Junji Ikewaki

Human Herpesvirus 6 DNA in Plasma after Allogeneic Stem Cell Transplantation: Incidence and Clinical Significance

BACKGROUND Human herpesvirus 6 (HHV-6) is increasingly recognized as an opportunistic and potentially life-threatening pathogen in recipients of allogeneic stem cell transplants (SCTs). METHODS To clarify the incidence and clinical relevance of active HHV-6 infection, serial titers of plasma HHV-6 DNA were determined for 50 allogeneic SCT recipients, using real-time polymerase chain reaction. RESULTS HHV-6 DNA was detected in plasma from 24 patients (48%). HHV-6 DNA was most frequently apparent approximately 14-27 days after transplantation. An increased risk of a positive result for HHV-6 DNA was associated with transplantation from an allelic-mismatch donor (P = .02) and administration of steroids (P = .04). Steroid use was associated with high HHV-6 DNA loads (P = .02). High HHV-6 DNA loads were correlated with delayed platelet engraftment (P = .04). Among patients who had positive results for HHV-6 DNA, the HHV-6 DNA load was higher in plasma from those who developed limbic encephalitis (n = 4) (P < .0001). CONCLUSIONS Active HHV-6 infection is not rare in SCT recipients. SCT from allelic-mismatch donors is associated with increased risk of active HHV-6 infection. Steroid therapy is associated with not only increased incidence of infection but also accelerated viral replication. Development of limbic encephalitis is associated with high HHV-6 DNA load.

Foscarnet against human herpesvirus (HHV)-6 reactivation after allo-SCT: breakthrough HHV-6 encephalitis following antiviral prophylaxis

High incidences of human herpesvirus (HHV)-6 encephalitis have recently been reported from several Japanese SCT centers. To evaluate the effect of low-dose foscarnet (PFA) in preventing HHV-6 infection among recipients of unrelated BM or cord blood (CB), we examined consecutive cohorts without prophylaxis against HHV-6 (Cohort 1, n=51) and with PFA prophylaxis (Cohort 2, PFA 50 mg/kg/day for 10 days after engraftment, n=67). Plasma real-time PCR assay was performed weekly. High-level reactivation defined as HHV-6 DNA⩾104 copies/mL by day 70 was the primary endpoint. No significant reduction of high-level reactivation was seen in Cohort 2 (19.4%) compared with Cohort 1 (33.8%, P=0.095). A trend was identified toward fewer high-level HHV-6 reactivations in Cohort 2 among recipients of unrelated BM (P=0.067), but no difference in incidence was observed among CB recipients (P=0.75). Breakthrough HHV-6 encephalitis occurred following PFA prophylaxis in three patients, and incidence of HHV-6 encephalitis did not differ between Cohort 1 (9.9%) and Cohort 2 (4.5%, P=0.24). In conclusion, 50 mg/kg/day of PFA does not effectively suppress HHV-6 reactivation and cannot prevent all cases of HHV-6 encephalitis. To effectively prevent HHV-6 encephalitis, alternative approaches based on the pathogenesis of HHV-6 encephalitis will probably be required.

Real-Time PCR Assay Compared to Nested PCR and Antigenemia Assays for Detecting Cytomegalovirus Reactivation in Adult T-Cell Leukemia-Lymphoma Patients

ABSTRACT We analyzed the efficiency of the quantitative real-time PCR assay for cytomegalovirus (CMV) reactivation in adult T-cell leukemia-lymphoma (ATL) patients and compared the results with those obtained with qualitative nested PCR and antigenemia assays. The viral load obtained by the real-time PCR assay closely paralleled the number of antigen-positive cells obtained with the antigenemia assay. Real-time PCR revealed that a large number of DNA copies could be present even in samples assessed as negative or low in antigen-positive cells (0 to 10 antigen-positive cells/50,000 cells) by antigenemia assay. CMV copy numbers did not differ between the negative and low-antigen-positive groups. When the input concentration for real-time PCR assay was 2,500 to 5,000 copies/ml, the positivity rate for the nested PCR assay was 47.3%, while the positivity rate was more than 90% at an input concentration of ≥50,000 copies/ml. Real-time PCR is more sensitive than the antigenemia and nested PCR assays. Moreover, real-time PCR was able to detect CMV reactivation earlier than the antigenemia and nested PCR assays through the use of longitudinal analysis in four ATL patients with CMV pneumonia. In longitudinal assessments, analysis of the results suggested that a cutoff level of 5,000 copies/ml might be used to initiate treatment. Real-time PCR is more suitable for monitoring CMV reactivation in ATL patients than the antigenemia and nested PCR assays. CMV viral loads of 5,000 copies/ml are proposed as the cutoff for initiating antiviral therapy in ATL patients.

