Infections Post Transplant Early Diagnosis of Adenovirus Infection and Treatment with Cidofovir After Bone Marrow Transplantation in Children

Bone Marrow Transplantation (2001) 27, 621–626  2001 Nature Publishing Group All rights reserved 0268–3369/01 $15.00 www.nature.com/bmt Infections post transplant Early diagnosis of adenovirus infection and treatment with cidofovir after bone marrow transplantation in children

F Legrand1,*, D Berrebi2,*, N Houhou3, F Freymuth4, A Faye1, M Duval1, JF Mougenot5, M Peuchmaur2 and E Vilmer1

1Service d’He´mato-Immunologie, 2Service d’Anatomie et de Cytologie Pathologiques and EA3102 universite´ de Paris VII, 5Gastro- Ente´rologie Pe´diatrique, Hoˆpital Robert Debre´, Paris; 3Laboratoire de Virologie, Hoˆpital Bichat-Claude Bernard, Paris; and 4Laboratoire de Virologie Humaine et Moleculaire, Hoˆpital Universitaire de Caen, Caen, France

Summary: Keywords: bone marrow transplantation; adenovirus infection; cidofovir Adenovirus infection remains an important cause of mortality after bone marrow transplantation (BMT). Currently no efficient antiviral treatment is known. Thus, testing new modalities of early diagnosis and Adenovirus infections are mild and self-limited in the treatment is a crucial objective. Adenovirus infection is immunocompetent host, whereas infection is often dissemi- defined by the combination of symptoms and the iso- nated and rapidly fatal in immunocompromised patients lation of virus from the source of clinical symptoms. The with a mortality of about 60%.1 The incidence of aden- involvement of two or more organs and the presence of ovirus infection is increased in allogeneic bone marrow virus in blood cultures define disseminated disease. transplantation (BMT).2–4 The incidence is higher among Seven children with a median age of 7 years received recipients of unrelated or HLA mis-matched transplants due bone marrow transplantation for leukemia. All received to the profound and persistent immunodeficiency.2,4 The an unrelated graft without T cell depletion. Adenovirus common disease manifestations of adenovirus infection was sought in blood, urine and biopsy specimens using after BMT are acute hemorrhagic cystitis, pneumonia, liver PCR and culture. Analysis of biopsy specimens included failure and diarrhoea.2,5 After BMT, acute diarrhoea is a systematic immunohistochemistry. Cidofovir treatment frequent event with a reported 43% incidence.6 The two was initiated as soon as biopsy revealed the histopatho- main etiologies are acute graft-versus-host disease (GVHD) logical signs of adenovirus. Cidofovir was given at and intestinal infection.6 Their clinical presentation may be 5 mg/kg once weekly for 3 weeks then every 2 weeks. similar, which makes diagnosis more difficult. Six patients had diarrhoea and one patient had cystitis. Adenoviral infection can be diagnosed by viral isolation Adenovirus infection and disseminated disease were in a tissue culture system or by polymerase chain reaction diagnosed in four cases and three cases, respectively. In (PCR) from urine, nasopharynx and blood.7,8 Morphologi- six cases, serotype A31 was isolated from gastrointes- cal features and intranuclear inclusions due to adenovirus tinal biopsy and in two cases serotypes B2 and C6 were are also characteristic and can be rapidly (Ͻ24 h) observed detected in blood and urine. Cidofovir treatment was by light microscopy and confirmed by immunohistochemis- associated with clinical improvement of diarrhoea, cys- try.9 Adenovirus types 1, 2, 4, 5, 6, 7, 7a, 11, 31, 32, 34 titis and fever in five patients, in whom the virus became and 35 have been recovered from children and adults with undetectable in cultures and PCR analyses despite the immunodeficiency diseases, malignancies, steroid therapy, persistence of immunodeficiency. The median follow-up and after transplantation (BMT and solid organ was 360 days after BMT (240–570). One child died of transplantation).5 No specific antiviral agent has been invasive aspergillosis and another of disseminated aden- reported to be effective in the treatment of adenovirus ovirus after interruption of cidofovir therapy. Further infection, which is sometimes the direct cause of death. studies in immunocompromised patients will be needed Previously known as (S)-1-[3-hydroxy-2 (phosphonyl- to extend these promising results concerning the role of methoxy) propyl] cytosine (HPMPC), cidofovir is a mono- cidofovir in adenovirus infection. Bone Marrow Trans- phosphate nucleotide analogue of cytosine that inhibits plantation (2001) 27, 621–626. viral DNA polymerase. This antiviral drug has in vitro and in vivo activity against several herpes viruses.10,11 The report of an in vitro effect of cidofovir on adenovirus led Correspondence: Dr F Legrand, Service d’He´mato-Immuno-Pe´diatrie, us to initiate a phase I/II study with cidofovir in grafted Hoˆpital Robert Debre´,48bdSe´rurier, 75019 Paris, France 12 *Dominique Berrebi and Faezeh Legrand have participated equally in patients with adenovirus infection. Seven children receiv- this work ing an unrelated BMT were treated with cidofovir follow- Received 21 June 2000; accepted 10 December 2000 ing early diagnosis of adenovirus infection. Clinical Cidofovir treatment for adenovirus infection after BMT F Legrand et al 622 improvement was observed in five of them despite the the conditioning regimen for GVH prophylaxis. All patients persistence of profound immunodeficiency. received T cell-unmanipulated marrow.

