Cytomegalovirus infections after allogeneic bone marrow transplantation.

REVIEWS OF INFECTIOUS DISEASES • VOL. 12, SUPPLEMENT 7 • SEPTEMBER-OCTOBER 1990

© 1990 by The University of Chicago. All rights reserved. 0162-0886/90/1205-0049$02.00

Cytomegalovirus Infections After Allogeneic Bone Marrow Transplantation Drew J. Winston, Winston G. Ho, and Richard E. Champlin

From the Division 01 Hematology-Oncology, Department 01 Medicine, UCLA Center lor the Health Sciences, Los Angeles, California

Patients undergoing bone marrow transplantation are susceptible to many different bacterial, fungal, and viral infections [1-3]. Among the viral pathogens, cytomegalovirus (CMV) causes the greatest morbidity and mortality and has been the most common infectious cause of death following the grafting of allogeneic marrow. CMV infections also occur after syngeneic or autologous marrow transplantation but are less severein these situations [4-7]. Thus, the focus of this discussion will be on recent progress that has been made in understanding the epidemiology and pathogenesis of CMV infection after allogeneic marrow transplantation and on new approaches for the diagnosis, treatment, and prevention of these infections. Epidemiology of CMV Infection and Disease The incidence of CMV infection after allogeneic transplantation at different transplantation centers

This work was supported by grant no. CA 23175 from the National Cancer Institute. The authors thank Karim Hirji for assistance in data analysis. Please address requests for reprints to Dr. Drew J. Winston, Department of Medicine, Room 42-121 CHS, UCLA Medical Center, Los Angeles, California 90024-1678.

is shown in table 1 [1, 8-13]. Approximately 50010 of all allogeneic transplant recipients develop CMV infection. The reported incidence of infection varies, ranging from 30010 to 70% at different centers. It is noteworthy that in recent reports from Minnesota [12] and Johns Hopkins [13], the incidence of CMV infection was only 30% and 32010, respectively, values consistent with a decline in CMV infections at some transplantation centers over the last several years. The reasons for this apparent decrease in CMV infections are not entirely obvious but may include alterations in immunosuppressive regimens for prevention of graft-vs.-host disease (GvRD) and the introduction of more effective measures for prevention of CMV infection. These prophylactic measures will be discussed later. The major risk factors for CMV infection after allogeneic marrow transplantation are CMV infection in the marrow recipient before transplantation, frequent blood transfusions from CMV-seropositive blood donors, and possibly GvRD in the recipient and CMV infection in the marrow donor. As shown in table 1, CMV infections are more common in patients who are CMV-seropositive before transplantation (mean incidence, 65%; range, 42010-87010) than in patients who are CMV-seronegative (mean incidence, 31010; range, 13010-54010) [1, 8-13]. S776

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Cytomegalovirus (CMV) infection occurs in rv50OJo of all recipients of allogeneic bone marrow transplants and is seen more frequently in CMV-seropositivepatients than in CMVseronegative patients. Sources of infection include reactivation of latent endogenous virus, blood products from CMV-seropositive blood donors, and the use of marrow from a CMV-seropositive donor for a CMV-seronegative recipient. The most common and severe clinical syndrome associated with CMV infection in allogeneic transplant recipients is interstitial pneumonia, which occurs in rv15OJo of patients. Risk factors for CMV pneumonia include old age, conditioning with total-body irradiation, and severe graft-vs.-host disease. The rapid diagnosis of CMV pneumonia has been facilitated by immunochemical staining of bronchoalveolar lavage fluid or by centrifugation of cell cultures with CMV monoclonal antibodies. The treatment of CMV pneumonia remains problematic, but therapy with a combination of intravenous immune globulin (IVIG) plus ganciclovir has resulted in survival rates substantially better than those achieved in previous trials of antiviral therapy. In CMV-seronegative patients, CMV infection and pneumonia can be prevented or modified by the use of CMV-seronegative blood products and IVIG. IVIG may also have the additional benefits of preventing other infectious complications and graft-vs.host disease in patients receiving CMV-seronegative blood products. For CMV-seropositive patients, effective prophylaxis for CMV reactivation and pneumonia has not yet been established, but a clinical trial of prophylactic ganciclovir is now under way.

CMV and Marrow Transplantation

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Table 1. Incidence of CMV infection after allogeneic bone marrow transplantation at various transplantation centers. No. of patients with CMV infection/no. with indicated serology (%) Seattle [8], 1977

UCLA [1], 1979

Seattle [9], 1980

Seattle [10], 1986

Sweden [11], 1986

Minnesota [12], 1986

Johns Hopkins [13], 1988

Seronegative Seropositive

10/44 (23) 27/36 (75)

12/30 (40) 6/10 (60)

43/79 (54) 49/79 (62)

103/285 (36) 178/258 (69)

8/22 (35) 39/45 (87)

26/137 (19) 28/44 (64)

15/115 (13) 97/232 (42)

37/80 (46)

18/40 (45)

92/158 (58)

281/543 (52)

47/67 (70)

54/181 (30)

112/347 (32)

Total

The incidence of CMV pneumonia in CMV-seropositive patients also is higher (table 2) [10, 12, 13]. It is assumed that these infections in CMV-seropositive patients are due to reactivation of latent endogenous virus. Indeed, studies of the molecular epidemiology of CMV infection after marrow transplantation show that after transplantation, CMVseropositive patients can develop pneumonia caused by a CMV strain genetically identical to a CMV isolate detected in their urine before transplantation (figure 1) [14]. Nonetheless, these observations do not preclude the possibility of exogenous infection with a different CMV strain, as has been described in renal and cardiac transplant recipients [15, 16]. The mechanism of reactivation of latent infection is not completely understood but may be related to immunosuppressive therapy [17, 18] or to the immunologic events associated with GvHD or another genetic disparity between the marrow donor and recipient [19]. In CMV-seronegative marrow transplant recipients, primary CMV infection usually is acquired from blood products infected with latent virus. The risk of acquiring CMV from blood products is related to the number and types of blood products administered and the CMV antibody serology of the blood donor. The risk of CMV infection has been estimated to be 70/0 after the administration of a single unit of blood and 290/0 after the administration of multiple units [20]. Bone marrow transplant recipients receive an average of 15-20 units of red blood cells and 90,...105 units of platelets [21-23]. Granulocyte transfusions, especially from CMVseropositive donors, are additional risk factors for infection (table 3) [13, 21, 22]. In contrast, CMVseronegative patients who receive only blood products from CMV-seronegative donors have a much lower incidence of CMV infection [24-26]. While pretransplant CMV infection in the marrow recipient and the transfusion of CMV-seropositive blood products have been consistent risk factors for CMV infection after marrow transplantation

in most studies, the effects of the serologic status of the marrow donor and GvHD are less clear. Table 4 summarizes the results of several studies of the relationship between the CMV serology of the marrow donor and the incidence of CMV infection [9-12, 27]. Only a second study from Seattle [10] and a smaller study from Hammersmith Hospital in London [27] found a higher incidence of CMV infection in CMV-seronegative patients when the marrow donor was CMV-seropositive rather than CMV-seronegative. An earlier study from Seattle and reports from Sweden and Minnesota did not confirm this relationship [9, 11, 12]. When the transplant recipient is CMV-seropositive before transplantation, the serologic status of the marrow donor has no effect on the incidence of CMV infection. Similarly, acute GvHD was associated with an increased risk for CMV infection in studies from Seattle, Minnesota, and Sweden but not in studies from UCLA and Johns Hopkins (table 5) [1, 10-13]. These combined results suggest that the impact of pretransplantation CMV infection in CMV-seropositive patients and of transfused blood products in CMV-seronegative patients on the incidence of CMV infection may be so Table 2. Severity of CMV infectionby pretransplantCMV serology, in allogeneic bone marrow transplant recipients. No. with No. with CMV Transplantation Pretransplant CMV infection/ pneumonia/total center CMV total no. no. of patients [reference], serology of patients (%) (%) year Seattle [10], 1986



Negative vs. Positive Negative vs. Positive Negative vs. Positive

103/285 (36)

30/285 (10)

178/258 (69)

60/258 (23)

26/137 (19)

12/137 (9)

28/44 (64)

11/44 (25)

15/115 (13)

1/115 (1)

97/232 (42)

37/232 (16)


Pretransplant CMV serology

Winston, Ho; and Champlin

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Figure 1. DNA fragment bands generated by digestion with restriction endonucleases £coRI, BamHI, and XbaI of CMV isolated before and after bone marrow transplantation from the same patient. After transplantation, patients 1 and 2 developed interstitial pneumonia, patient 3 developed fever with viremia, and patient 4 developed asymptomatic viruria; each condition was caused by a CMV strain identical to one that was isolated from the patient's urine before transplantation. Reprinted with permission from Annals of Internal Medicine [14].

strong that the effects of donor serology and GvHD are of secondary importance. Immunity to CMV The interaction between the host's immune system and CMV is complex. In bone marrow transplant recipients, this complexity is enhanced by the presence of immunocompetent cellsof donor origin, immunosuppressive agents, GvHD, and other factors affecting the immune response. CMV infection itself also suppresses host immunity [28]. Thus, it is not surprising that the immune responses most important in the control of CMV infection in marrow transplant recipients and the factors influencing the reconstitution of these responses remain incompletely defined.

