Agnès Gautheret-Dejean

Chromosomally integrated human herpesvirus 6: questions and answers

Chromosomally integrated human herpesvirus 6 (ciHHV‐6) is a condition in which the complete HHV‐6 genome is integrated into the host germ line genome and is vertically transmitted in a Mendelian manner. The condition is found in less than 1% of controls in the USA and UK, but has been found at a somewhat higher prevalence in transplant recipients and other patient populations in several small studies. HHV‐6 levels in whole blood that exceed 5.5 log10 copies/ml are strongly suggestive of ciHHV‐6. Monitoring DNA load in plasma and serum is unreliable, both for identifying and for monitoring subjects with ciHHV‐6 due to cell lysis and release of cellular DNA. High HHV‐6 DNA loads associated with ciHHV‐6 can lead to erroneous diagnosis of active infection. Transplant recipients with ciHHV‐6 may be at increased risk for bacterial infection and graft rejection. ciHHV‐6 can be induced to a state of active viral replication in vitro. It is not known whether ciHHV‐6 individuals are put at clinical risk by the use of drugs that have been associated with HHV‐6 reactivation in vivo or in vitro. Nonetheless, we urge careful observation when use of such drugs is indicated in individuals known to have ciHHV‐6. Little is known about whether individuals with ciHHV‐6 develop immune tolerance for viral proteins. Further research is needed to determine the role of ciHHV‐6 in disease. Copyright

Development of a real-time polymerase chain reaction assay for the diagnosis of human herpesvirus-6 infection and application to bone marrow transplant patients.

A quantitative real-time PCR assay was developed for human herpesvirus-6 (HHV-6) genome based on TaqMan technology. After choosing a region of interest into the U65-U66 genes of HHV-6 genome, its nucleotide sequence was determined among four HHV-6 strains (one variant A and three variants B) to exclude a variability of sensitivity due to interstrain sequence differences. A plasmid containing HHV-6 target sequences identical to those of reference type viruses was constructed with the aim of standardisation. This HHV-6 genomic quantitation assay has a threshold sensitivity of ten copy equivalents (EqCop) per reaction. In order to test the feasibility of this assay directly on human samples, the technique was applied to the quantitation of HHV-6 genome in 30 blood samples from healthy subjects as well as 31 blood samples and three samples of cerebrospinal fluid (CSF) from 21 bone marrow transplant (BMT) recipients and four patients with a haematological disease but not treated by bone marrow transplantation. HHV-6 load ranged between 0.00015 and 0.0008 equivalent DNA copy number (EqCop) per 100 peripheral blood mononuclear cells (PBMCs) in healthy subjects whereas it ranged from <10 to 7500 EqCop per 100 PBMCs, and from <10 to 415,820 EqCop per 100 microl of whole CSF in patients. The efficacy of treatment with antiherpetic drug was associated with a decrease of the viral load in the CSF of one patient. This method leads to relevant results in term of range of quantitation, sensitivity, and safety against contamination by amplicons, and might constitute a useful tool for the follow-up of BMT recipients particularly in the presence of antiherpetic therapy.

Human Herpesvirus (HHV)-6 and HHV-7: Two Closely Related Viruses with Different Infection Profiles in Stem Cell Transplantation Recipients

Human herpesvirus (HHV)-6 and HHV-7 loads were evaluated retrospectively in peripheral blood mononuclear cells (PBMC) from 78 recipients of stem cell transplantation (SCT) by real-time polymerase chain reaction. The median HHV-6 load in patients was 1357 genome equivalent copies (EqCop)/10(6) PBMC but was below the quantitation threshold in 31 immunocompetent individuals, which strongly suggests that HHV-6 reactivation occurred after SCT. The HHV-6 load was higher in patients with delayed neutrophil engraftment (P=.002) or severe graft-versus-host disease (P=.009). Moreover, the occurrence of at least 1 HHV-6-related manifestation (fever, cutaneous rash, pneumonitis, or partial myelosuppression) was statistically associated with a concomitant virus load >10(3) EqCop/10(6) PBMC (P=.007). Conversely, HHV-7 reactivation was not favored, because median HHV-7 loads were similar in patients and healthy control subjects (1053 vs. 1216 EqCop/10(6) PBMC). The kinetics of Roseolovirus loads during the posttransplantation period suggested that HHV-7 may act as a cofactor of HHV-6 reactivation.

Human herpesvirus-6 meningoencephalitis in a recipient of an unrelated allogeneic bone marrow transplantation.