Patients and methods Samples studied and immunohistochemistry Gastrointestinal biopsy specimens from children with dia- Patients rrhoea or vomiting and nausea were examined for GVHD The children (four boys, three girls, mean age 6.4 years) and viral infection. In each case, one or two biopsies were underwent BMT, from a serological HLA-A and B matched immediately frozen in liquid nitrogen and the others were and DRB1 matched unrelated donor, for acute lymphoblas- fixed in neutral-buffered formalin (4%), embedded in paraf- tic leukemia (ALL, n = 6) or acute myeloblastic leukemia fin and stained with hematoxylin and eosin. At least 10 (AML, n = 1) (Table 1). The patients were admitted semi-serial sections from each biopsy specimen were exam- between May 1998 and May 1999 to the Paediatric ined. Immunohistochemical analysis for adenovirus was Haemato-Immunology Unit of Robert Debre´ Hospital. performed on all cases either on frozen or paraffin-embed- Patients, primary disease, conditioning regimen, site and ded tissue samples using a three-stage immunoperoxidase type of adenoviral infection are given in Table 1. All technique with a mouse monoclonal anti-adenovirus anti- patients were treated in positive-pressure isolation rooms body (Arge`ne, Biosoft, clone H-60, Varilhes, France). (for 21–35 days) and received non-absorbable oral anti- Cryostat sections were also immunostained with the follow- biotics and a low bacteria-containing diet. On development ing antibodies: anti-HLA-DR, CD3, CD8, CD25 (Becton of febrile neutropenia, patients received empiric antibiotics Dickinson, San Jose, CA, USA), and CMV (Arge`ne, that included ceftazidime, vancomycin and amikacin. Two Biosoft, clone H-60). days later, empiric amphotericin B (1 mg/kg/day) was administered if fever persisted. All patients received weekly Virological studies intravenous immunoglobulin and aciclovir. All patients were monitored weekly for quantification of pp65 CMV Gastrointestinal biopsy specimens were cut into small frag- antigenaemia in peripheral blood. When CMV antigenae- ments and used for viral isolation and nucleic acid extrac- mia was positive, ganciclovir treatment was initiated tion. For viral isolation, the human embryonic lung diploid according to a pre-emptive strategy. fibroblast cell strain MRC-5 was cultured in 25 cm2 flasks GVHD prophylaxis consisted of cyclosporin A (from day and inoculated with several biopsy fragments, then fed with −1) and methotrexate (day +1, day +3 and day +6) followed maintenance medium and incubated at 35–36°C for 4 by steroid therapy after day +7. In this period of time anti- weeks exactly. When adenoviruses were recognized by thymoglobulin (ATG) (day −3 to day −1) was included in their characteristic cytopathic effect, infected cells were