It is generally believed that cell-mediated immunity is of primary importance in determining the severityand outcome of CMV infection in bone marrow transplant recipients and other immunosuppressed patients. The development of CMV disease (such as pneumonia) in transplant recipients seropositive for CMV antibody before transplantation [10] and the progression of disseminated CMV infection in other CMV-seropositive immunosuppressed patients (such as patients with AIDS) have been cited as evidence in support of the secondary role of humoral immunity [29]. The earliest studies of cellular immunity to CMV after marrow transplantation evaluated lymphocyte proliferation in response to CMV antigen and nonspecific natural killer (NK) cell activity against k562 target cells by peripheral blood lymphocytes. Lym-


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Table 3. Risk of CMV infection in CMV-seronegative patients who receive granulocyte transfusions. Transplantation center [reference], year

Seattle [22], 1982


Study groups

4/19 (21)

No granulocytes vs. Granulocytes

13/21 (62)

No granulocytes vs. Granulocytes from CMVseronegative donors vs. Granulocytes from CMVseropositive donors

No. of patients in indicated group with CMV infectionl total no. in group (%)

Transplantation center [reference], year UCLA [1], 1979 Seattle [10], 1986 Minnesota [12], 1986 Sweden [11], 1986 Johns Hopkins [13], 1988

GvHO

No GvHD

6/16 (38) 152/241 (63) 34/81 (42) 17120 (85) 46/135 (34)

12/20 (60) 128/304 (42) 20/100 (20) 34/53 (64) 73/251 (29)

37/113 (33)

18/57 (32)

24/31 (77)

No granulocytes vs. Granulocytes

7/87 (8) 8/28 (29)

phocyte transformation in response to CMV antigen is significantly suppressed immediately after transplantation and usually does not recover until the patient experiences an active CMV infection. However, the extent of lymphocyte proliferation correlates poorly with the outcome of CMV infection, and patients with CMV pneumonia actually have more pronounced responses to CMV antigen than do patients without pneumonia [9]. Similarly, although NK cell activity against k562 target cells is among the first cellular immune responses to reappear after marrow transplantation, studies correlating NK cell activity with outcome of CMV infection have produced conflicting results. Dokhelar et al. [31] and Quinnan et al. [32] found that normal or increased NK cell activity was associated with improved

rates of survival from CMV infection, while Livant et al. found no such relationship [33]. In contrast, the cytotoxicity of T lymphocytes or NK cells for CMV-infected target cells appears to be a more important determinant of the outcome of CMV infection. Quinnan et al. found that all marrow transplant recipients have depressed CMV-specific cytotoxic T lymphocyte activity before the onset of CMV infection [32]. However, CMV-specific T lymphocyte cytotoxicity usually develops in survivors of infection and rarely develops in patients with fatal CMV infection. Bowden et al. reported that cytotoxic NK cell activity against CMV-infected target cells is lower in marrow transplant recipients who develop CMV infection than in patients without infection and that the duration of survival from CMV infection is longer in patients whose natural cytotoxic responses increase during the second and third months after transplantation [34]. Other defects in the cell-mediated immune system, such as depressed production of interferon and impaired antibody-dependent killer cell activity, are also found in marrow transplant recipients and may be associated with more severe CMV infection [32, 35]. While it is clear that CMV-specific antibody does not necessarily protect against the development of

Table 4. Incidence of CMV infection, by patient (P) and marrow donor (D) CMV serologic status (+ or -) before allogeneic bone marrow transplantation. Transplantation center [reference], year Seattle [9], 1980 Seattle [10], 1986 Sweden [11], 1986 Minnesota [12], 1986 Hammersmith [27], 1988

No. of patients with CMV infection/total no. in group (%) p-O-

PrD"

p+O-

31/58 (53) 58/208 (28)

12/21 (57) 44/77 (57) 114(25)

81/118 (69)

35/55 (64) 97/140 (69)

9/9 (100)

24/27 (88)

6/30 (20) 4/11 (36)

15/21 (71) 9/10 (90)

13/23 (56) 8/10 (80)

3/14 (21)

20/107 (19) 0/17 (0)

14/24 (58)

P+O+


UCLA [21], 1980

No. with CMV infections/ total no. in group (%)

Table 5. Incidence of CMV infection in allogeneic bone marrow transplant recipients with or without GvHD.

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of donor origin may persist for several months after transplantation but is lost in certain patients, presumably as a consequence of the immunosuppressive effects of chemotherapy and GvHD [55]. In some cases, the loss of CMV humoral immunity is associated with the subsequent development of CMV pneumonia [1]. There is no apparent relationship between the CMV antibody titer of the marrow donor and the incidence of interstitial pneumonia [54J. Clinical Manifestations of CMV Infection A variety of clinical syndromes are associated with CMV infection in bone marrow transplant recipients. Most syndromes appear between 3 and 16 weeks after transplantation [1-3, 27J. In many cases, persistent unexplained fevers and nonspecific constitutional symptoms in the presence of negative bacterial and fungal cultural findings are the initial manifestations of CMV infection. Some patients may develop leukopenia, thrombocytopenia, or hepatitis. However, it is frequently difficult to distinguish CMV infection from GvHD or drug toxicity as the cause of marrow suppression or hepatitis. A needle biopsy specimen from the liverrarely shows intranuclear inclusion bodies and is frequently negative for CMV in culture. CMV is the most common infectious cause of esophagitis and enigmatic nausea and vomiting after marrow transplantation, but endoscopy with biopsy and brushings as well as culture of the resultant specimens is required for distinguishing CMV infection from herpes simplex virus infection or GvHD of the gastrointestinal tract [56, 57]. Hemorrhagic cystitis, retinitis, and CNS disease are rare complications of CMV infections in marrow transplant recipients. The clinical syndrome of greatest significance in allogeneic marrow transplants is CMV interstitial pneumonia, which is discussed below. Confirmation of the diagnosis of CMV infection in marrow transplant recipients is best achieved by isolation of virus from a culture of body fluids or tissue. The oropharynx, buffy coat, urine, lung, and gastrointestinal tract are the sites from which CMV is isolated most frequently [1-3, 8, 9]. CMV may continue to be excreted in the urine for several weeks or months after resolution of a CMV-related clinical syndrome. Some patients with CMV in their urine before transplantation excrete the virus in the urine throughout the posttransplant course [14]. The detection of CMV in cell cultures has recently been en-


CMV infection, current evidence suggests that humoral immunity can modify the severity of infection. Newborns who acquire maternal CMV antibodies and renal transplant recipients who manifest an antibody response to their CMV infection have fewer severe infections than do comparable patients who do not acquire or develop humoral immunity [36, 37]. Bone marrow transplant recipients can produce antibodies to a wide range of CMV proteins in a pattern similar to that shown by persons with naturally acquired infection [38J. Some studies describe a lower mortality due to CMV pneumonia in marrow transplant recipients who develop an antibody response to the virus [1, 8J, although other studies were not able to confirm these findings [9]. Passively acquired CMV antibody prevents viral replication and dissemination and protects against lethal infections in murine models of CMV infection [39-42J. Administration of CMV immune globulin or plasma to CMV-seronegative recipients of marrow or renal allografts reduces the incidence of CMV pneumonia and other CMV-related clinical syndromes [43-48J. The importance of the donor's immunity to CMV on the incidence and outcome of CMV infection after marrow transplantation is uncertain. Both cellular and humoral immunity are transferred by bone marrow transplantation, and donor lymphocytes of T and B cell types predominate after successful grafting [49-51]. Nonetheless, most studies have found no significant correlation between the donor's CMV immune status and the outcome of CMV infection in the marrow recipient. CMV-seronegative patients who receive a marrow graft from CMV-seropositive donors may have a greater risk for CMV infection than do CMV-seronegativepatients who receivemarrow from CMV-seronegative donors [10, 11]. A recent report described a greater incidence of CMV pneumonia and a higher mortality from CMV infection in CMV-seropositive patients who received T lymphocyte-depleted marrow from CMV-seronegative donors rather than from CMV-seropositive donors [52]. However, this observation was not confirmed in another study [53], and transplantation of marrow that was not depleted of T cells from a CMV-seronegative donor to a CMV-seropositive patient is not associated with a higher risk of CMV pneumonia [10, 54J. The CMV serologic status of the marrow donor also has little effect on the lymphocyte response to CMV antigen after transplantation [9J. Transferred antiviral humoral immunity



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Table 6. Incidence of interstitial pneumonia after allogeneic bone marrow transplantation at various transplantation centers. No. of patients with pneumonia/total no. of patients at center (%)

CMV Idiopathic P. carinii Other viruses Clinically diagnosed

85 (16) 63 (12) 34 (6) 16 (3) 32 (6)

Total

215/525 (41)

