Diseases, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Jeffrey Cohen
- Laboratory of Infectious Diseases, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Bianca M Nagata
- Infectious Disease Pathogenesis Section, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, Rockville, Maryland
| | - Derron A Alves
- Infectious Disease Pathogenesis Section, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, Rockville, Maryland
| | - Rajarshi Ghosh
- NIAID Centralized Sequencing Program, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Bryce A Seifert
- NIAID Centralized Sequencing Program, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Alexandra Freeman
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Corina Gonzalez
- Immune Deficiency Cellular Therapy Program, National Cancer Institute, Bethesda, Maryland
| | - Luigi D Notarangelo
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Kim Y Green
- Laboratory of Infectious Diseases, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Michael D Keller
- Center for Cancer and Immunology Research, Children’s National Hospital, Washington, District of Columbia
- Division of Allergy and Immunology, Children's National Hospital, Washington, District of Columbia
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Acevedo-Rodriguez JG, Contreras CA, Ochoa TJ. Viral diarrheas - newer advances in diagnosis and management. Curr Opin Infect Dis 2024; 37:385-391. [PMID: 39253867 PMCID: PMC11669399 DOI: 10.1097/qco.0000000000001053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
PURPOSE OF REVIEW Viruses are the most common etiological agents of diarrhea in children. Despite rotavirus vaccine introduction, rotavirus remains as the leading cause of death globally, followed by norovirus, which represents a diagnostic challenge. Here, we describe new advances in the diagnosis and management of viral diarrheas. RECENT FINDINGS Although immunoassays are widely used for their fast turnaround time and low cost, molecular techniques have become the most reliable diagnostic method due to their high sensitivity and capacity to analyze multiple pathogens in gastrointestinal panels. Isothermal nucleic acid amplification assays (LAMP and RPA) are promising techniques since they do not require sophisticated equipment and can be used as point-of-care testing. CRISPR/Cas nucleic acid detection systems are new diagnostic methods with great potential. Several recent published articles describe the role of human intestinal enteroids to characterize norovirus infection, to test new drugs, and for vaccine development. The interaction between the human gut microbiota and gastrointestinal viral infections has been extensively reviewed and offers some innovative mechanisms for therapeutic and preventive measures. SUMMARY Although important advances have been made, more research is needed to address remaining challenges and further improve diagnostic capabilities and better management strategies for this critical infectious disease.
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Affiliation(s)
- J. Gonzalo Acevedo-Rodriguez
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
- Facultad de Medicina, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Carmen A. Contreras
- Escuela de Medicina Humana, Universidad Privada Antenor Orrego, Trujillo, Perú
| | - Theresa J. Ochoa
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
- Facultad de Medicina, Universidad Peruana Cayetano Heredia, Lima, Peru
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Flynn TG, Olortegui MP, Kosek MN. Viral gastroenteritis. Lancet 2024; 403:862-876. [PMID: 38340741 DOI: 10.1016/s0140-6736(23)02037-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 08/17/2023] [Accepted: 09/18/2023] [Indexed: 02/12/2024]
Abstract
Since the discovery of norovirus in 1972 as a cause of what was contemporarily known as acute infectious non-bacterial gastroenteritis, scientific understanding of the viral gastroenteritides has continued to evolve. It is now recognised that a small number of viruses are the predominant cause of acute gastroenteritis worldwide, in both high-income and low-income settings. Although treatment is still largely restricted to the replacement of fluid and electrolytes, improved diagnostics have allowed attribution of illness, enabling both targeted treatment of individual patients and prioritisation of interventions for populations worldwide. Questions remain regarding specific genetic and immunological factors underlying host susceptibility, and the optimal clinical management of patients who are susceptible to severe or prolonged manifestations of disease. Meanwhile, the worldwide implementation of rotavirus vaccines has led to substantial reductions in morbidity and mortality, and spurred interest in vaccine development to diminish the impact of the most prevalent viruses that are implicated in this syndrome.
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Affiliation(s)
- Thomas G Flynn
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | | | - Margaret N Kosek
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA.
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Lewis MA, Cortés-Penfield NW, Ettayebi K, Patil K, Kaur G, Neill FH, Atmar RL, Ramani S, Estes MK. Standardization of an antiviral pipeline for human norovirus in human intestinal enteroids demonstrates nitazoxanide has no to weak antiviral activity. Antimicrob Agents Chemother 2023; 67:e0063623. [PMID: 37787556 PMCID: PMC10583671 DOI: 10.1128/aac.00636-23] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 08/02/2023] [Indexed: 10/04/2023] Open
Abstract
Human noroviruses (HuNoVs) are the leading cause of acute gastroenteritis. In immunocompetent hosts, symptoms usually resolve within 3 days; however, in immunocompromised persons, HuNoV infection can become persistent, debilitating, and sometimes life-threatening. There are no licensed therapeutics for HuNoV due to a near half-century delay in its cultivation. Treatment for chronic HuNoV infection in immunosuppressed patients anecdotally includes nitazoxanide, a broad-spectrum antimicrobial licensed for treatment of parasite-induced gastroenteritis. Despite its off-label use for chronic HuNoV infection, nitazoxanide has not been clearly demonstrated to be an effective treatment. In this study, we standardized a pipeline for antiviral testing using multiple human small intestinal enteroid lines representing different intestinal segments and evaluated whether nitazoxanide inhibits replication of five HuNoV strains in vitro. Nitazoxanide did not exhibit high selective antiviral activity against any HuNoV strain tested, indicating it is not an effective antiviral for HuNoV infection. Human intestinal enteroids are further demonstrated as a model to serve as a preclinical platform to test antivirals against HuNoVs to treat gastrointestinal disease. Abstr.
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Affiliation(s)
- Miranda A. Lewis
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas, USA
| | - Nicolás W. Cortés-Penfield
- Department of Medicine, Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Khalil Ettayebi
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas, USA
| | - Ketki Patil
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas, USA
| | - Gurpreet Kaur
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas, USA
| | - Frederick H. Neill
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas, USA
| | - Robert L. Atmar
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Sasirekha Ramani
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas, USA
| | - Mary K. Estes
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
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