Table 1 Patient characteristics

Patient/age Disease type Regimen GVHD Date of ADVa First symptoms Site(s) of virus Adenovirus diagnosis/BMT date/BMT serotype

1/9y ALL CR2 TAM12, ATG Gastro-intestinal 76d Diarrhea, fever Sigmoidal biopsy A31 GVHD, grade 1 /75d 2/9y ALL CR2 TAM12, ATG Gastro-intestinal 26d Diarrhoea, fever, Sigmoidal and gastric A31 (d25), C6 GVHD, grade II vomiting, erythematous biopsy (d25), urine (d45) maculopapule blood (d45) /25d 3/10y ALL CR3 FLU, Melphalan, 0 27d Diarrhoea, vomiting, Sigmoidal and gastric A31 ATG anorexia, and fever biopsy /26d 4/30m AML CR2 FLU, Melphalan, 0 21d Diarrhoea, conjunctivitis, Sigmoidal biopsy, throat A31 ATG fever, upper respiratory illness and eruption /20d 5/7y ALL CR2 TAM9, ATG Cutaneous 11d Diarrhoea Sigmoidal biopsy (d10), A31 (d10), B2 GVHD, grade I /10d CSF, blood, urine (d70) (d69) 6/3y ALL, CR2 TAM9, ATG 0 26d Diarrhoea Sigmoidal biopsy, gastric A31 /25d biopsy 7/4y ALL, CR2 TAM9, ATG Chronic 38d Cystitis Urine (d28), sigmoidal A31 cutaneous /28d biopsy (d38) GVHD

ALL = acute lymphoblastic leukemia; AML = acute myeloblastic leukemia; GVHD = graft-versus-host disease; ADV = adenovirus; TAM12 and TAM9 = TBI, aracytine (cytarabine) 12 g/m2 or 9 g/m2; Melphalan = 140 mg/m2; FLU, Melphalan = ﬂudarabine 125 mg/m2 and melphalan 140 mg/m2; ATG = anti-thymoglobulin. aThe date of diagnosis of adenoviral infection was 24 h after the ﬁrst symptoms except for patient No. 7.