UCLA 1974-1987* 67 34 7 4

(14) (7) (2) (1)

112/469 (24)

Johns Hopkins 1976-1985 [13] 45 57 6 5 53

(12) (15) (2) (1) (14)

166/386 (43)

IMTR 1978-1983 [62]t 99 (11) 134 (14) 11 (1) 11 (1) 13 (1)

IMTR 1978-1985 [63]* 31 (7) 32 (7)

}

268/932 (29)

16 (4) 79/439 (18)

NOTE. IMTR = International Marrow Transplant Registry. * D. J. Winston, unpublished observations. t Only patients with leukemia. * Only patients with severe aplastic anemia.

hanced by the rapid centrifugation culture technique [58,59]. Serologic tests for rapid diagnosis of CMV infection (such as detection of CMV IgM antibody) lack sensitivity for marrow transplant recipients [60]. Similarly, CMV intranuclear inclusions are rarely numerous in tissue specimens and cannot be relied upon for diagnosis [61]. CMV Interstitial Pneumonia Interstitial pneumonia occurs in 20070-40% of all allogeneic marrow transplant recipients (table 6) ([13, 54, 62, 63] and D. J. Winston, unpublished observations). CMV is associated with rv50OJo of the cases. Thus, the average incidence of CMV interstitial pneumonia among allogeneic transplant recipients is 15%. Most of the other pneumonias are either idiopathic or less commonly caused by other viruses or by Pneumocystis carinii. The idiopathic cases have been attributed to pulmonary toxicity of the pretransplantation chemotherapy and radiotherapy used in preparing the patient for transplantation [62, 64]. Interstitial pneumonia occurs less frequently in patients with aplastic anemia who are not treated with radiation than in patients with leukemia, who usually receive radiation therapy (table 6) [13, 54, 62-64]. The overall mortality from interstitial pneumonia is high (60%-80070) and is somewhat greater in patients with CMV pneumonia (80070-90%) than in patients with idiopathic pneumonia (60%-80%). The use of trimethoprim-sulfamethoxazole prophylactically has reduced the incidence and mortality of pneumonia due to R carinii [25]. Risk factors associated with the development of

interstitial pneumonia after allogeneic marrow transplantation are summarized in table 7 ([13, 54, 62] and D. J. Winston, unpublished observations). Old age, severe GvHD, and the use of total-body irradiation in patients with either leukemia or aplastic anemia have been the most consistent risk factors. Studies from UCLA, Johns Hopkins, and the International Bone Marrow Transplant Registry also found that the use of methotrexate for prevention of GvHD was associated with a higher incidence of pneumonia than the use of cyclosporine ([13, 62] and D. J. Winston, unpublished observations). The presence of CMV infection before transplantation (defined by seropositivity for CMV antibody in the marrow recipient) or the excretion of CMV after

Table 7. Risk factors for interstitial pneumonia after allogeneic bone marrow transplantation at various transplantation centers. Risk factors at indicated center

Risk factor Old age of patient Leukemia Conditioning with total-body irradiation in aplastic anemia Severe GvHD Methotrexate use CMV infection Transplantation before 1984

Johns Hopkins IMTR Seattle [62] [54] UCLA* [13]

+ + + +

+

+ +

+ +

+ + + +

+ +

+ + + + +

NOTE. IMTR = International Marrow Transplant Registry. * D. J. Winston, unpublished observations.


Type of pneumonia

Seattle 1969-1979 [54]


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YEAR OF TRANSPLANT Figure 2. Incidence of interstitial pneumonia, by year of transplantation, among recipients of allogeneic marrow transplants at UCLA.

transplantation was a risk factor for CMV pneumonia in studies from Seattle and Johns Hopkins [13, 54]. It is interesting that both the UCLA and Johns Hopkins transplantation centers have noted a significant decrease in interstitial pneumonia among allogeneic marrow transplant recipients since 1983. As shown in figure 2, the overall incidence of interstitial pneumonia at UCLA was 32070 before 1984 but only 12% from 1984 to 1987. The decline in the incidence of pneumonia was due more to a decrease in CMV pneumonia than to a change in the incidence of idiopathic pneumonia. The reasons for this lower incidence of CMV interstitial pneumonia are not entirely clear but may include better control of GvHD with cyclosporine or T cell depletion of the donor's marrow, the use of CMV-seronegative blood products and intravenous immune globulin (IVIG) in CMV-seronegative patients, and the use of prophylactic antiviral drugs in CMV-seropositive patients. The pathogenesis of CMV interstitial pneumonia after bone marrow transplantation remains poorly understood and has been the subject of considerable speculation. The simplest explanation for the high incidence of CMV pneumonia after allogeneic transplantation is that the immunosuppressive agents and radiation used before and after transplantation damage the pulmonary tissues and impair the patient's ability to control replication and dissemination of the virus [9, 32, 34, 62, 65]. However, despite a frequency of CMV infection similar to that in allogeneic transplant recipients and the use of similar immunosuppressive agents, CMV pneumonia is rare both in syngeneic twin transplant recipients and in


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autologous transplant recipients [4-7]. On the other hand, GvHD, which is not an expected complication of syngeneic or autologous transplantation, is commonly associated with CMV interstitial pneumonia in allogeneic transplant recipients ([13, 54, 62] and D. J. Winston, unpublished observations). These observations suggest that immunologic reactions associated with GvHD may be involved in the development of CMV pneumonia. Indeed, the GvHD reaction in mice is associated with enhancement of CMV infection and the development of CMV pneumonia [19, 66]. Nonetheless, the use of an antiviral agent against CMV (ganciclovir) in mice challenged with cells eliciting a GvHD reaction plus CMV does not prevent the development of pneumonia despite the elimination of detectable virus in the lung [67]. Similarly, administration of ganciclovir to allogeneic marrow transplant recipients with CMV pneumonia reduces the CMV titers in the lungs but does not prevent death [68, 69]. In contrast, when CMV pneumonia in marrow transplant recipients is treated with a combination of ganciclovir plus high doses of IVIG, the survival rate is 50070-75070, which is substantially higher than that produced by treatment with either ganciclovir or IVIG alone [70, 71]. The unifying hypothesis to explain these observations is that some component of the immune response to CMV is responsible for determining the occurrence of CMV pneumonia [72]. CMV pneumonia in patients and animals who receive marrow transplants is associated with an increase in the number of cytotoxic lymphocytes in the lungs [73, 74]; in athymic/nude mice the absence of these T cells prevents CMV pneumonia despite viral replication [75]. Thus, the interstitial pneumonia associated with CMV infection in allogeneic marrow transplant recipients may be an immunopathologic process mediated by a T cell response to CMV antigens whose expression on the surface of infected lung cells is enhanced by GvHD. Blockage of this T cell response by immunomodulating agents may explain the lower mortality of CMV pneumonia in human transplant recipients treated with IVIG plus ganciclovir and in mice treated continuously with Cytoxan (BristolMyers Oncology, Evansville, Ind.) [70, 71, 76]. The clinical presentation of CMV interstitial pneumonia typically occurs between 3 and 12 weeks after transplantation and has a median time of onset of 7 weeks after transplantation [13, 54, 62]. Most cases of interstitial pneumonia that occur before 3 weeks or after 12 weeks are either idiopathic or


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tion and pneumonia in bone marrow transplant recipients [25, 90]. Table 9 summarizes the results of several trials of antiviral therapy of CMV pneumonia. Earlier studies used vidarabine (adenine arabinoside), human leukocyte interferon, acyclovir, recombinant leukocyte interferon, lymphoblastoid interferon, foscarnet sodium (trisodium phosphonoformate), or combinations of these agents [91-99]. Responses were unfavorable in most cases and frequently were associated with toxicity to the marrow, CNS, or kidneys (table 9). More recently, ganciclovir (9-[(l,3-dihydroxy-2-propoxy)methyl]guanine), a new acyclicnucleoside, has been shown to have increased potency against CMV in vitro [104]. Ganciclovir is structurally similar to acyclovir but, unlike acyclovir, does not require viral thymidine kinase for phosphorylation or activation. Because human CMV does not code for thymidine kinase, acyclovir has lesser activity for CMV than does ganciclovir, which is phosphorylated intracellularly by cellular enzymes [105]. Ganciclovir is rv50 times more active than acyclovir in vitro against CMV isolates [106]. Nonetheless, despite the elimination of CMV from cultures of respiratory secretions and other body fluids, only six (200/0) of 30 patients with CMV interstitial pneumonia treated with ganciclovirat the Seattle, Minnesota, and UCLA transplantation centers survived (table 9) [68, 69, 100, 107]. Combining high doses of corticosteroids with ganciclovir for antiinflammatory and antiviral effects, respectively, also did not improve the outcome (only one of six patients survived) [101]. The most frequent toxic effect of ganciclovir is neutropenia, which usually occurs after one or more weeks of therapy and is reversible when the drug is discontinued. The results of using CMV immune globulin alone

Treatment of CMV Infection Previously available antiviral agents have generally not been effective for the treatment of CMV infec-

Table 8. Diagnosis of CMV pneumonia in bone marrow transplant recipients by bronchoalveolar lavage (BAL) or openlung biopsy (OLB).

