Quantification of Cytomegalovirus DNA in BAL Fluid: A Longitudinal Study in Lung Transplant Recipients

doi:10.1378/chest.118.6.1653

Chest

Volume 118, Issue 6, December 2000, Pages 1653-1660

https://doi.org/10.1378/chest.118.6.1653 Get rights and content

Study objectives:

Cytomegalovirus (CMV) infection iscommon in patients receiving solid organ transplants, and it isassociated with increased morbidity as well as risk for development ofchronic rejection. A rapid and sensitive diagnostic method wouldimprove the therapeutic management of CMV infection, including themonitoring of treatment effects. We investigated whether longitudinaldeterminations of CMV DNA quantities in BAL fluid could be useful forthis purpose.

Design:

CMV DNA levels in 340 BALsamples from 35 consecutive lung transplant recipients were studiedduring a median of 18 months. Seventeen (49%) of the patientsdeveloped CMV disease with pneumonitis. Twenty-seven CMV diseaseepisodes were diagnosed.

Results:

Patients with CMVdisease had a significantly higher mean level of CMV copies permilliliter BAL fluid (1,120 ± 4,379) compared with those without(180 ± 1,177, p < 0.01). Viral load as well as acute rejectionrequiring treatment (≥ A2) were independent risk factorsassociated with CMV disease. Differences between the groups concerning, HLA-DR matching, basic immunosuppressive therapy, and CMV serologicstatus D/R –/+ vs D/R +/+ were not significant. A diagnosticdefinition of normality based on the mean level of all episodes without, CMV disease +2 SD would discriminate only 9 of the 27 CMVepisodes.

Conclusions:

Although the viral load isincreased during episodes of clinical CMV disease in lung transplantrecipients, the quantitative PCR assessment of CMV DNA in BAL fluid isnot discriminative enough to be useful as a diagnostic tool for CMVdisease.

Section snippets

Subjects

Thirty-five consecutive patients undergoing single lung(n = 17), bilateral lung (n = 11), or heart-lung (n = 7)transplantation from September 1994 to November 1996 were studiedlongitudinally.

In 30 cases, donors (D) and recipients (R) were matched for CMVserologic status (4 D/R –/– and 26 D/R +/+). In five cases, CMV–organs were given to CMV+ recipients (5 D/R –/+). All CMVserologically positive recipients received prophylaxis consisting of IVganciclovir 5 mg/kg body weight twice daily for 2

Results

Of the 35 patients in the study, 16 were studied for a period of 2years, 7 for 18 months, and 10 patients for 12 months after surgery(median, 18 months). Two patients died within 7 months after surgery; one of multiorgan failure and the other of malignant lymphoma. A totalof 340 protocol and diagnostic bronchoscopies were performed, with anaverage of eight episodes per patient within the first postoperativeyear.

Altogether 27 episodes of CMV disease were diagnosed, 26 as CMVpneumonitis and one

Discussion

This longitudinal study of 35 lung transplant recipients showsthat although the viral load is increased during episodes of clinical, CMV disease, the method of quantitative PCR assessment of CMV DNA in, BAL fluid is not discriminative enough to clearly separate patientswith and without CMV disease.

A total of 49% of our patients developed CMV disease, and in patientsreceiving solid organ transplants, a range from 60 to 100% has beenreported to acquire CMV infection in the

References (24)

H Einsele et al.
Polymerase chain reaction to evaluate antiviral therapy for cytomegalovirus disease
Lancet
(1991)
L Barkholt et al.
Determination of cytomegalovirus DNA load for monitoring of cytomegalovirus disease and antiviral treatment in solid organ transplant recipients, comparing limiting-dilution PCR and hybrid capture assay with cytomegalovirus isolation
Clin Microbiol Infect
(1999)
GC Riise et al.
Activation of eosinophils and fibroblasts assessed by eosinophil cationic protein and hyaluronan in BAL: association with acute rejection in lung transplant recipients
Chest
(1996)
H Scherstén et al.
Increased levels of endothelin-1 in bronchoalveolar lavage fluid of patients with lung allografts
J Thorac Cardiovasc Surg
(1996)
M Studahl et al.
Cytomegalovirus encephalitis in four immunocompetent patients [letter]
Lancet
(1992)
CA Gutierrez et al.
Cytomegalovirus viremia in lung transplant recipients receiving ganciclovir and immune globulin
Chest
(1998)
DJ Ross et al.
Lung allograft dysfunction correlates with gamma-interferon gene expression in bronchoalveolar lavage
J Heart Lung Transplant
(1999)
JD Cooper et al.
A working formulation for the standardization of nomenclature and for clinical staging of chronic dysfunction in lung allografts
J Heart Lung Transplant
(1993)
G Gerna et al.
Monitoring of human cytomegalovirus infections and ganciclovir treatment in heart transplant recipients by determination of viremia, antigenemia, and DNAemia
J Infect Dis
(1991)
M Boeckh et al.
Quantitation of cytomegalovirus: methodologic aspects and clinical applications
Clin Microbiol Rev
(1998)