Bone Marrow Transplantation Cidofovir treatment for adenovirus infection after BMT F Legrand et al 623 harvested, pelleted by centrifugation, deposited on micro- Results scope slides, and fixed in acetone. Adenoviruses were identified by immunofluorescence, using a group-specific Clinical symptoms monoclonal antibody (Arge`ne, Biosoft) and by PCR From May 1998 to May 1999, seven patients presented hybridization-EIA.13 Further subgenus identification was with adenovirus infection which is defined by the combi- performed using two adenovirus genus-specific primers in 14 nation of symptoms and the isolation of virus from the the VA RNA gene previously described by Kidd et al, source of clinical symptoms. Involvement of two or more and amplification products were detected by agarose gel organs and presence of virus in blood culture define dis- electrophoresis: band at 240–290 bp for one VA RNA gene seminated adenovirus. Clinical symptoms are shown in (adenovirus of subgenera A, B2, F), and band at 410– Table 1. Six patients had diarrhoea (Ͼ300 ml per day) at 520 bp for two VA RNA genes (adenovirus of subgenera initial presentation (patients 1, 2, 3, 4, 5 and 6), four had B1, C, D, E). The adenovirus serotypes were then identified fever (single temperature Ͼ38.5°C) (patients 1, 2, 3 and 4), by neutralization tests with specific rabbit antiserum three patients had evidence of cystitis (gross haematuria) obtained from the American Type Culture Collection (patients 2, 5 and 7), one at initial presentation and two a (Rockville, MD, USA). few weeks later. Anorexia (patients 1 and 3), erythematous maculopapular rash (patients 3 and 4 ) or conjunctivitis (patient 4) appeared within 2 weeks of isolation of adenovirus. One patient had invasive infection: pneumonia, Cidofovir management encephalitis, nephritis, and hepatitis, which were the cause of death. All patients had elevated liver function tests. Cidofovir (Vistide, Pharmacia & Upjohn, Luxembourg) is Some patients also developed other viral infections sev- a nucleotide analogue of cytosine that is converted to an eral weeks after adenoviral infection: oral necrotic HSV1 active intracellular metabolite, cidofovir diphosphate. Thus, and EBV post-transplantion lymphoproliferative disease, in unlike the nucleotide analogues (aciclovir and ganciclovir) patient 6, CMV infection in patients 5, 6 and 7. cidofovir does not require viral thymidine kinase for phosphorylation by the cellular enzymes. The long intracellular half-life of the diphosphate (17–65 h) may explain the pro- Pathological findings longed antiviral activity and the feasible intermittent The early detection of adenovirus inclusions in gastrointes- administration of this drug.11 However, its use is limited by tinal biopsies allowed early diagnosis of the adenoviral the renal toxicity on the proximal convoluted tubule cells. infection. In seven patients with diarrhoea, light Concomitant administration of probenecid is thought to microscopy identified the presence of epithelial cells con- reduce this side-effect by competing for cidofovir taining inclusions in their nuclei that were characteristically uptake.15,16 In our children, treatment with cidofovir was amphophilic or eosinophilic (Figures 1 and 2). Nuclear started as soon as adenovirus infection was diagnosed. The inclusions were present in one or several intestinal sites, theoretical dose of cidofovir for CMV retinitis in patients mainly in the duodenum and the rectum and were found in with AIDS is 5 mg/kg once weekly for 2 weeks then once the gastric mucosa in only one case. The morphological every 2 weeks.10,11 For our patients, cidofovir was adminis- features were confirmed by immunohistochemistry using an tered at 5 mg/kg once weekly for 3 weeks followed by maintenance therapy at 5 mg/kg once every 2 weeks or 10 days. Each infusion of cidofovir was administered in combination with oral probenecid and intravenous saline hydration. A total dose of 2 g probenecid per 1.73 m2 of body surface (BS) was given orally 3 h before infusion and 1 g per 1.73 m2 was given 2 h and 8 h after the end of cidofovir infusion. Hydration consisted of 1 liter of normal saline per 1.73 m2 of BS before infusion and 1 to 2 liters (if patients could tolerate) during or immediately after the cidofovir infusion. Urinalysis consisted of creatinine clear- ance and proteinuria determined before and after cidofovir infusion. The adaptation of cidofovir dose in patients is based on data published in AIDS patients for treatment of cytomegalovirus retinitis.10 If urinalysis before cidofovir administration revealed proteinuria Ͼ2+ or creatinine clear- ance level (CCL) Ͻ55 ml/min, or serum creatinine Ͼ133 (mol/l), cidofovir administration was interrupted. Cidofovir dose was adapted according to CCL: from 60–90 ml/min, cidofovir was administered at half the theoretical dose, and Figure 1 Histological features of adenoviral inclusions in small bowel from 90–120 ml/min at two-thirds of the theoretical dose. biopsy specimen. Epithelial nuclear inclusions were preferentially found in the surface (arrows). The outline of infected nuclei was normal and Cidofovir was not administered concomitantly with con- their size was not or only slightly enlarged. Hematoxylin and ventional amphotericin B, pentamidine or foscarnet. counterstained with eosin. Original magnification ×250.