Procedure [reference] BAL BAL BAL BAL BAL

[83] [84] [85] [86] [87]

OLB [88] OLB [89] OLB [87]

No. of cases ofCMV pneumonia 17 5 20 23 29 13 27 22

No. (%) positive by indicated method Conventional culture

Centrifugation culture

Immunochemical staining

17 (100) 1 (20) 18 (90) 21 (91) 25 (86)

17 (100)

1 (20) 14 (70) 6 (26)

11 (65) 5 (100) 15 (75) 13 (57)

9 (69) 21 (78) 20 (91)

13 (100) 27 (100) 22 (100)

Cytology

22 (96) 28 (97)

22 (100)

DNA hybridization

18 (62) 13 (100) 25 (93) 20 (91)

9 (69) 13/14 (93)


caused by organisms other than CMV [13, 54, 77]. The onset of symptoms may be rapid, with fulminant respiratory failure developing over 2-3 days in association with the formation of bilateral diffuse interstitial infiltrates [78]. On the other hand, many cases have a more insidious course characterized by prolonged fevers for one or more weeks followed by the development of a nonproductive cough, dyspnea, and lower-lobe interstitial infiltrates, which progress to more diffuse infiltrates. Previous CMV viremia has been associated with an increased risk of subsequent CMV pneumonia in some studies [79] but not in others [80]. Detection of CMV in routine bronchoalveolar lavage fluid at day 35 after transplantation may also be an early risk factor for the later development of CMV pneumonia [81]. Open-lung biopsy has generally been considered the procedure of choice for the diagnosis of CMV pneumonia [82]. However, the centrifugation culture technique, direct immunochemical staining with CMV monoclonal antibodies, and DNA hybridization have greatly enhanced the sensitivity of bronchoalveolar lavage for the diagnosis of CMV pneumonia and have obviated the need for open-lung biopsy in many cases (table 8) [83-87]. In general, cytology is the least sensitive method for diagnosis. Centrifugation culture is more sensitive than immunochemical staining, which is more sensitive than DNA hybridization for detection of CMV in bronchoalveolar lavage. These same techniques have been applied to open-lung biopsy specimens (table 8) [86, 88, 89].

Winston; Ho; and Champlin

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Table 9. Results of antiviral therapy for CMV pneumonia after bone marrow transplantation. Treatment [reference], year

No. of survivors/ no. treated 1/6

Total

for treatment of CMV pneumonia have been conflicting (table 9). Nine of 18 marrow transplant recipients with CMV pneumonia treated with a CMV immune globulin by Griffiths et al. in London survived [102]. In contrast, only three of 14 patients treated with a CMV immune globulin by Reed et al. in Seattle survived [103]. However,improved survival has been observed in recent trials of a combination of CMV immune globulin or a polyvalent IVIG containing CMV antibody and ganciclovir. As summarized in table 10, 60070 of marrow transplant recipients treated for CMV pneumonia with an antiCMV IVIG plus ganciclovir survived [70, 71, 108, 109]. These survival rates are significantly better than those noted in previous trials of antiviral agents (table 9). The mechanism by which the combination of ganciclovir and IVIG may be effective remains to be defined. It has been speculated that the IVIG may block T cell-mediated destruction of lung tissue while the ganciclovir reduces viral replication [72]. Therapy with ganciclovir plus CMV antiserum is also more effective for murine CMV infection than therapy with either agent alone [110]. Ganciclovir used alone appears to be more efficacious in marrow transplant recipients when it is used for the treatment of CMV gastroenteritis, retinitis, or viremia associated with feverand generalized wasting. Ganciclovir therapy for CMV gastrointestinal infection was associated with clinical improvement and cessation of viral excretion in 11 of 15 pa-

0/8 1/7 1/8

3/13 3/5 0/5 1/8

0/14 1/10 3/11 2/9 1/6

Marrow Marrow Marrow, neurologic Marrow, neurologic Marrow, neurologic, renal Marrow Marrow Marrow, neurologic, renal, hepatic Renal, hepatic Marrow Marrow Marrow Marrow

9/18 3/14 29/142 (20%)

tients treated by Reed et al. in Seattle [111]. Similar improvement was noted in three cases of CMV gastroenteritis and one case of CMV retinitis treated by Erice et al. in Minnesota [100]. At UCLA, all six patients who receivedganciclovir for CMV viremia with fever and wasting improved and none developed pneumonia [69]. Since CMV viremia at UCLA has been associated with subsequent development of pneumonia [79], these results suggest that ganciclovir may be more effective in marrow transplant recipients when given earlier in the course of CMV infection - before the onset of pneumonia. Accordingly, we have initiated a trial of prophylactic ganciclovir in recipients of allogeneic marrow transplants (discussed below).

Table 10. Results of therapy with IVIG plus ganciclovir for CMV pneumonia after bone marrow transplantation. Treatment [reference] Immune globulin (Gamimune; Cutter) plus ganciclovir [108] Immune globulin (Gammagard; Travenol Labs, Deerfield, Ill.) plus ganciclovir [70] CMV immune globulin (Cutter) plus ganciclovir [71] Immune globulin (Gammagard) plus ganciclovir [109] Total

No. of survivors/ no. treated (%) 6/12 (50) 7/10 (70) 13/25 (52) 10/13 (77) 36/60 (60)


Vidarabine [91], 1978 Human leukocyte interferon [92], 1980 Human leukocyte interferon plus vidarabine [93], 1982 Acyclovir [94], 1982 Human leukocyte interferon plus acyclovir [95], 1983 Recombinant leukocyte interferon [96], 1983 Recombinant leukocyte interferon [97], 1983 Lymphoblastoid interferon plus acyclovir [98], 1984 Foscamet [99], 1988 Ganciclovir [68], 1985 Ganciclovir [100], 1987 Ganciclovir [69], 1988 Ganciclovir plus corticosteroids [101], 1986 CMV immune globulin (Cytotec; Searle, Chicago) [102], 1988 CMV immune globulin (Cutter Labs, Berkeley, Calif.) [103], 1986

Toxicity


Prevention of CMV Infection

fection and pneumonia in CMV-seronegative transplant recipients is the exclusive use of CMV-seronegative blood products (table 12) [24-26]. The effectiveness of this approach for CMV prophylaxis and the significant expense of IVIG have raised questions about the need for and cost-effectiveness of IVIG for CMV-seronegative patients. However, the benefit provided by the use of CMV-seronegative blood products appears limited to CMV-seronegative patients who have a CMV-seronegative marrow donor [24]. Moreover, blood donor centers are not always able to provide screened blood products in emergency situations in which rapid replacement of large amounts of blood and platelets is necessary. At the Minnesota transplantation center, the use of CMV-seronegative blood products in recipients of CMV-seronegative allogeneic marrow transplants was not associated with improved survival, despite a modest reduction in the incidence of CMV infection (table 12) [26]. Gram-negative bacteremia occurred significantly more frequently in patients who receivedCMV-seronegative blood products and negatively influenced survival. Thus, there may be a role for the combined use of CMV-seronegative blood products and IVIG in CMV-seronegative patients. The IVIG may provide additional benefits such as modification of GvHD and the reduction of infectious complications due to bacteria, fungi, or other viruses [47, 114, 115]. In patients who are CMV-seropositive before transplantation, effective prophylaxis for CMV reactivation and pneumonia has not yet been established. Previous trials of prophylactic vidarabine (adenine arabinoside), human leukocyte interferon, and lowdose acyclovir showed no significant effect [91, 116-118]. Similarly, the efficacy of CMV immune plasma or immune globulin in CMV-seropositivepatients remains uncertain [113]. Recently, patients seropositive for antibodies to both CMV and herpes simplexvirus weregiven high doses of prophylactic intravenous acyclovir (500 mg/m" every 8 hours from 5 days before to 30 days after transplantation) and werecompared with nonrandomized control patients who were seropositive for CMV but seronegative for herpes simplex [119]. CMV infection (59% vs. 75%) and pneumonia (19% vs, 31%) were less frequent in the recipients of high-dose acyclovir (table 13). It should be noted that the incidence of CMV pneumonia in the control patients (31%) was higher


