Husam Osman

Adoptive transfer of cytomegalovirus-specific CTL to stem cell transplant patients after selection by HLA–peptide tetramers

Stem cell transplantation is used widely in the management of a range of diseases of the hemopoietic system. Patients are immunosuppressed profoundly in the early posttransplant period, and reactivation of cytomegalovirus (CMV) remains a significant cause of morbidity and mortality. Adoptive transfer of donor-derived CMV-specific CD8+ T cell clones has been shown to reduce the rate of viral reactivation; however, the complexity of this approach severely limits its clinical application. We have purified CMV-specific CD8+ T cells from the blood of stem cell transplant donors using staining with HLA–peptide tetramers followed by selection with magnetic beads. CMV-specific CD8+ cells were infused directly into nine patients within 4 h of selection. Median cell dosage was 8.6 × 103/kg with a purity of 98% of all T cells. CMV-specific CD8+ T cells became detectable in all patients within 10 d of infusion, and TCR clonotype analysis showed persistence of infused cells in two patients studied. CMV viremia was reduced in every case and eight patients cleared the infection, including one patient who had a prolonged history of CMV infection that was refractory to antiviral therapy. This novel approach to adoptive transfer has considerable potential for antigen-specific T cell therapy.

Failure to clear persistent vaccine-derived neurovirulent poliovirus infection in an immunodeficient man

BACKGROUND Individuals who chronically excrete neurovirulent poliovirus of vaccine-origin are of considerable concern to the Global Polio Eradication programme. Chronic infection with such polioviruses is a recognised complication of hypogammaglobulinaemia. METHODS We did a series of in-vitro and in-vivo therapeutic studies, with a view to clearing persistent neurovirulent poliovirus infection in an individual with common variable immunodeficiency, using oral immunoglobulin, breast milk (as a source of secretory IgA), ribavirin, and the anti-picornaviral agent pleconaril. We undertook viral quantitation, antibody neutralisation and drug susceptibility assays, and viral gene sequencing. FINDINGS Long-term asymptomatic excretion of vaccine-derived neurovirulent poliovirus 2 was identified in this hypogammaglobulinaemic man, and was estimated to have persisted for up to 22 years. Despite demonstrable in-vitro neutralising activity of immunoglobulin and breast milk, and in-vitro antiviral activity of ribavirin, no treatment was successful at clearing the virus, although in one trial breast milk significantly reduced excretion levels temporarily. During the course of study, the virus developed reduced susceptibility to pleconaril, precluding the in-vivo use of this drug. Sequence analysis revealed the emergence of a methionine to leucine mutation adjacent to the likely binding site of pleconaril in these isolates. INTERPRETATION Chronic vaccine-associated poliovirus infection in hypogammaglobulinaemia is a difficult condition to treat. It represents a risk to the strategy to discontinue polio vaccination once global eradication has been achieved.

Respiratory virus infections in transplant recipients after reduced‐intensity conditioning with Campath‐1H: high incidence but low mortality

Summary. Respiratory virus infections can cause serious morbidity and mortality after conventional allogeneic stem cell transplantation. However, the incidence and outcome of these infections after reduced intensity conditioning has not been reported. Between 1997 and 2001, 35 episodes of respiratory virus infections were noted in 25 of 83 transplant recipients conditioned with fludarabine, melphalan and Campath‐1H, and 80% of them received early antiviral therapy. Parainfluenza virus (PIV) 3 was the commonest isolate (45·7%) followed by respiratory syncytial virus (37%). Patients with myeloma were more susceptible to these infections [odds ratio (OR) 4·1, P = 0·01] which were often recurrent in patients with severe acute or chronic graft‐versus‐host disease (GVHD) (OR 10·6, P = 0·03). Infection within the first 100 d (OR 5·0, P = 0·05) and PIV 3 (OR 9·2, P = 0·01) isolation were risk factors for developing lower respiratory infection. Although more than half of the episodes progressed to lower respiratory infection, the mortality was only 8%. This could have been due to early initiation of antiviral therapy, but the attenuation of pulmonary damage due to the reduced‐intensity conditioning, low incidence of GVHD and, paradoxically, the low CD4+ T‐cell subset in this setting might also have been contributory factors.

Management of cytomegalovirus infection in haemopoietic stem cell transplantation