High incidence of cytomegalovirus, human herpesvirus-6, and Epstein–Barr virus reactivation in patients receiving cytotoxic chemotherapy for Adult T cell leukemia

The etiology of cytomegalovirus (CMV), human herpesvirus‐6 (HHV‐6), and Epstein–Barr virus (EBV) reactivation and the potential for complications following cytotoxic chemotherapy in the absence of allogeneic transplantation are not clearly understood. Patients with adult T cell leukemia (ATL) are susceptible to opportunistic infections. In this study, the incidence, kinetics and clinical significance of reactivation of CMV, HHV‐6, and EBV in ATL patients were investigated. Viral DNA in a total of 468 plasma samples from 34 patients was quantified using real‐time PCR. The probability of CMV, HHV‐6, and EBV reactivation by 100 days after the start of chemotherapy was 50.6%, 52.3%, and 21.6%, respectively. Although most CMV reactivations were self‐limited, plasma CMV DNA tended to persist or increase if the CMV DNA levels in plasma reached ≥104 copies/ml. CMV reactivation was negatively associated with survival, but the P‐value for this association was near the borderline of statistical significance (P = 0.052). One patient developed fatal interstitial pneumonia concomitant with peak CMV DNA accumulation (1.6 × 106 copies/ml plasma). Most HHV‐6 and EBV reactivations were self‐limited, and no disease resulting from HHV‐6 or EBV was confirmed. HHV‐6 and EBV reactivation were not associated with reduced survival (P = 0.35 and 0.11, respectively). These findings demonstrated that subclinical reactivation of CMV, HHV‐6, and EBV were common in ATL patients receiving chemotherapy. There were differences in the viral reactivation patterns among the three viruses. A CMV load ≥104 copies/ml plasma was indicative of subsequent exacerbation of CMV reactivation and developing serious clinical course. J. Med. Virol. 83:702–709, 2011.

Development of hyperammonemic encephalopathy in patients with multiple myeloma may be associated with the appearance of peripheral blood myeloma cells

Hyperammonemia is one of the causes of metabolic encephalopathy with a wide spectrum of neuropsychiatric abnormalities. Recently, few patients with multiple myeloma (MM) have been reported to develop a loss of consciousness due to hyperammonemia [1–13]. However, little is known about the characteristics of this entity, its etiology or its prognosis. The present report describes three cases of MM with hyperammonemic encephalopathy and analyses the clinical features of this condition by including patients described in previously published reports.

Response to Cyclosporine Therapy in Patients with Myelodysplastic Syndrome : A Clinical Study of 12 Cases and Literature Review

Cyclosporine (CyA) was administered to 12 patients with myelodysplastic syndrome (MDS), and a response (major erythroid response, according to International Working Group criteria) was observed in 7 patients (58.3%). The median duration of response was 18 months (range, 3–22 months). Two patients are still responding and continuing to take CyA. Three patients stopped because of malignancy complications. To identify variables associated with responsiveness to CyA therapy, we analyzed the treatments of 72 MDS patients, comprising the 12 new patients and 60 patients previously described in the literature. Responses were observed in 44 of the 72 patients (61.1%). Univariate analyses revealed that higher daily dose of CyA (P for trend test, .007) and shorter disease duration (median, 5 months versus 17.5 months, P = .04) were factors significantly associated with response. No significant associations were observed between response and bone marrow features such as erythroid hypoplasia or hypoplastic marrow. Multivariate analysis also demonstrated that high CyA dose (>5 mg/kg per day) was significantly associated with response (P = .02). The present study showed that CyA therapy is useful for MDS patients with any marrow cellularity. Shorter disease duration is a pretreatment variable correlated with response, and a higher CyA dose results in a higher response rate. Int J Hematol. 2004;80:35-42. doi: 10.1532/IJH97.04051