BACKGROUND Human herpesvirus-6 (HHV-6) has been implicated in bone marrow suppression, interstitial pneumonitis, and fatal meningoencephalitis in bone marrow transplant (BMT) recipients. METHODS We describe the case of a woman with acute myeloid leukemia in second remission who developed febrile meningoencephalitis 8 months after a second unrelated BMT. RESULTS Computed tomography and magnetic resonance images of the brain were nonspecific. Analysis of cerebrospinal fluid (CSF) revealed lymphocytosis and an increased protein level. Using polymerase chain reaction methods, HHV-6 was the only pathogen detected in CSF, peripheral blood mononuclear cells, and bone marrow. The patient was treated with ganciclovir and foscarnet for 3 months. All clinical manifestations resolved and HHV-6 polymerase chain reaction analysis of CSF became negative 40 days after the beginning of antiviral treatment. CONCLUSIONS This observation strongly suggests that HHV-6 should be sought in BMT patients with neurological complications and that HHV-6 meningoencephalitis may respond to ganciclovir and foscarnet therapy.

Susceptibility of human herpesvirus 6 to antiviral compounds by flow cytometry analysis

BACKGROUND The emergence of human herpesvirus 6 (HHV-6) as a human pathogen led to the possibility of specific therapy against HHV-6 and the development of standardized susceptibility assays of HHV-6 to antivirals. METHODS We have developed a flow cytometry method to analyze the multiplication of the HST strain of human herpesvirus 6 (HHV-6) variant B in vitro using monoclonal antibodies specific to virus proteins. This method was subsequently used to determine the sensitivity of HST multiplication in MT4 cells to four antiviral compounds of three different classes: acyclovir (ACV) and ganciclovir (GCV), two acyclic guanosine analogs; cedofovir (CDV), an acyclic nucleoside phosphonate; and phosphonoformic acid (PFA), a pyrophosphate analog. RESULTS The 50% inhibitory concentrations (IC(50)) of ACV, GCV, CDV, and PFA determined by flow cytometry assay were 25.3, 6.4, 0.95, and 6.0 microM, respectively (5.7, 1.6, 0.3, and 1.8 microg/ml, respectively). These data together with the results of cytotoxicity assays confirmed the high efficiency and selectivity of CDV and PFA against HHV-6 B in vitro, suggested by previous results. CONCLUSIONS Our flow cytometric assay appeared as a reproducible specific method to characterize HHV-6 susceptibility to antiviral compounds. It can be considered as a convenient alternative to the other immunologic and DNA hybridization assays used for that purpose.

Selection of the same mutation in the U69 protein kinase gene of human herpesvirus-6 after prolonged exposure to ganciclovir in vitro and in vivo

After serial passage in the presence of increasing concentrations of ganciclovir (GCV) in vitro, a human herpesvirus-6 (HHV-6) mutant exhibiting a decreased sensitivity to the drug was isolated. Analysis of drug susceptibility showed that the IC(50) of this mutant was 24-, 52- and 3-fold higher than that of the wild-type (wt) IC(50) in the case of GCV, cidofovir and foscarnet, respectively. Genotypic analysis showed two single nucleotide changes as compared to the wild-type: an A-->G substitution of the U69 protein kinase (PK) gene resulted in an M(318)V amino acid substitution and the other change, located in the C-terminal part of the U38 gene, resulted in an A(961)V amino acid substitution within the DNA polymerase. The M(318)V change was located within the consensus sequence DISPMN of the putative catalytic domain VI of the PK. This change was homologous to the M(460)V and M(460)I changes that had been reported previously within the consensus sequence DITPMN of the human cytomegalovirus (HCMV) UL97 PK and associated with the resistance of HCMV to GCV. The M(318)V change was also detected by PCR in HHV-6-infected PBMCs from an AIDS patient who had been treated with GCV for a long period of time and exhibited a clinically GCV-resistant HCMV infection. These findings provide strong circumstantial evidence that the M(318)V change of the PK gene is associated with resistance to GCV and raise the question of cross resistance to this drug among different betaherpesviruses.