The ineffectiveness of antiviral drugs previously used for treatment or prevention of CMV infection and pneumonia after marrow transplantation has been the basis for multiple studies of passiveimmunoprophylaxis with immunoglobulins containing CMVantibodies [25, 112]. These trials were also prompted by animal studies demonstrating the modification of the severity of CMV infection by passive immunoprophylaxis and by earlier observations of a possible association between CMV antibody synthesis and less-severe CMV infection [1, 8, 39-42]. Table 11 summarizes the results of sevencontrolled trials of prophylactic CMV immune plasma, CMV hyperimmune globulin, or polyvalent IVIG containing CMV antibodies [24,43-47, 113]. Except for patients in a trial conducted by the Nordic Bone Marrow Transplant Group, most of the patients were seronegative for CMV antibody. Five of the seven studies showed a beneficial effect of passive immunoprophylaxis in modifying the severity of CMV infection and reducing the incidence of CMV pneumonia. At the Seattle transplantation center, two studies of CMV hyperimmune globulin were done, with conflicting results. In one study, an intramuscular CMV hyperimmune globulin was found to prevent CMV infection in CMV-seronegative patients who did not receive .granulocyte transfusions [44]. No benefit was observed among patients who received granulocyte transfusions. In a second study of CMV-seronegative patients who were not given granulocyte transfusions [24], an intravenous CMV hyperimmune globulin was used but failed to prevent CMV infection (table 11). The incidence of CMV pneumonia in the control patients (50/0) in this second Seattle study was much lower than that in the controls in the other trials (26%-33%) and likely precluded any opportunity of demonstrating the alleviating effect of immune globulin on the severity of CMV infection observed in the other studies. Similarly, the inclusion of mostly CMV-seropositive patients and the low incidence of CMV pneumonia in controls may have prevented the Nordic investigators from showing a beneficial effect for CMV immune plasma [113]. Thus, the negative results of the second Seattle study and the Nordic trial do not necessarily contradict the positive results of the other studies. Another approach to the prevention of CMV in-

5785

Winston, Ho, and Champlin

5786

Table 11. Controlled trials of prophylactic immune plasma or globulin in recipients of allogeneic bone marrow transplants. Transplantation center [reference] , year UCLA [43], 1982

Sloan-Kettering [45], 1983

Europe [46], 1985

Seattle [24], 1986

UCLA [47], 1987

Nordic [113], 1987

NOTE.

(%)

Regimen

Benefit

(%)

CMV immune plasma vs. No prophylaxis

12/24 (50)

3/24 (13)

15/24 (63)

8/24 (33)

CMV immune globulin vs. No prophylaxis

10/30 (33)

2/30 (7)

14/32 (44)

3/32 (9)

0/17 (0)

0/17 (0)

10/20 (50)

6/20 (30)

CMV immune globulin vs. No prophylaxis

CMV immune plasma vs. No prophylaxis

Greater benefit with no WBC transfusions

Yes

Greater benefit with no WBC transfusions

Yes

6/23 (26)

CMV immune globulin vs. No prophylaxis Gamimune vs. No prophylaxis

Yes

Yes

1/26 (4)

CMV immune globulin vs. Normal immune globulin

Comments

5/21 (24)

1/21 (5)

8/20 (40)

1/20 (5) 6/~8

18/38 (47)

No

(16)

21/37 (57)

12/37 (32)

21/27 (78)

3/27 (11)

18/27 (67)

3/27 (11)

Very low incidence of pneumonia in controls

Yes

No

Mostly CMV -seropositive patients; low incidence of pneumonia in controls

WBC = white blood cell.

Table 12. Controlled trials of CMV-seronegative blood products for prevention of CMV infection in CMV-seronegative recipients of allogeneic bone marrow transplants.

Transplantation center [reference], year Seattle [24], 1986

UCLA [25], 1986


No. with CMV infection/total no. of patients

No. with CMV pneumonia/total no. of patients

Study group

(%)

Seronegative blood vs. Controls

1/17 (6)

0/17 (0)

4/11 (36)

2/11 (18)

1/8 (13)

0/8 (0)

4/10 (40)

3/10 (30)

20/66 (30)

2/66 (3)

26/64 (41)

7/64 (11)

Seronegative blood vs. Controls Seronegative blood vs. Controls

(%)

Comments Effective only when marrow donor is CMV -seronegative

Gram-negative bacteremia more frequent with seronegative blood


Seattle [44], 1983

No. with CMV No. with CMV infection/total pneumonia/total no. of patients no. of patients


S787

Table 13. Effects of intravenous high-dose acyclovir or ganciclovir on prevention of CMV reactivation and pneumonia in CMV-seropositive recipients of allogeneic bone marrow transplants.

Reference, year [119], 1988

Acyclovir vs. Controls Ganciclovir vs. Placebo (double-blinded)

1

No. with CMV pneumonia/total no. of patients

(%)

(%)

51/86 (59)

16/86 (19)

49/65 (75)

20/65 (31)

10/32 (31)

1

3/32 (9)

Comments Not randomized

Study code not broken; neutropenia in 11 (34 %) of 32 patients

* D. J. Winston, unpublished observations.

than the incidence of CMV pneumonia previously observed in CMV-seropositive transplants at Seattle over 13years (19070-21070) [54]. Furthermore, marrow transplant recipients havedevelopedCMV pneumonia while receiving high doses of intravenous acyclovir for a previous varicella-zoster infection [120]. Thus, additional controlled, randomized studies are needed before acyclovircan be recommended for prophylaxis of CMV infection or disease. At UCLA, a trial of prophylactic ganciclovir in CMV-seropositive patients is under way [69]. Ganciclovir is given intravenously at a dosage of 2.5 mg/kg every 8 hours for 1 week before transplantation and then stopped on the day of infusion of the donor marrow. After transplantation, when the granulocyte count reaches 500 cells/rum", ganciclovir therapy is resumed at a dosage of 6 mg/tkg-d), Monday through Friday, until day 120after transplantation. A total of 32 patients have completed the study. The trial is double-blinded and placebo-controlled. The study code has not been broken. Nonetheless, the incidences of CMV infection (31%) and pneumonia (9%) are rv50070 of those expected in CMVseropositive patients (tables 1 and 2) and much lower than the incidences of infection and pneumonia in patients given prophylactic high-dose intravenous acyclovir (table 13).Neutropenia developed in about one-third of the patients in this study, but none lost their marrow graft while taking the study drug. In dogs receiving autologous transplants, prophylactic administration of ganciclovir also did not affect marrow engraftment except at higher doses [121]. Active immunization with a subunit or recombinant CMV vaccine is another approach for protection against CMV infection [122]. While the im-

munity engendered by vaccination of the patient is likely to be ablated by immunosuppressive therapy, the ability to transfer donor T cell and B cell immunity provides a rational basis for immunization of the marrow donor [49-52]. However, since previous studies have not found any convincing relationship between the donor's CMV immune status and the outcome of CMV infection in the patient, this approach may not be successful [10, 53].

References

1. Winston DJ, Gale RP, Meyers DV, Young LS, UCLA Bone Marrow Transplantation Group. Infectious complications of human bone marrow transplantation. Medicine (Baltimore) 1979;58:1-31 2. Winston DJ, Ho WG, Champlin RE, Gale RP. Infectious complications of bone marrow transplantation. Exp Hematol 1984;12:205-15 3. Meyers JD, Atkinson K. Infection in bone marrow transplantation. Clin Hematol 1983;12:791-811 4. Appelbaum FR, Meyers JD, Fefer A, Flournoy N, Cheever MA, Greenberg PD, Hackman R, Thomas ED. Nonbacterial nonfungal pneumonia following marrow transplantation in 100 identical twins. Transplantation 1982;33: 265-8 5. Pecego R, Hill R, Appelbaum FR, Amos D, Buckner CD, Fefer A, Thomas ED. Interstitial pneumonitis following autologous bone marrow transplantation. Transplantation 1986;42:515-7 6. Wingard JR, Sostrin MB, Vriesendorp HM, Mellits ED, Santos GW, Fuller DJ, Braine HG, Yeager AM, Burns WH, Saral R. Interstitial pneumonitis following autologous bone marrow transplantation. lhmsplantation 1988; 46:61-5 7. Wingard JR, Chen DY-H, Burns WH, Fuller DJ, Braine HG, Yeager AM, Kaiser H, Burke PJ, Graham ML, Santos GW, Saral R. Cytomegalovirus infection after autologous bone marrow transplantation with comparison to infec-