Bone Marrow Transplantation Cidofovir treatment for adenovirus infection after BMT F Legrand et al 624 intestinal biopsy. Two patients had a mixed infection with A31 and B2 (patient 5) and with A31 and C6 (patient 2). Four patients had virus isolated from more than one site. Adenovirus was isolated from a mean of 1.42 sites per patient (Table 1): one site (gut biopsy) in three patients, two sites (gut biopsy and urine or throat) in two patients, three sites (gut biopsy, urine, and blood) in one patient and more than three sites in one patient (gut biopsy, urine, blood, cerebrospinal ﬂuid, liver and bone marrow). Adenovirus A31 was never isolated from blood. Culture and PCR of blood and urine identiﬁed C6 adenovirus in patient 2, A31 adenovirus from urine in patient 7 and B2 from CSF, urine and blood of patient 5.

Cidofovir treatment Cidofovir was given immediately after histopathological diagnosis. The median duration of cidofovir therapy was Figure 2 Higher magnification of Figure 1 showing numerous intra- 180 days in five patients (days 60–330). nuclear inclusions. When the nuclear inclusions were numerous (Ͼ50 per biopsy), we observed epithelium buds on the surface or cryptic epithelium with sometimes shedding of the infected epithelial cells into the gland or Clinical safety: The most common adverse effects of cido- intestinal lumen (asterisk). Hematoxylin and counterstained with eosin. fovir were nephrotoxicity manifested as proteinuria and Original magnification ×1000. increased serum creatinine level (SCL). No other adverse effects were observed in our patients. Patients 1, 4, 6 and 7 tolerated cidofovir without renal dysfunction. Nephrotox- anti-adenovirus antibody (Figure 3). In one case, aden- icity was observed after the second dose of cidofovir in ovirus staining was found in a single epithelial cell. CMV patients 2, 3 and 5. Patients 2 and 3 had a CCL Ͻ60 ml/mn, antigens were not identified on gastrointestinal samples cidofovir was interrupted and reintroduced 20 days later using an anti-CMV antibody. No histological features of for patient 2 (Figure 4). Patient 5 had a CCL Ͻ40 ml/min, GVHD were observed in biopsy specimens. cidofovir was stopped at day 60 and he died at day 111 from invasive adenovirus infection (Figure 5). Evaluation Adenovirus species and sites of isolation of renal function 360 days (240-570) after BMT revealed a normal SCL in four patients (40–60 ␮mol/l) and an In our patients, identified species were adenovirus type 31 abnormal SCL (129 ␮mol/l) in patient 2. This patient had subgenus A, type 2 subgenus B and type 6 subgenus C. received amphotericin B for 30 days before adenoviral Sites of viral isolation are shown in Table 1. In six patients diagnosis and cidofovir for 330 days (Table 2). During with diarrhoea, adenovirus A31 was isolated from gastro- maintenance therapy (cidofovir every 15 days), the clinical symptoms of adenovirus reappeared a few days before

% theoretical 100% 0 0 50% 100% 100% 100% dose CDF

Symptoms Diarrhea Cystitis

Viral detection Blood **+ Urine + Gut biopsy + +

CD4 number 0000

Virus subgenus A31 C6

Post-BMT days: 25 32 39 43 50 57 64 71 78

Figure 4 Case report of patient 2. Adenovirus was first detected in sigmoidal biopsies on D25 (adenovirus serotype 31, subgenus A). Cidofovir treatment was initiated on day 27 and discontinued after first infusion because of a CCL at 60 ml/min. Diarrhoea persisted and cystitis appeared on day 45. Adenovirus serotype 6, subgenus C was detected in urine and Figure 3 Immunohistochemistry with anti-adenovirus antibody in a blood (by culture and PCR). Cidofovir was reintroduced at half the theor- digestive biopsy specimen. The inclusions are labeled with anti-adenovirus etical dose and after the second injection, the patient’s general condition antibody (L: lumen). These inclusions are numerous and located in the improved. Adenovirus was not isolated from blood, urine, or stool after nucleus of epithelial cells mainly in enterocytes. Original magnification day 57. *The patient continued to excrete adenovirus in the stool but the ×400. gut biopsy was not performed in these 2 weeks.

