Association of BK viremia with human leukocyte antigen mismatches and acute rejection, but not with type of calcineurin inhibitor.

INTRODUCTION: BK viremia and polyomavirus-associated nephropathy (PVN) represent a significant problem after kidney transplantation. Both are associated with intensified immunosuppression, but other risk factors and the impact of a screening program on outcome are incompletely understood. METHODS: Here, we report on the short- and long-term outcome of a cohort of patients, who were transplanted in 2006/2007 and included in a newly introduced systematic 3-monthly screening for BK viremia at the University Hospital Zurich. In patients testing positive for BK viremia, screening frequency was intensified and immunosuppression reduced. Patients with suspected PVN underwent transplant biopsy. RESULTS: Among 152 included patients, 49 (32%) tested positive for BK viremia, but only 8 developed biopsy-proven PVN. BK viremia had a significant impact on estimated glomerular filtration rate and proteinuria in the first 2 years. Acute rejection episodes and the number of human leukocyte antigen (HLA) mismatches were the strongest independent predictors of BK viremia in a multiple logistic model. In contrast, no particular immunosuppressive agent or regimen was associated with enhanced risk. CONCLUSION: Taken together, systematic BK viremia screening led to detection of a high percentage of viremic patients. With adjustment of immunosuppression, an excellent outcome was achieved. The independent association of HLA mismatches with BK viremia suggests impaired polyomavirus immunosurveillance in highly mismatched allografts.

Family outbreak of an infection with a recombinant Coxsackie A virus in eastern Switzerland.

PURPOSE: We report on an unusual familial outbreak of a coxsackie virus infection in Switzerland in which five family members were affected. Most of the patients presented with signs of meningitis, and four were hospitalized. METHODS: In three individuals, the virus was detected in the cerebrospinal fluid, pharynx, and stool, respectively. The genome was sequenced in specimens of two patients. RESULTS: The nucleotide sequences of both virus strains were identical. Blast search revealed that the first half of the sequence was 88 % homologous to Enterovirus 75 (EV-75), 87 % with Echovirus 11 (E-11), and 84 % homologous to Coxsackie virus A9 (CV-A9). The second half of the sequence was 77 % homologous to EV-75, 75 % to E-11, and 91 % to CV-A9. CONCLUSION: We propose that the isolated virus strain is a recombinant strain with a 5' untranslated region and with the start of the VP4 sequence originating from E-11/EV-75 and the rest of the genome originating from CV-A9. Interestingly, this novel virus strain showed an exceptional virulence and rapid spread. Two weeks after the initial outbreak in this family, a similar outbreak was observed in a second geographic area roughly 100 km distant to the primary identification site, and another 2 months later this virus strain was found to circulate in the western part of Switzerland some 250 km distant to the primary locus. These findings suggest that genetic recombination has resulted in a novel enterovirus with features of high virulence, contagiosity, and spreading.

Hemophagocytic syndrome caused by primary herpes simplex virus 1 infection: report of a first case.

INTRODUCTION: Hemophagocytic syndrome represents a severe hyperinflammatory condition by activated macrophages. Leading viral triggering agents are Epstein-Barr virus (EBV), cytomegalovirus (CMV), and adenovirus. MATERIALS AND METHODS: We present a patient with Wegener's granulomatosis on azathioprine and prednisone medication, who developed a life-threatening hemophagocytic syndrome. Positive plasma polymerase chain reaction (PCR) with negative serology revealed a primary, disseminated infection with herpes simplex virus-1 as the triggering pathogen. After treatment with acyclovir, high-dose steroids, immunoglobulins, and etoposide, the patient recovered. CONCLUSION: Early diagnosis of potentially underlying infections of hemophagocytic syndrome influences the therapeutic approach. It is important to consider a variety of infectious agents, particularly in immunosuppressed individuals. The reported case emphasizes the importance of screening for herpes simplex virus 1.

Herpes virus and Ménière's disease.