1988*

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S788

fection after marrow transplantation. Considerations for blood banks. Transfusion 1987;27:478-81 24. Bowden RA, Sayers M, Flournoy N, Newton B, Banaji M, Thomas ED, MeyersJD. Cytomegalovirus immune globulin and seronegative blood products to prevent primary cytomegalovirus infection after marrow transplantation. N Engl J Med 1986;314:1006-10 25. Winston OJ, Ho WG, Gale RP, Champlin RE. Treatment and prevention of interstitial pneumonia after bone marrow transplantation. In: Gale RP, Champlin RE, 005. Progress in bone marrow transplantation. New York: Alan R. Liss, 1987:525-44 26. Miller W, McCullough J, Balfour HH, Haake R, Ramsay NKC, Goldman A, Bowman R, Kersey J. Prevention of CMV infection by blood products: a randomized trial [abstract no. K128J. J Cell Biochem 1988;12(Suppl C):93 27. Apperley JF, Goldman JM. Cytomegalovirus: biology, clinical features and methods for diagnosis. Bone Marrow Transplant 1988;3:253-64 28. Rook AH. Interactions of cytomegalovirus with the human immune system. Rev Infect Dis 1988;IO(SuppI3):S460-7 29. Jacobson MA, Mills J. Serious cytomegalovirus disease in the acquired immunodeficiency syndrome (AIDS): clinical findings, diagnosis, and treatment. Ann Intern Med 1988;108:585-94 Reference [30J was deleted in proof. 31. Dokhelar M-C, Wiels J, Lipinski M, Tetaud C, Devergie A, Gluckman E, Thrsz T. Natural killer cell activity in human marrow recipients: early reappearance of peripheral natural killer activity in graft-versus-host disease. Transplantation 1981;31:61-5 32. Quinnan GV Jr, Kirmani N, Rook AH, Manischewitz JF, Jackson L, Moreschi G, Santos GW, Saral R, Burns WHo Cytotoxic T cells in cytomegalovirus infection: HLArestricted 'f-lymphocyte and non-f-lymphocyte cytotoxic responses correlate with recovery from cytomegalovirus infection in bone-marrow-transplant recipients. N Engl J Med 1982;307:7-13 33. Livnat S, Seigneuret M, Storb R, Prentice RL. Analysis of cytotoxic effector cell function in patients with leukemia or aplastic anemia before and after marrow transplantation. J Immunol 1980;124:481-90 34. Bowden RA, Day LM, Amos DE, Meyers JD. Natural cytotoxic activity against cytomegalovirus-infected target cells following marrow transplantation. Transplantation 1987; 44:504-8 35. Levin MJ, Parkman R, Oxman MN, Rappeport JM, Simpson M, Leary PL. Proliferative and interferon responses by peripheral blood mononuclear cells after bone marrow transplantation in humans. Infect Immun 1978;20: 678-84 36. Yeager AS, Grumet FC, Hafleigh EB, Arvin AM, Bradley JS, Prober CG. Prevention of transfusion-acquired cytomegalovirus infections in newborn infants. J Pediatr 1981;98:281-7 37. Simmons RL, Matas AJ, Ratazzi LC, Balfour HH Jr, Howard RJ, Najarian JS. Clinical characteristics of the lethal cytomegalovirusinfection following renal transplantation. Surgery 1977;82:537-46 38. Zaia JA, Forman SJ, Ting Y-P, Vanderwal-UrbinaE, Blume KG. Polypeptide-specific antibody response to human cy-


tion after allogeneic bone marrow transplantation. Blood 1988;71: 1432-7 8. Neiman PE, ReevesW, Ray G, Flournoy N, Lerner KG, Sale GE, Thomas ED. A prospective analysis of interstitial pneumonia and opportunistic viral infection among recipients of allogeneic bone marrow grafts. J Infect Dis 1977;136:754-67 9. Meyers JD, Flournoy N, Thomas ED. Cytomegalovirus infection and specific cell-mediated immunity after marrow transplant. J Infect Dis 1980;142:816-24 10. Meyers JD, Flournoy N, Thomas ED. Risk factors for cytomegalovirus infection after human marrow transplantation. J Infect Dis 1986;153:478-88 11. Paulin T, Ringden 0, Lonnqvist B, Wahren B, Nilsson B. The importance of pre bone marrow transplantation serology in determining subsequent cytomegalovirus infection: analysis of risk factors. Scand J Infect Dis 1986; 18:199-209 12. Miller W, Flynn P, McCullough J, Balfour HH Jr, Goldman A, Haake R, McGlave P, Ramsay N, Kersey J. Cytomegalovirus infection after bone marrow transplantation: an association with acute graft-v-host disease. Blood 1986;67:1162-7 13. Wingard JR, Mellits ED, Sostrin MB, Chen DY,Burns WH, Santos GW, Vriesendorp HM, Beschorner WE, Saral R. Interstitial pneumonitis after allogeneic bone marrow transplantation: nine-year experience at a single institution. Medicine (Baltimore) 1988;67:175-86 14. Winston DJ, Huang E-S, Miller MJ, Lin C-H, Ho WG, Gale RP, Champlin RE. Molecular epidemiology of cytomegalovirus infections associated with bone marrow transplantation. Ann Intern Med 1985;102:16-20 15. Grundy JE, Super M, Griffiths PD. Reinfection of a seropositive allograft recipient by cytomegalovirus from donor kidney [letter]. Lancet 1986;1:159-60 16. Chou S. Cytomegalovirus infection and reinfection transmitted by heart transplantation. J Infect Dis 1987;155: 1054-6 17. Jordan MC, Shanley JD, Stevens JG. Immunosuppression reactivates and disseminates latent murine cytomegalovirus. J Gen Virol 1977;37:419-23 18. Mayo DR, Armstrong JA, Ho M. Reactivation of murine cytomegalovirus by cyclophosphamide. Nature 1977; 267:721-3 19. Dowling IN, Wu BC, Armstrong JA, Ho M. Enhancement of murine cytomegalovirus infection during graft-vs.-host reaction. J Infect Dis 1977;135:990-4 20. Prince AM, Szmuness W, Millian SJ, Davis OS. A serologic study of cytomegalovirus infections associated with blood transfusions. N Engl J Med 1971;284:1125-31 21. Winston OJ, Ho WG, Howell CL, Miller MJ, Mickey R, Martin WJ, Lin C-H, Gale RP. Cytomegalovirus infections associated with leukocyte transfusions. Ann Intern Med 1980;93:671-5 22. Hersman J, Meyers JD, Thomas ED, Buckner CD, Clift R. The effect of granulocyte transfusions on the incidence of cytomegalovirus infection after allogeneic marrow transplantation. Ann Intern Med 1982;96:149-52 23. Bowden RA, Sayers M, Gleaves CA, Banaji B, Newton B, MeyersJD. Cytomegalovirus-seronegative blood components for the prevention of primary cytomegalovirus in-



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tomegalovirus after infection in bone marrow transplant recipients. J Infect Dis 1986;153:780-7 39. Araullo-Cruz TP, Ho M, Armstrong JA. Protective effect of early serum from mice after cytomegalovirus infection. Infect Immun 1978;21:840-2 40. Shanley JD, Jordan MC, Stevens JG. Modification by adoptive humoral immunity of murine cytomegalovirus infection. J Infect Dis 1981:143:231-7 41. Shanley JD, Pesanti EL. The relation of viral replication to interstitial pneumonitis in murine cytomegalovirus lung infection. J Infect Dis 1985;151:454-8 42. Rubin RH, Wilson EJ, Barrett LV, Medearis ON. The protective effects of hyperimmune anti-murine cytomegalovirus antiserum against lethal viral challenge: the case for passive-activeimmunization. Clin Immunol Immunopathol 1986;39:151-8 43. Winston OJ, Pollard RB, Ho WG, Gallagher JG, Rasmussen LE, Huang SN-Y, Lin C-H, Gossett TG, Merigan rc, Gale RP. Cytomegalovirus immune plasma in bone marrow transplant recipients. Ann Intern Med 1982;97:11-8 44. Meyers JD, Leszcynski 1, Zaia JA, Flournoy N, Newton B, Snydman DR, Wright GG, Levin Ml, Thomas ED. Prevention of cytomegalovirus infection by cytomegalovirus immune globulin after marrow transplantation. Ann Intern Med 1983;98:442-6 45. O'Reilly RJ, Reich L, Gold J, Kirkpatrick 0, Dinsmore R, Kapoor N, Condie R. A randomized trial of intravenous hyperimmune globulin for the prevention of cytomegalovirus (CMV) infections following marrow transplantation: preliminary results. Transplant Proc 1983;15:1405-11 46. Kubanek B, Ernst P, Ostendorf P, Schafer U, Wolf H. Preliminary data of a controlled trial of intravenous hyperimmune globulin in the prevention of cytomegalovirus infection in bone marrow transplant recipients. Transplant Proc 1985;17:468-9 47. Winston OJ, Ho WG, Lin CH, Bartoni K, Budinger MD, Gale RP, Champlin RE. Intravenous immune globulin for prevention of cytomegalovirus infection and interstitial pneumonia after bone marrow transplantation. Ann Intern Med 1987;106:12-8 48. Snydman DR, Werner BG, Heinze-Lacey B, Berardi VP, Tilney NL, Kirkman RL, Milford EL, Cho SI, Bush HL Jr, LeveyAS, Strom TB, Carpenter CB, LeveyRH, Harmon WE, Zimmerman CE 2nd, Shapiro ME, Steinman T, LoGerfo F, Idelson B, Schroter GPJ, Levin MJ, McIver J, Leszczynski J. Grady GF. Use of cytomegalovirus immune globulin to prevent cytomegalovirusdiseasein renaltransplant recipients. N Engl J Med 1987;317:1049-54 49. Witherspoon RP, Lum LG, Storb R. Immunologic reconstitution after human marrow grafting. Semin Hematol 1984;21:2-10 50. Wimperis JZ, Brenner MK, Prentice HG, Reittie JE, Karayiannis P, Griffiths PO, Hoffbrand AV. Transfer of a functioning humoral immune system in transplantation of T-Iymphocyte-depleted bone marrow. Lancet 1986; 1:339-43 51. Saxon A, Mitsuyasu R, Stevens R, Champlin RE, Kimata H, Gale RP. Designed transfer of specific immune responses with bone marrow transplantation. J Clin Invest 1986;78:959-67 52. Grob JP, Grundy JE, Prentice HG, Griffiths PO, Hoffbrand