Bone Marrow Transplantation Cidofovir treatment for adenovirus infection after BMT F Legrand et al

% theoretical 100% 100% 50% 100% 100% 625 dose CDF Discussion Symptoms Diarrhea Cystitis The present study reports the outcome of adenovirus infec- Confusion Respiratory tion in seven children who received a matched unrelated deficiency Viral detection donor graft and were treated with cidofovir. These infec- Gut biopsy + Blood + tions occurred in the context of profound immunodefi- Urine + CSF + ciency in all patients. ATG administered during the con- Throat + CD4 number 0 0 0 0 00 ditioning regimen contributed to the immunosuppression and the mean CD4 counts were zero at the time of aden- Virus subgenus A31 B2 ovirus infection. Diarrhoea was the initial symptom in six cases and hemorrhagic cystitis in one. Rectal biopsies per- Post-BMT days 10 17 24 39 53 60 69 80 90 100 111 mitted early diagnosis based on histology and immunohistochemistry with a polyclonal antibody and this was con- Figure 5 Case report of patient 5, death at day 111. Adenovirus A31 was isolated on day 10 from sigmoidal biopsies. Cidofovir treatment was firmed by direct viral detection. These gastrointestinal initiated on day 10. Cidofovir was continued for 44 days and discontinued biopsies may be informative when adenovirus infection is after day 60 because of renal impairment (CCL = 40 ml/min). The suspected even in the absence of gastrointestinal symptoms patient’s clinical condition worsened and adenovirus 2 subgenus B was (patient 7). Serotype 31 subgenus A was recovered from detected by culture of sigmoidal biopsies and urine. On day 90, adenovirus all patients, suggesting an outbreak in our ward. Among B2 was detected in blood culture and CSF analysis. This patient died from disseminated adenoviral infection. Postmortem examination revealed the serotypes, type 31 is known to be associated with a numerous and disseminated typical viral inclusions in the liver, lungs, higher case fatality rate (61%) with the involvement of dif- heart, kidneys, brain, bone marrow and throughout the gastrointestinal ferent sites in BMT patients.1 In our series gastrointestinal tract. In all organs, endothelial cells also contained INI, in particular in symptoms were predominant at least during the initial per- heart specimens and in digestive specimens. A special stain for acid-fast and fungal organisms and immunohistochemistry with anti-CMV antibody iod of adenovirus infection. The two patients co-infected was negative. with a second serotype (C6 or B2) exhibited a more diffuse and disseminated infection. The clinical management and treatment regimen of adenovirus infection in BMT patients are not well defined. No administration of the drug in all patients (cystitis, diarrhoea, antiviral drugs are known to be effective. Neither polyclonal immunoglobulins nor ganciclovir have shown any fever or vomiting). This observation prompted us to extend 17,18 initial treatment of 5 mg/kg/week to 3 weeks instead of 2 clinical benefit in immunocompromised patients. Riba- virin has been reported to be useful in cases of hemorrhagic and to decrease the maintenance therapy interval to 10 days 19,20 instead of 15. cystitis, pneumonia and gastroenteritis due to adenovirus in BMT patients but these findings are contro- versial.21 There is some evidence to support the use of cido- 12 Patient outcome fovir in adenovirus infection. This monophosphate nucleotide analogue of cytosine undergoes intracellular The median time to resolution of clinical symptoms after phosphorylation to its active diphosphate form and inhibits cidofovir therapy was 15 days. Median follow-up after viral DNA polymerase. Cidofovir has in vitro and in vivo BMT was 360 days (240–570). Clinical improvement in activity against several herpesviruses and is used for the diarrhoea, cystitis, and fever was observed in five patients treatment of cytomegalovirus retinitis.10,11 Adenovirus rep- in whom the virus became undetectable by urine and blood lication is inhibited in vitro by concentrations of cidofovir culture and PCR analysis (Table 2). Outcomes that were that can be reached in vivo. favourable (patient 2) and unfavorable (patient 5) are Cidofovir has been successfully used for treating aden- shown in Figures 4 and 5. ovirus cholecystitis and colitis in a patient with AIDS and