Sarcoidosis in donor-derived tissues after haematopoietic stem cell transplantation

To the Editor: This is the first case of sarcoidosis in donor-derived tissues, confirmed by fluorescence in situ hybridisation (FISH), after haematopoietic stem cell transplantation (HSCT). A 64-year-old Japanese female was diagnosed to have adult T-cell leukaemia in December 2009. She had neither any past history nor a family history of sarcoidosis. She underwent HSCT (unrelated bone marrow transplantation) in May 2010, after receiving treatment with fludarabine, busulfan, and total body irradiation, from a human leukocyte antigen (HLA)-matched male donor who had no history of sarcoidosis. Although no lung involvement was seen in the early phase after HSCT, she was complicated by cytomegalovirus viraemia and acute graft versus host disease (GVHD), which required ganciclovir, systemic steroids and tacrolimus hydrate. She had achieved a negative proviral load of human T-cell lymphocytic virus (HTLV)-1 in her peripheral blood, 3 months after the transplant. At that time, the patient did not show any skin or eye symptoms or liver dysfunction, which are symptoms that are often seen in patients with chronic GVHD. A subcutaneous mass developed on her left upper arm in September 2011 (16 months after the transplant), although the proviral load of HTLV-1 remained negative. Fluorodeoxyglucose positron emission tomography (FDG-PET) or computed tomography (CT) imaging showed FDG accumulations in the mediastinal and hilar lymphadenopathy, in addition to the mass lesion located on the left upper arm. Although …

Drug-induced hypersensitivity syndrome due to carbapenem antibiotics.

Drug‐induced hypersensitivity syndrome (DIHS) is characterized by a serious adverse systemic reaction that usually appears after a 3–6‐week exposure to certain drugs, for example, anticonvulsants. Many different precipitating factors have been reported, but the pathophysiology of DIHS remains unknown. However, reactivation of members of the human herpesvirus (HHV) family, and of HHV‐6 in particular, has been reported in patients with DIHS. We report the case of a 64‐year‐old man who developed a generalized erythematous rash, fever, hepatic failure, lymphadenopathy and an increased number of atypical lymphocytes. In addition, reactivation of HHV‐6 and cytomegalovirus (CMV) was demonstrated by real‐time quantitative amplification by polymerase chain reaction. The patient was given a diagnosis of DIHS due to carbapenem antibiotics based on his clinical course, laboratory data, and results of lymphocyte‐stimulation tests with various drugs. This is the first report, to our knowledge, of DIHS induced by carbapenem antibiotics.

Splenectomy for hypersplenism caused by adult T-cell leukemia: Report of a case

A 45-year-old woman with previously diagnosed chronic type adult T-cell leukemia (ATL) presented with abdominal discomfort and red eruptions on her arms and legs. Anemia, thrombocytopenia, hypercalcemia, and splenomegaly indicated progression to acute-type ATL. Combined chemotherapy resulted in normalization of the serum calcium level and improvement in her symptoms. However, the severe anemia and thrombocytopenia persisted, necessitating transfusions of red blood cells (RBC) and platelets three times a week. We performed splenectomy in an attempt to reduce the total volume of malignant cells and improve the hypersplenism. After the operation, the RBC and platelet counts increased gradually, and the transfusions were stopped on postoperative day (POD) 3. Splenectomy should be considered as an optional treatment for hypersplenism caused by ATL when hypersplenism cannot be controlled by chemotherapy in patients without a high surgical risk.

An acquired CSF3R mutation in an adult chronic idiopathic neutropenia patient who developed acute myeloid leukaemia