S789

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veolar lavage (BAL) specimen as a predictor for interstitial pneumonia (lP) in allogeneic bone marrow transplant (BMT) recipients [abstract no. 1531]. Blood 1988;72(Suppl 1):405A 82. Springmeyer SC, SilvestriRC, Sale GE, Peterson DL, Weems CE, Huseby JS, Hudson LD, Thomas ED. The role of transbronchial biopsy for the diagnosis of diffuse pneumonias in immunocompromised marrow transplant recipients. Am Rev Respir Dis 1982;126:763-5 83. Miller MJ. Rapid diagnosis of pulmonary cytomegaloviral infection [abstract no. C-294]. In: Abstracts of the Annual Meeting of the American Society for Microbiology. Washington, DC: American Society for Microbiology, 1986 84. Emanuel D, Peppard J, Stover D, Gold J, Armstrong D, Hammerling U. Rapid immunodiagnosis of cytomegalovirus pneumonia by bronchoalveolar lavage using human and murine monoclonal antibodies. Ann Intern Med 1986;104:476-81 85. Cordonnier C, Escudier E, Nicolas J-C, Fleury J, Deforges L, Ingrand D, Bricout F, Bernaudin J-F. Evaluation of three assays on alveolar lavage fluid in the diagnosis of cytomegalovirus pneumonitis after bone marrow transplantation. J Infect Dis 1987;155:495-500 86. Crawford SW, Bowden RA, Hackman RC, Gleaves CA, Meyers JD, Clark JG. Rapid detection of cytomegalovirus pulmonary infection by bronchoalveolar lavage and centrifugation culture. Ann Intern Med 1988;108:180-5 87. GleavesCA, Myerson D, Bowden RA, Hackman RC, Meyers JD. Direct detection of cytomegalovirus from bronchoalveolar lavage using a rapid in situ DNA hybridization assay compared to centrifugation culture [abstract no. 808]. In: Program and abstracts of the 28th Interscience Conference on Antimicrobial Agents and Chemotherapy. Washington, DC: American Society for Microbiology, 1988 88. Myerson D, Hackman RC, Meyers JD.. Diagnosis of cytomegaloviral pneumonia by in situ hybridization. J Infect Dis 1984;150:272-7 89. Hackman RC, Myerson D, Meyers JD, Shulman HM, Sale GE, Goldstein LC, Rastetter M, Flournoy N, Thomas ED. Rapid diagnosis of cytomegaloviral pneumonia by tissue immunofluorescence with a murine monoclonal antibody. J Infect Dis 1985;151:325-9 90. Winston DJ, Ho WG, Gale RP, Champlin RE. Prevention and treatment of infections after bone marrow transplantation. In: Baum SJ, Santos GW, Takaku F, eds. Experimental hematology today -1987. Recent advances and future directions in bone marrow transplantation. New York: Springer-Verlag, 1987:177-86 91. Kraemer KG, Neiman PE, ReevesWC, Thomas ED. Prophylactic adenine arabinoside following marrow transplantation. Transplant Proc 1978;10:237-40 92. Meyers JD, McGuffin RW,Neiman PE, Singer JW, Thomas ED. Toxicity and efficacy of human leukocyte interferon for treatment of cytomegalovirus pneumonia after marrow transplantation. J Infect Dis 1980;141:555-62 93. Meyers JD, McGuffin RW, Bryson YJ, Cantell K, Thomas ED. Treatment of cytomegalovirus pneumonia after marrow transplant with combined vidarabine and human leukocyte interferon. J Infect Dis 1982;146:80-4


graft-versus-host reaction: effect of ganciclovir therapy. J Infect Dis 1988;158:1391-4 68. Shepp DH, Dandliker PS, de Miranda P, Burnette TC, Cederberg DM, Kirk LE, Meyers JD. Activity of 9-[2hydroxy-l-(hydroxlmethyl)ethoxymethylj guanine in the treatment of cytomegalovirus pneumonia. Ann Intern Med 1985;103:368-73 69. Winston DJ, Ho WG, Bartoni K, Holland GN, Mitsuyasu RT, Gale RP, Busuttil RW, Champlin RE. Ganciclovir therapy for cytomegalovirus infections in recipients of bone marrow transplants and other immunosuppressed patients. Rev lnfect Dis 1988;IO(Suppl 3):S547-53 70. Emanuel D, Cunningham I, Jules-Elysee K, Brochstein JA, Kerman NA, Laver J, Stover D, White DA, FelsA, Polsky B, Castro-Malaspina H, Peppard JR, Bartus P, Hammerling U, O'Reilly RJ. Cytomegalovirus pneumonia after bone marrow transplantation successfully treated with the combination of ganciclovir and high-dose intravenous immune globulin. Ann Intern Med 1988;109:777-82 71. Reed EC, Bowden RA, Dandliker PS, Lilleby KE, Meyers JD. Treatment of cytomegalovirus pneumonia with ganciclovir and intravenous cytomegalovirus immunoglobulin in patients with bone marrow transplants. Ann Intern Med 1988;109:783-8 72. Grundy JE, Shanley JD, Griffiths PD. Is cytomegalovirus interstitial pneumonia in transplant recipients an immunopathological condition? Lancet 1987;2:996-9 73. Bowden RA, Dobbs S, Kopecky KJ, Crawford S, Meyers JD. Increased cytotoxicity against cytomegalovirusinfected target cells by bronchoalveolar lavage cells from bone marrow transplant recipients with cytomegalovirus pneumonia. J Infect Dis 1988;158:773-9 74. Shanley JD, Via CS, Sharrow SO, Shearer GM. Interstitial pneumonitis during murine cytomegalovirusinfection and graft-versus-host reaction. Characterization of bronchoalveolar lavage cells. Transplantation 1987;44:658-62 75. Shanley JD. Murine cytomegalovirus pneumonitis in T-cell deficient nude mice [abstract]. In: Abstracts of the 12th Herpesvirus Workshop, Philadelphia, 1987 76. Shanley JD, Pesanti EL, Nugent KM. The pathogenesis of pneumonitis due to murine cytomegalovirus. J Infect Dis 1982;146:388-96 77. Wingard JR, Santos GW, Saral R. Late-onset interstitial pneumonia following allogeneic bone marrow transplant. Transplantation 1985;39:21-3 78. Beschorner WE, Hutchins GM, Burns WH, Saral R, Thtschka PJ, Santos GW. Cytomegalovirus pneumonia in bone marrow transplant recipients: miliary and diffuse patterns. Am Rev Respir Dis 1980;122:107-14 79. Bryson YJ, Jordan MC, Winston DJ, Coloma L, Gale RP. Prospective study of viral infections and interstitial pneumonia in bone marrow transplant recipients [abstract]. Clin Res 1980;28:111A 80. zaia JA, Forman SJ, Gallagher MT, Vanderwal-Urbina E, Blume KG. Prolonged human cytomegalovirus viremia following bone marrow transplantation. Transplantation 1984;37:315-7 81. Schmidt GM, Zaia J, Horak D, Kovacs A, Hawkins G, Nademanee A, O'Donnell MR, Snyder DS, Stein AS, Parker PM, Hill R, Blume KG, Forman SJ. Human cytomegalovirus (HCMV) detection in routine bronchoal-