C Kjellstrom et al.

Relation between polymerase chain reaction findings and morphological changes during cytomegalovirus infection in transplanted lung

Diagn Mol Pathol

(1997)

JC Fox et al.

Longitudinal analysis of cytomegalovirus load in renal transplant recipients using a quantitative polymerase chain reaction: correlation with disease

J Gen Virol

(1995)

Cited by (53)

Opportunistic Infections Post-Lung Transplantation: Viral, Fungal, and Mycobacterial
2024, Infectious Disease Clinics of North America
Detection of cytomegalovirus in bronchoalveolar lavage fluid from immunocompromised patients with pneumonitis by viral culture and DNA quantification
2023, Journal of Virological Methods
To compare the detection of human cytomegalovirus (HCMV) in bronchoalveolar lavage (BAL) fluid by viral culture and quantitative polymerase chain reaction (qPCR), and to establish a viral load threshold that can identify cases of HCMV replication indicative of pneumonitis. There is currently no universal viral load cut-off to differentiate between patients with and without pneumonitis, and the interpretation of qPCR results is challenging.
176 consecutive BAL samples from immunosuppressed hosts with signs and/or symptoms of respiratory infection were prospectively studied by viral culture and qPCR.
Concordant results were obtained in 81.25% of the BAL samples. The rest were discordant, as only 34% of the qPCR-positive BAL samples were positive by culture. The median HCMV load was significantly higher in culture-positive than in culture-negative BAL samples (5038 vs 178 IU/mL). Using a cut-off value of 1258 IU/mL of HCMV in BAL, pneumonia was diagnosed with a sensitivity of 76%, a specificity of 100%, a VPP of 100% and VPN of 98%, and HCMV was isolated in 100% of the BAL cultures.
We found that a qPCR-negative was a quick and reliable way of ruling out HCMV pneumonitis, but a positive result did not always indicate clinically significant replication in the lung. However, an HCMV load in BAL fluid of ≥ 1258 IU/mL was always associated with disease, whereas < 200 IU/mL rarely so.
Opportunistic Infections Post-Lung Transplantation: Viral, Fungal, and Mycobacterial
2023, Clinics in Chest Medicine
Cytomegalovirus pneumonitis-induced secondary hemophagocytic lymphohistiocytosis and SIADH in an immunocompetent elderly male literature review
2020, IDCases
Citation Excerpt :
This inconsistency is due to different test platforms, lack of standardization of CMV PCR kits, specimen types, and bronchoscopy methods. As the BAL viral load increased, so did the specificity [15,16]. Our patient's BAL viral load was 664,962 IU/mL, more than 100 times above the cutoff value.
Hemophagocytic lymphohistiocytosis (HLH) is also known as hemophagocytic syndrome. It is a lethal hematologic condition due to a dysregulated immune response which results in inappropriately activated macrophages damaging host tissues. Based on the etiology, HLH can be primary (genetic) or secondary (acquired). The most common cause of a secondary HLH is an infection. Viral infections are the most common cause of secondary HLH. Among the viral causes of secondary HLH, Epstein–Barr virus is the most common etiologic agent. Cytomegalovirus (CMV) is a common causative pathogen in the immunocompromised host but is rare in an immunocompetent adult. In infection- associated secondary HLH, treatment includes antimicrobial therapy. HLH carries a high mortality and morbidity rate as it is an underdiagnosed clinical condition. Successful early diagnosis allows for adequate time for curative therapy. Treatment for HLH includes chemotherapy, immunomodulators, and a hematopoietic stem-cell transplant. The 2004 diagnostic criteria set by the Histiocyte Society serves as a guide to make an earlier clinical diagnosis. A review of PubMed literature revealed only five reported cases of CMV-induced HLH. We describe the sixth case of CMV pneumonitis-induced HLH and syndrome of inappropriate antidiuretic hormone secretion in a 72-year-old White male. He was treated successfully with oral valganciclovir and corticosteroids.
Comparison of two commercial quantitative PCR assays and correlation with the first WHO International Standard for human CMV
2018, Diagnostic Microbiology and Infectious Disease
Citation Excerpt :
A concern in CMV routine diagnostics is the inter-assay quantification variability (Hirsch et al., 2013; Pang et al., 2009), possibly complicating therapeutic decisions in patients who might have testing performed in different laboratories. Quantification of CMV DNA in other body fluids, for example in bronchoalveolar lavage, is also relevant because patients with CMV disease, especially pneumonitis, have a higher CMV DNA load in bronchoalveolar lavage than patients without CMV disease (Riise et al., 2000). Recently the first World Health organization (WHO) international standard for human CMV (Fryer et al., 2016) (WHO standard) was developed to improve comparability of quantitative results between different laboratories and assays.
Comparability between CMV assays could be facilitated by the first WHO International Standard for human CMV (standard). Standard dilutions were submitted to nucleic acid extraction with Versant kPCR Molecular systems SP or MagNA Pure LC System followed by the kPCR PLX™ CMV DNA (kPCR) or the CMV R-gene™ assay (R-gene), respectively; 139 clinical specimens were tested. Both assays correlated well with the standard (R² > 0.96) and a matrix effect was observed. Quantitative results correlated reasonably between both assays for whole blood (R² = 0.79) and well for other specimen types (R² = 0.93). Quantification differences were within one log₁₀ of the averaged log₁₀ results for 25/27 blood specimens and for 32/33 other specimens. Calibration to the standard did not increase this percentage. In conclusion, results of both assays showed reasonable correlation with each other and good correlation with the standard. Calibration to the standard did not improve comparability of quantitative results.
CMV: Prevention, diagnosis and therapy
2013, American Journal of Transplantation
Cytomegalovirus (CMV) is the most common infection after organ transplantation and has a major impact on morbidity, mortality and graft survival. Optimal prevention, diagnosis and treatment of active CMV infection enhance transplant outcomes, and are the focus of this section. Methods to prevent CMV include universal prophylaxis and preemptive therapy; each has its merits, and will be compared and contrasted. Diagnostics have improved substantially in recent years, both in type and quality, allowing for more accurate and savvy treatment; advances in diagnostics include the development of an international standard, which should allow comparison of results across different methodologies, and assays for cellular immune function against CMV. Therapy primarily involves ganciclovir, now rendered more versatile by data suggesting oral therapy with valganciclovir is not inferior to intravenous therapy with ganciclovir. Treatment of resistant virus remains problematic, but is enhanced by the availability of multiple novel therapeutic agents.