● Cytomegalovirus (CMV) infection and CMV diseaseshould be diagnosed according to established, interna-tionally accepted, standardized criteria (Grade 1C).● Risk-adapted patient assessment should inform clinicalmanagement (Grade 1B).● All potential haemopoietic stem cell transplantation(HSCT) recipients should be tested for the presence ofCMV IgG antibody at diagnosis (Grade 1C).● Once optimum human leucocyte antigen (HLA) match-ing has been performed, a CMV IgG-negative donorshould be chosen for a CMV IgG-negative recipient anda CMV IgG-positive donor should be chosen for a CMVIgG-positive recipient when possible (Grade 1A).● Donors or recipients who are initially found to be CMVIgG-negative should be retested pre-transplant toexclude primary CMV infection (Grade 1C).● Apparent CMV seroconversion in potential allograftrecipients who have received unscreened blood productsshould be actively investigated to exclude passive acqui-sition of antibody (Grade 1C)● Any CMV IgG-negative HSCT recipient transplantedfrom a CMV IgG-negative donor who develops CMVinfection post-transplant must be reported to the SeriousHazards of Transfusion (SHOT) scheme (Grade 1C).● Primary prophylaxis with ganciclovir is not generallyrecommended as toxicity outweighs efficacy in HSCTpatients (Grade 1B).● Primary prophylaxis with aciclovir or valaciclovir canbe deployed but only in conjunction with appropriatemonitoring of CMV in blood (Grade 1B).● Valaciclovir or valganciclovir are valid treatmentoptions for secondary prophylaxis with appropriatemonitoring of CMV in blood (Grade 1C).● Intravenous immunoglobulin is not recommended forprophylaxis of CMV infection (Grade 1A).● Real time quantitative polymerase chain reaction (PCR)is the preferred choice for monitoring CMV DNA levelsin HSCT patients (Grade 1B).● All diagnostic laboratories should deploy the CMVinternational standard to allow viral loads to becompared between centres (Grade 1C).● Monitoring of CMV load should be undertaken atleast weekly for the first 3 months post-HSCT (Grade2C).● CMV viral load monitoring should continue for 6-12 months if the patient has chronic graft-versus-hostdisease (GvHD) or prolonged T-cell immunodeficiency(Grade 1B).● Each transplant centre should have a risk-adapted policydetailing threshold values for treatment of CMV infec-tion, taking into account patient factors and PCR meth-odology (Grade 2C).● Ganciclovir is recommended as first line pre-emptivetherapy for CMV in HSCT patients (Grade 1A).● Oral valganciclovir is a valid alternative when gastroin-testinal absorption is normal or only minimallyimpaired (Grade 1A).● Foscarnet is recommended as an alternative first-lineagent if neutropenia is present or for ganciclovir treat-ment failure (Grade 1A).

Holiday haemodialysis and imported hepatitis C virus infection: A series of sixteen cases in two large haemodialysis units

BACKGROUND Patients in haemodialysis units are at an increased risk of blood borne virus infections. Birmingham city (West Midlands, UK) has a large number of its population from an ethnic origin other than white (30%). Recently due to the increase in number of haemodialysis centres abroad and particularly in the Indian Subcontinent, a large number of haemodialysis patients from these ethnic minorities are encouraged to take holidays in their countries of origin. OBJECTIVES To present the data on a series of cases of holiday haemodialysis acquired hepatitis C virus (HCV) infections from two large dialysis units in Birmingham. STUDY DESIGN In this retrospective study we have reviewed the case records of all patients in two large dialysis units who had holiday dialysis abroad and developed HCV infection after returning to the UK. RESULTS A total of 16 patients from two large dialysis units in Birmingham who developed HCV infection after haemodialysing abroad mainly in the Indian Subcontinent are being described. This constituted 44% of the total HCV positive patients in the two haemodialysis units (16/36). The cases occurred over a period of 9 years between 2000 and 2008. The last twelve of these fifteen cases had been diagnosed in the past 17 months. There were 10 male patients with a mean age 62.8 years (range 26-84 years) and 6 female patients with a mean age of 57 years (range 44-68 years). HCV genotypes 1, 3 and 4 were found in 9, 4 and 3 patients, respectively. CONCLUSION These cases underline the importance of enhanced surveillance and infection control procedures in haemodialysis units for patients who return after dialysing in resource poor countries. To the best of our knowledge this represents the largest series of imported HCV infection after holiday haemodialysis, and demonstrates clearly the significance of the perceived risk with increasing number of incident infections.

An audit of the results of the Roche Amplicor gonorrhoea test on female genital samples – a cheaper and more sensitive method than culture in an urban English population

We report an audit of the use of the Roche Amplicor gonorrhoea test in an urban English genitourinary (GU) medicine clinic. A number of studies have shown polymerase chain reaction (PCR) to be more sensitive than culture in detecting Neisseria gonorrhoea (NG) in genital samples. PCR also offers benefits over culture in terms of samples transport and storage requirements but cannot produce antibiotic sensitivities. In this audit, the use of both methods within an algorithm has reduced the overall cost of NG detection by approximately 30%. In all, 4.2% (99 out of 2336) of the endocervical samples were positive, but only 69% (68 out of 99) of these were also positive by culture. Urine samples showed twice as many inhibitory results as positive results: 19 (3%) inhibitory and 10 (1.5%) positive out of 662 samples. The use of the GC PCR in this protocol has been cost-saving and has increased the sensitivity of GC detection, but some results have been difficult to interpret. We hope to remedy this by the introduction of confirmatory testing for discrepant PCR results.

A case study of delayed HIV-1 seroconversion highlights the need for Combo assays.

Summary This report describes a case in which a patient took at least four months to seroconvert to anti-HIV positivity. A concomitant CMV infection probably contributed to the profound immune suppression observed. It is essential that fourth generation HIV antigen/antibody combo assays be used to ensure that such cases are not missed.

Dysphagia and right leg weakness in a renal transplant patient

A 54-year-old man presented with a one-week history of right eg weakness, headaches and blurring of vision. Three months arlier he had experienced isolated dysphagia developing over our weeks. Magnetic resonance imaging (MRI) of the brain at he time showed restricted diffusion in the left medulla and left ccipital lobe (Fig. 1a). A diagnosis of ischaemic lateral medullary yndrome was made and he was discharged with a nasogastric eeding tube in situ. Past medical history included renal transplanation 13 years earlier for IgA nephropathy, hypertension and atrial brillation. The patient was on mycophenolate mofetil 500 mg wice daily and prednisolone 5 mg once daily. His renal function as poor but stable with an estimated glomerular filtration rate f 16 mL/min/1.73 m2. On admission he had reduced tone and power and brisk reflexes n the right lower limb. There was no cranial nerve deficit. Comuted tomography imaging of the brain did not show any changes