Laboratory and Clinical Aspects of Human Herpesvirus 6 Infections

SUMMARY Human herpesvirus 6 (HHV-6) is a widespread betaherpesvirus which is genetically related to human cytomegalovirus (HCMV) and now encompasses two different species: HHV-6A and HHV-6B. HHV-6 exhibits a wide cell tropism in vivo and, like other herpesviruses, induces a lifelong latent infection in humans. As a noticeable difference with respect to other human herpesviruses, genomic HHV-6 DNA is covalently integrated into the subtelomeric region of cell chromosomes (ciHHV-6) in about 1% of the general population. Although it is infrequent, this may be a confounding factor for the diagnosis of active viral infection. The diagnosis of HHV-6 infection is performed by both serologic and direct methods. The most prominent technique is the quantification of viral DNA in blood, other body fluids, and organs by means of real-time PCR. Many active HHV-6 infections, corresponding to primary infections, reactivations, or exogenous reinfections, are asymptomatic. However, the virus may be the cause of serious diseases, particularly in immunocompromised individuals. As emblematic examples of HHV-6 pathogenicity, exanthema subitum, a benign disease of infancy, is associated with primary infection, whereas further virus reactivations can induce severe encephalitis cases, particularly in hematopoietic stem cell transplant recipients. Generally speaking, the formal demonstration of the causative role of HHV-6 in many acute and chronic human diseases is difficult due to the ubiquitous nature of the virus, chronicity of infection, existence of two distinct species, and limitations of current investigational tools. The antiviral compounds ganciclovir, foscarnet, and cidofovir are effective against active HHV-6 infections, but the indications for treatment, as well as the conditions of drug administration, are not formally approved to date. There are still numerous pending questions about HHV-6 which should stimulate future research works on the pathophysiology, diagnosis, and therapy of this remarkable human virus.

Utilization of Microsatellite Polymorphism for Differentiating Herpes Simplex Virus Type 1 Strains

The herpes simplex virus type 1 (HSV-1) genome is a linear double-stranded DNA of 152 kpb. It is divided into long and short regions of unique sequences termed UL and US, respectively, and these are flanked by regions of inverted internal and terminal repeats. Microsatellites are short tandem repeats of 1- to 6-nucleotide motifs; they are often highly variable and polymorphic within the genome, which raises the question of whether they may be used as molecular markers for the precise differentiation of HSV-1 strains. In this study, 79 different microsatellites (mono-, di-, and trinucleotide repeats) in the HSV-1 complete genome were identified by in silico analysis. Among those microsatellites, 45 were found to be distributed in intergenic or noncoding inverted repeat regions, while 34 were in open reading frames. Length polymorphism analysis of the PCR products was used to investigate a set of 12 distinct HSV-1 strains and allowed the identification of 23 polymorphic and 6 monomorphic microsatellites, including two polymorphic trinucleotide repeats (CGT and GGA) within the UL46 and US4 genes, respectively. A multiplex PCR method that amplified 10 polymorphic microsatellites was then developed for the rapid and accurate genetic characterization of HSV-1 strains. Each HSV-1 strain was characterized by its own microsatellite haplotype, which proved to be stable over time in cell culture. This relevant innovative tool was successfully applied both to confirm the close relationship between sequential HSV-1 isolates collected from patients with multiple recurrent infections and to investigate putative nosocomial infections.

Quantitation of HHV-7 genome by real-time polymerase chain reaction assay using MGB probe technology

A real-time PCR assay was developed to quantify human herpesvirus-7 (HHV-7) genome based on TaqMan technology using the new MGB probe. Primers and probe were chosen in the conserved U100 gene. Plasmid containing the sequence of interest was constructed for the standardisation of the method and to assess its sensitivity. This HHV-7 genomic quantitation assay has a threshold sensitivity of fourteen equivalent genome copy number (EqCop) per reaction. This method was applied to the quantitation of HHV-7 in the peripheral blood mononuclear cells (PBMCs) obtained from 31 healthy subjects. Eighty seven per cent had HHV-7 positive detection in the PBMCs with a viral load ranging from 275 to 14545 EqCop per million of cells. This method presents interesting characteristics with a wide range of quantitation, a good sensitivity, and constitutes a new tool for the study of HHV-7 infection in vivo and in vitro.

Prevalence of Human Herpesvirus-6 Chromosomal Integration (CIHHV-6) in Italian Solid Organ and Allogeneic Stem Cell Transplant Patients

The unique phenomenon of human herpesvirus‐6 (HHV‐6) chromosomal integration (CIHHV‐6) may account for clinical drawbacks in transplant setting, being misinterpreted as active infection and leading to unnecessary and potentially harmful treatments. We have investigated the prevalence of CIHHV‐6 in 205 consecutive solid organ (SO) and allogeneic stem cell transplant (alloSCT) Italian patients. Fifty‐two (38.5%) of 135 solid organ transplant (SOT) and 16 (22.8%) of 70 alloSCT patients resulted positive for plasma HHV‐6 DNA by real‐time polymerase chain reaction. Seven SOT and three alloSCT patients presented HHV‐6‐related diseases, requiring antivirals. Two further patients (0.9%) were identified, presenting high HHV‐6 loads. The quantification of HHV‐6 on hair follicles disclosed the integrated state, allowing the discontinuation of antivirals. Before starting specific treatments, CIHHV‐6 should be excluded in transplant patients with HHV‐6 viremia by the comparison of HHV‐6 loads on different fluids and tissues. Pretransplantation screening of donors and recipients may further prevent the misdiagnosis of CIHHV‐6.