Table 2 Treatment and patient outcome

Patient No. Duration of Deferred Secondary ADV symptoms Other nephrotoxic Outcome of ADV Follow-up after therapy treatment drugs infection BMT

1 60d no no CSA, AmphoB Recovery Alive, 570d 2 330d yes Cystitis CSA Recovery Alive, 545d 3 197d yes no CSA Recovery Alive, 300d 4 25 no no CSA, AmphoB Death at d45 Death due to Aspergillosis 5 44d yes Nephritis, encephalitis, cystitis, CSA Death at d111 Death due to ADV pancytopenia, pneumonia, myocarditis 6 180d no no CSA Recovery Alive, 330d 7 90d no Diarrhoea CSA Recovery Alive, 240d

Bone Marrow Transplantation Cidofovir treatment for adenovirus infection after BMT F Legrand et al 626 after BMT.22,23 However, the nephrotoxicity of this drug 5 Cherry JD. Adenoviral infections. In: Feigin RD, Cherry JD hampers its usage especially in BMT patients treated with (eds). Textbook of Pediatric Infectious Diseases. WB Saunders other nephrotoxic drugs such as cyclosporin A and ampho- Co: Philadelphia, 1992, pp 1670–1687. tericin B. The high case fatality rate of adenovirus in these 6 Cox JG, Matusi SM, Lo RS et al. Etiology and outcome of transplant patients, nevertheless warrants evaluation of the diarrhea after marrow transplantation: a prospective study. Gastroenterology 1994; 107: 1398–1407. safety and clinical benefit of cidofovir after BMT. 7 Dalapathy S, Lily TK, Roy S et al. Development and use of Strict monitoring of renal function was performed in our nested polymerase chain reaction (PCR) for the detection of patients so as to be able to adapt the dose or postpone adenovirus from conjunctivitis specimens. J Clin Virol 1998; administration of cidofovir. Combination with other 11: 77–84. nephrotoxic drugs was undertaken very cautiously or avo- 8 Hierholzer JC, Halonen PE, Dahlen PO et al. Detection of ided. Cyclosporin A or liposomal, rather than conventional, adenovirus in clinical specimens by polymerase chain reaction amphotericin B were sometimes given but never both and liquid-phase hybridization quantitated by time-resolved together. Under these conditions four patients received fluorimetry. J Clin Microbiol 1993; 31: 1886–1891. cidofovir treatment without major renal impairment. The 9 Larousserie F, Berrebi D, Florentin A et al. Down-regulation evaluation of renal function 360 days (240–570) later in of CD95 (Fas/Apo-1) in the epithelia of adenovirus-infected appendices. Histopathology 1997; 31: 342–346. five survivors did not show abnormalities except in one ␮ 10 Studies of ocular complications of AIDS Research Group in patient with a SCL of 129 mol/l. The most severe renal collaboration with AIDS Clinical Trial Group. A randomized impairment observed in one patient was in fact due to aden- controlled trial. Parenteral Cidofovir for CMV retinitis in ovirus as confirmed by autopsy. Similar complications have patients with AIDS: the HPMPC peripheral CMV retinitis already been reported.10,11 Several lines of evidence suggest trial. Ann Intern Med 1997; 126: 264–274. that cidofovir may have been effective in controlling aden- 11 Jacob P, Lalezari JP, Robert J et al. Intravenous cidofovir for ovirus in our patients. Five patients who received the com- peripheral CMV retinitis in patients with AIDS. Ann Intern plete dosing schedule showed clinical improvement, more- Med 1997; 126: 257–263. over, adenovirus was no longer detected from different sites 12 De Oliveira CB, Stevenson D, LaBree L et al. Evaluation of despite the protracted immunodeficiency. For patients 2, 3 cidofovir (HPMPC, GS-504) against adenovirus type 5 infection in vitro and in a New Zealand rabbit ocular model. Anti- and 5 it is possible to establish