108. Bratanow NC, Ash RC, Thrner PA, Smith R, Haasler G, Chitambar C, Hansen R, Casper J. Successful treatment of serious cytomegalovirus (CMV) disease with 9(1,3dihydroxy-2-propoxymethyl)guanine (gancic1ovir, DHPG) and intravenous immunoglobulin (IVIG) in bone marrow transplant (BMT) patients [abstract no. 254]. Exp Hematol 1987;15:541 109. Kovacs A, Schmidt GM, Horak DA, Forman SI, Zaia JA. Ganciclovir plus intravenous immunoglobulin treatment of human cytomegalovirus interstitial pneumonia in recipients of allogeneic bone marrow transplantation [abstract no. 738]. In: Program and abstracts of the 28th Interscience Conference on Antimicrobial Agents and Chemotherapy. Washington, DC: American Society for Microbiology, 1988 110. Wilson EJ, Medearis DN Jr, Hansen LA, Rubin RH. 9-(1-3dihydroxy-2-propoxymethyl)guanine prevents death but not immunity in murine cytomegalovirus-infected normal and immunosuppressed BALB/c mice. Antimicrob Agents Chemother 1987;31:1017-20 111. Reed EC, Shepp DH, Dandliker PS, Meyers JD. Ganciclovir treatment of cytomegalovirus infection of the gastrointestinal tract after marrow transplantation. Bone Marrow Transplant 1988;3:199-206 112. Winston DJ, Ho WG, Gale RP, Champlin RE. Prophylaxis of infection in bone marrow transplants. Eur J Cancer Clin Oncol 1988;24(Suppl 1):SI5-23 113. Ringden 0, Pihlstedt P, Volin L, Nikoskelainen J, Lonnqvist B, Ruutu P, Ruutu T, Toivanen A, Wahren B. Failure to prevent cytomegalovirus infection by cytomegalovirus hyperimmune plasma: a randomized trial by the Nordic Bone Marrow Transplantation Group. Bone Marrow Transplant 1987;2:299-305 114. Peterson FB, Bowden RA, Thornquist M, Meyers JD, Buckner CD, Counts GW, Nelson N, Newton BA, Sullivan KM, Mciver J, Thomas ED. The effect of prophylactic intravenous immune globulin on the incidence of septicemia in marrow transplant recipients. Bone Marrow Transplant 1987;2:141-7 115. Sullivan KM, Kopecky K, Jocom J, Buckner CD, Counts G, Meyers JD, Witherspoon RP, Storb R, Thomas ED. Antimicrobial and immunomodulatory effects of intravenous immunoglobulin in bone marrow transplantation [abstract no. 609]. In: Program and abstracts of the 28th Interscience Conference on Antimicrobial Agents and Chemotherapy. Washington, DC: American Society for Microbiology, 1988 116. Meyers JD, Flournoy N, Sanders JE, McGuffin RW, Newton BA, Fisher LD, Lum LG, Appelbaum FR, Doney K, Sullivan KM, Storb R, Buckner CD, Thomas ED. Prophylactic use of human leukocyte interferon after allogeneic marrow transplantation. Ann Intern Med 1987; 107:809-16 117. Saral R, Burris WH, Laskin OL, Santos GW, Lietman PS. Acyclovir prophylaxis of herpes-simplex-virus infections: a randomized, double-blind, controlled trial in bonemarrow-transplant recipients. N Engl J Med 1981;305: 63-7 118. Wade JC, Newton B, Flournoy N, Meyers JD. Oral acyclovir for prevention of herpes simplex virus reactivation after marrow transplantation. Ann Intern Med 1984;100:823-8


94. Wade JC, Hintz M, McGuffin RW, Springmeyer SC, Conner JD, Meyers JD. Treatment of cytomegalovirus pneumonia with high-dose acyclovir. Am J Med 1982;73(Suppl A):249-56 95. Wade JC, McGuffin RW, Springmeyer SC, Newton 13. Singer JW, Meyers JD. Treatment of cytomegaloviral pneumonia with high-dose acyclovir and human leukocyte interferon. J Infect Dis 1983;148:557-62 96. Winston DJ, Ho WG, Schroff RW, Champlin RE, Gale RP. Safety and tolerance of recombinant leukocyte A interferon in bone marrow transplant recipients. Antimicrob Agents Chemother 1983;23:846-51 97. Meyers JO, Day LM, Lum LG, Sullivan KM. Recombinant leukocyte A interferon for the treatment of serious viral infections after marrow transplant: a phase I study. J Infect Dis 1983;148:551-6 98. Shepp DH, Newton BA, Meyers JD. Intravenous lymphoblastoid interferon and acyclovir for treatment of cytomegalovirus pneumonia. J Infect Dis 1984;150:776-7 99. Ringden 0, Lonnqvist B, Paulin T, Ljungman P, Wahren B, Lernestedt J -0. A pilot trial using foscarnet for cytomegalovirus infections in marrow transplant recipients. In: Gale RP, Champlin RE, eds. Progress in bone marrow transplantation. New York: Alan R. Liss, 1987:589-93 100. Erice A, Jordan MC, Chace BA, Fletcher C, Chinnock BJ, Balfour HH Jr. Ganciclovir treatment of cytomegalovirus disease in transplant recipients and other immunocompromised hosts. JAMA 1987;257:3082-7 101. Reed EC, Dandliker PS, Meyers JO. Treatment of cytomegalovirus pneumonia with 9-[2-hydroxy-l-(hydroxymethyl)ethoxymethyl]guanine and high-dose corticosteroids. Ann Intern Med 1986;105:214-5 102. Griffiths PD, Stirk PR, Blacklock HA, Milburn HJ, DuBois RM, Prentice HG. Rapid diagnosis and treatment of cytomegalovirus pneumonitis. In: Gale PR, Champlin RE, eds, Progress in bone marrow transplantation. New York: Alan R. Liss, 1987:583-7 103. Reed EC, Bowden RA, Dandliker PS, Gleaves CA, Meyers JD. Efficacy of cytomegalovirus immunoglobulin in marrow transplant recipients with cytomegalovirus pneumonia. J Infect Dis 1987;156:641-5 104. Cheng Y-C, Huang E-S, Lin J-C, Mar E-C, Pagano JS, Dutschman GE, Grill SP. Unique spectrum of activity of 9[(1,3-dihydroxy-2-propoxy)methyl] guanine against herpesviruses in vitro and its mode of action against herpes simplex virus type 1. Proc Natl Acad Sci USA 1983; 80:2767-70 105. Biron KK, Stanat SC, Sorrell JB. Fyfe JA, Keller PM, Lambe CU, Nelson DJ. Metabolic activation of the nucleoside analogue 9-([2-hydroxy-l-(hydroxymethyl)ethoxy]methyl)guanine in human diploid fibroblasts infected with human cytomegalovirus. Proc Nat! Acad Sci USA 1985; 82:2473-7 106. Tyms AS, Davis JM, Jeffries DJ, Meyers JD. BWB759U, an analogue of acyclovir, inhibits human cytomegalovirus in vitro. Lancet 1984;2:924-5 107. Winston DJ, Ho WG, Champlin RE. Use of DHPG (ganciclovir) and intravenous immune globulin irabone marrow transplants. In: Gale RP, Champlin RE, eds. Bone marrow transplantation: current controversies. New York: Alan R. Liss, 1989:533-51

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121. Appelbaum FR, Meyers JO, Deeg HJ, Graham T, Schuening F, Storb R. Toxicitytrial of prophylactic 9-[2-hydroxy1-(hydroxymethyl)ethoxymethyl]guanine (ganciclovir) after marrow transplantation in dogs. Antimicrob Agents Chemother 1988;32:271-3 122. Plotkin SA, Gonczol E, Starr SE. Subunit/vaccine against human cytomegalovirus [abstract no. 735]. In: Program and abstracts of the 28th Interscience Conference on Antimicrobial Agents and Chemotherapy. Washington, OC: American Society for Microbiology, 1988


119. Meyers JO, Reed EC, Shepp OH, Thornquist M, Dandliker ps, Vicary CAt Flournoy N, Kirk LE, KerseyJH, Thomas ED, Balfour HH Jr. Acyclovirfor prevention of cytomegalovirus infection and disease after allogeneic marrow transplantation. N Engl J Med 1988;318:70-5 120. Spector SA, Connor JO, Hintz M, Large K, McMillan R, Higginbottom P. Acyclovir treatment of varicella zoster virus infections complicated by cytomegalovirus pneumonia in bone marrow transplant patients [abstract no. 188]. In: Program and abstracts of the 22nd Interscience Conference on Antimicrobial Agents and Chemotherapy. Washington, OC: American Society for Microbiology, 1982


Prophylaxis of cytomegalovirus disease in allogeneic bone marrow transplantation.

Eosinophilic gastroenteritis after allogeneic bone marrow transplantation.

Early treatment with ganciclovir to prevent cytomegalovirus disease after allogeneic bone marrow transplantation.

Pneumococcal infections after human bone-marrow transplantation.

Abnormal cervical cytology after allogeneic bone marrow transplantation.

Response to tetanus toxoid immunization after allogeneic bone marrow transplantation.

Bone Marrow GvHD after Allogeneic Hematopoietic Stem Cell Transplantation.

Hepatosplenic γδ T-cell lymphoma after allogeneic bone marrow transplantation.

Sjögren-type syndrome after allogeneic bone-marrow transplantation.

Current status of allogeneic bone marrow transplantation.

Allogeneic bone marrow transplantation: problems and prospects.

Allogeneic bone marrow transplantation for primary myelofibrosis.

Conditioning regimens for allogeneic bone marrow transplantation.

Allogeneic bone marrow transplantation in childhood leukemia.

Late complications of allogeneic bone marrow transplantation.

Prophylaxis of cytomegalovirus infection with ganciclovir in allogeneic marrow transplantation.

Prophylactic use of ganciclovir in allogeneic bone marrow transplantation: absence of clinical cytomegalovirus infection.

Prevention of viral infections after bone marrow transplantation.

Allogeneic bone marrow transplantation in multiple myeloma. European Group for Bone Marrow Transplantation.

Quantification of cytomegalovirus in bronchoalveolar lavage fluid after allogeneic marrow transplantation by centrifugation culture.

Marrow repopulation after bone marrow transplantation.

Long-term sequelae after recovery from cytomegalovirus pneumonia in allogeneic bone marrow transplant recipients.

Migraine after bone-marrow transplantation.

Early reconstitution of haematopoiesis after allogeneic bone marrow transplantation: a prospective histopathological study of bone marrow biopsy specimens.