View all citing articles on Scopus

View full text

Chest

Clinical InvestigationsTRANSPLANTATIONQuantification of Cytomegalovirus DNA in BAL Fluid: A Longitudinal Study in Lung Transplant Recipients

Study objectives:

Design:

Results:

Conclusions:

Section snippets

Subjects

Results

Discussion

Lancet

Clin Microbiol Infect

Chest

J Thorac Cardiovasc Surg

Lancet

Chest

J Heart Lung Transplant

A working formulation for the standardization of nomenclature and for clinical staging of chronic dysfunction in lung allografts

J Heart Lung Transplant

Monitoring of human cytomegalovirus infections and ganciclovir treatment in heart transplant recipients by determination of viremia, antigenemia, and DNAemia

J Infect Dis

Quantitation of cytomegalovirus: methodologic aspects and clinical applications

Clin Microbiol Rev

Relation between polymerase chain reaction findings and morphological changes during cytomegalovirus infection in transplanted lung

Diagn Mol Pathol

Longitudinal analysis of cytomegalovirus load in renal transplant recipients using a quantitative polymerase chain reaction: correlation with disease

J Gen Virol

Clinical Investigations
TRANSPLANTATION
Quantification of Cytomegalovirus DNA in BAL Fluid: A Longitudinal Study in Lung Transplant Recipients