Measurement of JCV DNA in CSF for diagnosis and monitoring of PML

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1 Measurement of JCV DNA in CSF for diagnosis and monitoring of PML Paola Cinque Department of Infectious Diseases San Raffaele Scientific Institute Milano, Italy SoGAT Clinical Diagnostics Istambul, 30 September 2009

2 JC virus infection and PML Ubiquitous human polyomavirus Persists in the host following primary infection (peripheral sites? CNS?) May reactivates with immunodeficiency PML results from JCV infection of oligodendrocytes

3 Productive JCV infection of the brain: PML

4 Virological techniques in PML Direct - Virus isolation - Electron microscopy - Protein detection (IHC) - DNA detection (ISH) Tissue - DNA detection and quantification (PCR) - DNA genotyping Tissue, CSF, blood, urine Indirect -Demonstration of T-cell immune response -Identification of antibody Blood, CSF Blood, CSF, CSF/blood

5 Number of cases Number of cases Qualitative CSF PCR for detection of JCV DNA 40 72% Diagnostic Sensitivity 72-92% % 77% 82% 92% 74% 83% 74% Moret 1993 Gibson 1993 Weber 1994 McGuire 1995 Fong 1995 Cinque 1996 Perrons 1996 De Luca 1996 Diagnostic Specificity % % 100% 100% 92% 96% 99% 100% 99% Moret 1993 Gibson 1993 Weber 1994 McGuire 1995 Fong 1995 Cinque 1996 Perrons 1996 De Luca 1996

6 Number of cases CSF PCR for detection of JCV DNA: Increased detection rate with disease progression 15 14/14 (100%) JCV DNA + JCV DNA /8 (50%) 2/5 (40%) 1/4 (25%) >90 Days between sampling and death Cinque et al., AIDS 1996

7 Diagnostic criteria of PML In the presence of appropriate clinical and MRI findings Histology-confirmed PML (on brain biopsy or postmortem examination) typical pathologic features AND JCV confirmed either by IHC or ISH Laboratory-confirmed PML JCV DNA in CSF by nucleic acid amplification methods Possible PML Absence of both histological and laboratory confirmation JNV Consensus (Cinque P, Koralnik IJ, Clifford DB) - ESN Guidelines (Portegies P et al., J Neurol 2004) - DHHS-IDSA Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-infected adults (MMWR 2009)

8 Quantitative CSF PCR for detection of JCV DNA Dx sensitivity 74%

9 Cum. Survi val Quantification of JCV-DNA in CSF as prognostic marker for PML HAART-untreated patients 1,8 p = 0.016,6,4, Days Yiannoutsos et al., AN 1999 Bossolasco et al., CID 2005

10 Log CSF JCV DNA c/ml Quantification of JCV-DNA in CSF as a marker for monitoring PML activity No HAART HAART progression HAART stabilization Days from first CSF sample Bossolasco et al., CID 2005

11 JCV-DNA level in CSF in a PML case with favorable outcome PML onset ART August 2005 October 2005 March 2006 August 2006 JCV-DNA 10,792 c/ml CD4 495 (11%); VL 262,000 c/ml JCV-DNA 335 c/ml CD4 619 (33%) VL 4198 c/ml JCV-DNA <100 c/ml CD4 804 (44%) VL <50 c/ml JCV-DNA nd CD (45%) VL <50 c/ml

12 PCR quantification of JCV DNA level in CSF: the weak side Diagnostic sensitivity of only 70-80% Possible false positives e.g., patients with MS: Ferrante et al. JMV /121 (9%) Alvarez-Lafuente et al. MS /43 (4.7%) Iacobaeus et al. MS /217 (<1%) Franciotta et al. MS /54 Bogdanovic et al. JCM /45 Variability of results between studies

13 Conclusions In PML, quantification of JCV DNA in CSF is a reliable marker for Diagnosis Prognosis in HIV-infected untreated patients Monitoring disease activity Laboratory proficiency is essential to provide specific, sensitive and accurate measurement

14 1 st Meeting on JCV PCR Standardization: Berlin, October 2006 Need to re-examine the value of CSF PCR for JCV DNA following reports of PML in patients receiving natalizumab Actions planned Distribution of proficiency panels for JCV and BKV DNA Preparation of a universal standard for JCV and BKV molecular diagnostics

15 2 nd Meeting on JCV PCR Standardization: Towards Establishment of International Standards Milan, July 2008 Summary of results of 2007 and 2008 QCMD proficiency panels Review of the basics for microbiology molecular diagnostic assays standards Discussion of strategies (and consensus on a plan!) for development of an International Standard for JCV and BKV DNA PCR Summer 2009: EBSC presentation of proposal for 1 st WHO International Standard for JCV and BKV for NAT-based assays