Diagnosingneurotropicvirus infectionsin immunocompromised individuals
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1 Molecular Virology Unit, Microbiology and Virology Dept IRCCS Policlinico San Matteo, Pavia DptClinical and Surgical Sciences, Diagnostics and Pediatrics University of Pavia Diagnosingneurotropicvirus infectionsin immunocompromised individuals Fausto Baldanti, MD Diagnostic tools in Virology Direct Diagnosis 1. Virus isolation 2. Detection of virus components a) antigens b) Nucleic acids Indirect Diagnosis 1. Evaluation of humoral response (serology) 2. Evaluation of cellular response (cellular immunology) 2 1
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3 Neurotropic viruses α-herpesviruses HSV1, HSV2 VZV β-herpesviruses CMV HHV-6 ɣ-herpesviruses EBV HHV-8 Bunyaviridae Toscana virus Sicily virus Naples virus Cyprus Virus California Encephalitis Virus Picornaviridae Enteroviruses poliovirus parechovirus Polyomaviruses JCV BKV Retroviridae HIV Flaviviridae WNV TBE JEV Paramyxoviridae Mumps virus Measles virus Orthoyxoviridae Influenzavirus Rhabdoviridae Rabies virus Togaviridae Venezuelan Equine Encephalitis Eastern Equine Encephalitis Rubella virus Neurotropic viruses: impact in immunocompromised pts α-herpesviruses HSV1, HSV2 VZV β-herpesviruses CMV HHV-6 ɣ-herpesviruses EBV HHV-8 Picornaviridae Enteroviruses poliovirus parechovirus Polyomaviruses JCV BKV Flaviviridae WNV TBE JEV Paramyxoviridae Mumps virus Measles virus Orthoyxoviridae Influenzavirus Bunyaviridae Toscana virus Sicily virus Naples virus Cyprus Virus California Encephalitis Virus Retroviridae HIV Rhabdoviridae Rabies virus Togaviridae Venezuelan Equine Encephalitis Eastern Equine Encephalitis Rubella virus 3
4 Diagnosis of neurotropic viruses Panel investigation Clinically-oriented investigation Panel investigation Sample-based investigation Rapid turnaround time No need of Lab-Clinic interactions Needof a wide rangeof assays Expensive Analyses limited by CSF volume Difficult clinical interpretation of results 4
5 Clinically-oriented investigation Patient-based investigation Crucial Lab-Clinic interaction Needof a wide rangeof assays Less expensive(stepwise analysis) Results interpreted in the clinical context Turnaround time dependent on clinical/lab skills Virologic investigations Serology and molecular assays on paired blood and CSF samples CSF IgM CSF/serum IgGratio correctedfor BBB damage CSF/serum virus DNA or RNA levels corrected for BBB damage Sequential Blood and CSF samples IgM kinetics IgG kinetics Virus DNA or RNA kinetics 5
6 The clinical value of being Positive Negative Neurol Sci. Sep 2008; 29(4): Varicella Zoster Virus Meningo-Encephalo-Myelitis in an Immunocompetent Patient Eleonora Tavazzi, MD, Lorenzo Minoli, Professor, Pasquale Ferrante, Professor, Paola Scagnelli, MD, Serena Del Bue, PhD, Alfredo Romani, MD, Sabrina Ravaglia, MD,PhD, and Enrico Marchioni 85 year old immunocompetent woman with mild hyperthermia and acute, severe MEM. Marked CSF lymphomonocytic pleocytosis, BBB damage. MRI revealed lesionsof the meninges, brain and spinalcord. No evidence of immunosuppression. HSV 1-2 DNA NEG VZV DNA POS copies/ml CSF CMV DNA NEG HHV-6 DNA NEG EBV DNA NEG JCV DNA NEG 6