a parallel between the viral Res 1996; 31: 165–172. improvement of clinical symptoms, the absence of detec- 13 Freymuth F, Vabret A, Galateau-Salle F et al. Detection of tion of virus and the administration of cidofovir, the inter- respiratory syncytial virus, parainfluenza virus 3, adenovirus ruption of treatment being associated with the reappearance and rhinovirus in respiratory tract of infants by PCR and of symptoms and detection of virus. These observations do hybridization. Clin Diagn Virol 1997; 8: 31–40. not lend support to the argument that our clinical and virol- 14 Kidd AH, Jonsson M, Garwicz D et al. Rapid subgenus identi- ogical results only reflect the natural history of adenovirus fication of human adenovirus isolates by a general PCR. J Clin infection in these patients. Finally, it is likely that the strat- Microbiol 1996; 34: 622–627. egy of rapid initiation of treatment may contribute to the 15 Masereeuw R, van Pelt AP, van Os SH et al. Probenecid inter- clinical response. Our current strategy consists of monitor- feres with renal oxidative metabolism: a potential pitfall in its ing adenovirus viremia by rapid culture whenever a patient use as an inhibitor of drug transport. Br J Pharmacol 2000; 131: 57–62. with profound immunodeficiency presents some signs com- 16 Cundy KC, Li ZH, Lee WA. Effect of probenecid on the dis- patible with adenoviral infection. The early and simple tribution, metabolism, and excretion of cidofovir in rabbits. rectal biopsy may also be an advantage. Drug Metab Dispos 1996; 24: 315–321. The exact dosage of cidofovir remains to be determined. 17 Chen FE, Liang RH, Lo JY et al. Treatment of adenovirus- Pharmacological studies and the sensitivity of different associated haemorrhagic cystitis with ganciclovir. Bone Mar- adenovirus strains will need to be investigated. Large clini- row Transplant 1997; 20: 997–999. cal studies will be required to confirm our findings which 18 Sabroe I, McHale J, Tait DR et al. Treatment of adenoviral seem to offer some hope for treatment of this otherwise pneumonitis with intravenous ribavirin and immunoglobulin. incurable BMT infection. Thorax 1995; 50: 1219–1220. 19 Maslo C, Girard PM, Urban T et al. Ribavirin therapy for adenovirus pneumonia in an AIDS patient. Am J Respir Crit Care Med 1997; 156: 1263–1264. 20 Kawakami M, Ueda S, Maeda T et al. Vidarabine therapy for References virus-associated cystitis after allogenic bone marrow transplantation. Bone Marrow Transplant 1997; 20: 485–490. 1 Hierholzer JC. Adenoviruses in the immunocompromised 21 Mann D, Moreb J, Smith S et al. Failure of intravenous ribavi- host. Clin Microbiol 1992; 5: 262–274. rin in the treatment of invasive adenovirus infection following 2 Flomenberg P, Babbitt J, Drobyski WR et al. Increasing inci- allogenic bone marrow transplantation: a case report. J Infect dence of adenovirus disease in bone marrow transplant recipi- 1998; 36: 227–228. ents. Infect Dis 1994; 169: 775–781. 22 Ribaud P, Scieux C, Freymuth F et al. Successful treatment 3 Hale GA, Heslop HE, Krance RA et al. Adenovirus infection of adenovirus disease with intravenous cidofovir in an unre- after pediatric bone marrow transplantation. Bone Marrow lated stem-cell transplant recipient. Clin Infect Dis 1999; 28: Transplant 1999; 23: 277–282. 690–691. 4 Shields AF, Hackman RC, Fife KH et al. Adenovirus infec- 23 Hedderwick SA, Greenson JK, McGaughy VR et al. Aden- tions in patients undergoing bone-marrow transplantation. ovirus cholecystitis in a patient with AIDS. Clin Infect Dis New Engl J Med 1985; 312: 529–533. 1998; 26: 997–999.

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