Granulocyte colony-stimulating factor (G-CSF, CSF3) and its receptor (G-CSFR, CSF3R) play an essential role in the regulation of granulopoiesis. Recently, it was shown that point mutations in the gene encoding CSF3R (CSF3R) were detected in 20% of severe congenital neutropenia (SCN) patients. In particular, a truncation mutation in the cytoplasmic domain of CSF3R has been identified in some SCN patients who eventually developed myelodysplastic syndrome (MDS) and acute myeloid leukaemia (AML), and it was thought that this mutation was strongly related to leukemogenesis (Hunter & Avalos, 2000). On the other hand, chronic idiopathic neutropenia (CIN) is characterized by a low incidence of developing AML, and usually has a benign outcome. However, various point mutations in CSF3R have also been reported in a few cases of CIN patients who developed AML (Forbes et al, 2002; Papadaki et al, 2004). There has been some controversy about the association between the pathogenesis of CIN and CSF3R point mutations, as well as about the existence of a subset of CIN patients with a tendency to develop AML (Papadaki et al, 2002). We identified a point mutation in the cytoplasmic domain of CSF3R in a patient with a history of acquired unexplained neutropenia who developed AML. We herein discuss the association between CSF3R mutations and the development of MDS and AML. A 55-year-old male was admitted to our hospital in September 1998 because of neutropenia. At presentation, he had a low peripheral blood neutrophil count 0Æ077 · 10/l), normal haemoglobin level and platelet count (260 · 10/l), was negative for antineutrophil antibodies, and had a normal bone marrow karyotype, with hypocellularity and maturation arrest of precursor neutrophils, and no signs suggestive of myelodysplasia. He was diagnosed to have non-immune CIN on the basis of the diagnostic criteria (Papadaki et al, 2001). He suffered frequent and severe infectious episodes whilst receiving intermittent recombinant human G-CSF therapy. In 2003, the patient was readmitted because of the appearance of blast cells in his peripheral blood. Bone marrow aspiration demonstrated 52Æ7% infiltration with blast cells that were positive for CD7, CD19, CD13, CD33, and CD34 on a flow cytometric analysis. The cytogenetic analysis showed 46, XY, add (7) (q22), add (14) (q32). He was diagnosed to have AML and underwent allogeneic stem cell transplantation from a human leucocyte antigen (HLA)-matched related donor, but he died of idiopathic pulmonary syndrome. The Ethics Committee of Oita University Faculty of Medicine approved the use of patient-derived cells and the protocols used for this study. Reverse transcription polymerase chain reaction and a nucleotide sequence analysis were carried out using the bone marrow mononuclear cells from the patient by conventional methods. A point mutation in the CSF3R cDNA from this patient was identified. The mutation occurred at nucleotide 2396 and was a C-to-T transition, changing the CAG codon at position 743 (Gln 743) to a TAG stop codon (National Center for Biotechnology Information GenBank accession No.M59818) (Fig 1). This mutation is predicted to result in a protein product with a 120-amino acid C-terminal truncation. However, this mutation was not detected in the CSF3R cDNA during the first bone marrow examination when the patient was initially diagnosed with CIN. Further investigations revealed no mutations in the transmembrane domain or the extracellular region of the CSF3R. CSF3R mutations are exclusively detected in patients with SCN, primarily those who develop secondary MDS or AML, and these mutations play an important role in leukemogenesis. These SCN cases show similar types of molecular defects that introduce premature stop codons leading to a truncation of the CSF3R. A previous report demonstrated that most patients with MDS/ AML secondary to SCN harboured nonsense mutations at nucleotides 2384, 2390, 2396, 2412, 2425, and 2429 (Germeshausen et al, 2007). Although CSF3R mutations in a few de novo AML and MDS cases have been reported, the breakpoint was variable, involving extracellular or transmembrane domains. The relationship with leukemogenesis has also remained unclear. Link et al (2007) reported that no CSF3R mutations located between nucleotide 2384 and 2429 were detected in cases of de novo AML, suggesting that CSF3R mutations are rare in de novo AML. In addition, although mutations of tyrosine kinase genes were common in de novo AML, no mutations in these genes were detected in the SCN patients (Link et al, 2007). It is therefore thought that the leukemogenic mechanism differs between de novo AML, and AML with SCN. In addition, while monitoring the Severe Chronic Neutropenia International Registry, it was discovered that CIN patients do not show an increased propensity to develop MDS or AML, despite longterm G-CSF treatment (Dale et al, 2003). In the present case, the mutation occurred at nucleotide 2396, and we thought that it played an important role in the clinical pathogenesis of the disease, because the mutation was not detected when the patient had CIN without AML, but it was detected after he was diagnosed with AML that developed from CIN. Carapeti et al (1997) reported a similar point mutation (nucleotide 2390) in a case that developed AML from MDS. However, we could find no other case reports. The present case is therefore only the second case with a truncated Correspondence