7 Male Pt, 45 yrs old, HIV/HCV coinfected, meningoencephalitis EBV DNA (CSF) 200 copies/ml (whole blood) copies/ml JC DNA (CSF) copies/ml (whole blood) 50 copies/ml Female Pt, 51 yrs old, HIV/HCV coinfected, meningoencephalitis EBV DNA (CSF) 1300 copies/ml (whole blood) 9250 copies/ml HSV DNA (CSF) 25 copies/ml (whole blood) --- (not performed) HIV RNA (CSF) 2919 copies/ml (plasma) 389 copies/ml HCMV 7
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10 HCMV encephalitis in an adult HSCTR, 59 years old AML HSCT from matched unrelated donor encephalitis CMV DNA copies/ml Death GCV GCV GCV Steroid GCV PFA RTX Days after HSCT CMV DNA in blood CMV DNA in CSF CD4 CD8 T cells/µl 10
11 HCMV radicolomyelitis in a pediatric HSCTR, 4 years old ALL haploidentical T-cell depleted HSCT from father radicolomyelitis CMV DNA copies/ml PFA CTL anti-cmv PFA+GCV GVHD ALL relapse Death Days after HSCT T cells/µl CMV DNA in blood CMV DNA in CSF CD4 CD8 Aspecific human IgG HHV-6 Β-herpesvirus Seroprevalencebetween 90-95% in the adult population of the world. Primary infection usually within the first 6-15 months of life, with peak infection in infants 6-9 months of age, after the protection of maternal antibodies cease. HHV-6B is more seroprevalent, causing the majority of clinically observed infections. HHV-6A seropositivityis usually observed in immunocompromised individuals or in adult patients who display clinical signs of exanthema subitum (roseola). HHV-6 transmission likely occurs through saliva. Germ line transmission of HHV-6 can occur, and is observed in approximately 2% of births. 11
12 Human Herpesvirus 6: An Emerging Pathogen Gabriella Campadelli-Fiume, Prisco Mirandola, and Laura Menotti
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14 CI-HHV6 in hematopoitetic stem cell transplant recipients: a diagnostic conundrum Donor CIHHV6+: hair& blood (1 HHV6DNA copy/cell) Recipient CIHHV6+: hair& blood (1 HHV6DNA copy/cell) DonorCIHHV6+ RecipientCIHHV6-: hair- blood+ (1 HHV6DNA copy/cell) DonorCIHHV6-RecipientCIHHV6+: hair+ blood- (1 HHV6DNA copy/cell) DonorCIHHV6+ RecipientCIHHV6+: hair+ blood+ (1 HHV6DNA copy/cell, maybe different genotypes) RecipientCIHHV6-RecipientCIHHV6-: hair- blood- 14
15 HHV-6, 12 years old ALL haploidentical T-cell depleted HSCT from father meningo-encephalitis HHV 6 DNA 0 copies/ hair follicle cells NO Chromosomal Integrated HHV-6 HHV6 DNA copies/ml sample 10 9 hair follicle cells test negative GCV+PFA whole blood CSF Days after HSCT HHV-6, 63 years old osteomyelitis and sepsis due to MRSA signs of meningo-encephalitis HHV 6 DNA copies/ hair follicle cells Chromosomal Integrated HHV-6 HHV6 DNA copies/ml sample HHV6 DNA copies/ cells CSF whole blood hair follicle 15
16 HHV-6, 5 years old AML haploidentical T-cell depleted HSCT from mother recipient: HHV 6 DNA copies/ hair follicle cells donor: HHV 6 DNA copies/ hair follicle cells Chromosomal Integrated HHV-6 cells or copies/ml whole blood PFA acute rejection 2 o HSCT positive mother positive HHV6 DNA copies/ cells HHV6 DNA whole blood CTL anti-hhv6 hair follicle cells WBC Days after first HSCT Can CI HHV6 reactivate? 16
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18 Molecular Virology Unit, Microbiology and Virology Department IRCCS Policlinico San Matteo, Pavia Clinical and Surgical Sciences Department, Diagnostics and Pediatrics University of Pavia 18
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