OBJECTIVE: The main goal of this study was to examine the vestibular ganglia from patients with intractable classic Ménière's disease (MD) for the presence or absence of DNA from three neurotropic viruses herpes simplex virus 1 and 2 (HSV1, HSV2) and varicella zoster virus (VZV) and to investigate the hypothesis that MD is associated with virus reactivation within Scarpa's ganglion. STUDY DESIGN: Polymerase chain reaction (PCR) was performed with nested primer sets specific for viral genomic DNA of HSV1, HSV2 and VZV in biopsies of the ganglion scarpae of patients with MD who underwent vestibular neurectomy. Included were patients with MD classified as definite MD according to American Academy of Otolaryngology/Head and Neck Surgery criteria. The ganglion scarpae and ganglion geniculi harvested at autopsy from patients without history of MD or facial palsy served as control specimens. RESULTS: No viral DNA was detected in the vestibular ganglion of 7 patients with definite MD. In 34% of the vestibular ganglia of the control group we detected either HSV1 or VZV. Only one Scarpa's ganglion had both viruses present at the same time. Thirty-two out of 34 ganglia from the geniculate segment of the facial nerve contained either HSV1 and/or VZV genomic DNA. Eight specimens contained both viruses simultaneously. Altogether viral DNA was found in 94% of ganglia. Viral genomic DNA of HSV2 was not detected. CONCLUSION: Although HSV and VZV appear to be present in many ganglion cells throughout the human body, we were unable to find genomic DNA of these viruses in patients with definite MD and disabling vertigo, who underwent vestibular neurectomy. Based on these results, reactivation of HSV1 and VZV in the vestibular ganglion does not seem to play a role in the pathogenesis of MD.

[Povidone-iodine for treatment of adenoviral conjunctivitis: an in vitro study]. / Povidoniod zur Behandlung von Adenoviruskonjunktivitis: eine In-vitro-Studie.

BACKGROUND: Adenoviral conjunctivitis causes high socioeconomic costs due to high contagiousness and therefore the need for extended quarantine. To date the only potentially active, topical antiviral agent is povidone-iodine (PVI). The aim of this study was to investigate the effect of diluted PVI on free adenovirus and adenoviral infected cells as well as to evaluate the cellular toxicity of PVI on non-infected cells. MATERIAL AND METHODS: PVI was diluted to a final concentration of 0.0008 %. Virucidal activity was measured IN VITRO using adenovirus 8 and A549 human epithelial cell cultures. Cytotoxicity effects on healthy cells after short- and long-term exposure to diluted PVI were measured in A549 cell cultures. RESULTS: Exposure to PVI at a concentration of 1:10 (0.8 %) completely extinguishes infectivity of free adenovirus after an exposure time of 10 minutes. PVI is less effective against intracellular adenovirus resulting in a decreased infectivity and viral activity for approximately one day with a narrow spectrum between toxicity and virucidal activity. Healthy epithelial cells can be exposed to PVI for up to 6 hours without a cytotoxic effect. CONCLUSIONS: PVI is highly effective against free adenovirus but less effective against intracellular adenoviral particles in already infected cell. Short- and long-term exposure of PVI causes little cytotoxicity for healthy cells. Therefore, administration of diluted PVI at a concentration of 1:10 is a potential option to reduce contagiousness in cases of adenoviral infections.

Retrospective analysis of varicella zoster virus (VZV) copy DNA numbers in plasma of immunocompetent patients with herpes zoster, of immunocompromised patients with disseminated VZV disease, and of asymptomatic solid organ transplant recipients.

BACKGROUND: Varicella zoster virus (VZV) causes significant morbidity and mortality in immunocompromised patients. Subclinical reactivation has been described in solid organ recipients and has been associated with graft versus host disease in bone marrow transplantation. Newer studies assessing the prevalence and impact of subclinical VZV reactivation in solid organ transplant (SOT) recipients are lacking. METHODS AND RESULTS: In a first step we developed a highly sensitive quantitative polymerase chain reaction (qPCR) assay for VZV DNA with a detection limit of < or = 20 copies/mL. Using this assay, we retrospectively analyzed plasma samples of different patient groups for VZV DNA. VZV DNA was found in 10/10 plasma samples of immunocompetent patients with herpes zoster (VZV copy numbers/mL: mean+/-SEM 1710+/-1018), in 1/1 sample of a human immunodeficiency virus-infected patient with primary VZV disease (15,192 copies/mL) and in 4/4 plasma samples of immunocompromised patients with visceral VZV disease (mean of first value 214,214+/-178,572). All 108 plasma samples of asymptomatic SOT recipients off any antiviral therapy, randomly sampled over 1 year, were negative for VZV DNA. CONCLUSION: Our qPCR assay proved to be highly sensitive (100%) in symptomatic VZV disease. We did not detect subclinical reactivation in asymptomatic SOT recipients during the first post-transplant year. Thus, subclinical VZV reactivation is either a rare event or does not exist. These data need to be confirmed in larger prospective trials.

[Fever after a tick bite: clinical manifestations and diagnosis of acute tick bite-associated infections in northeastern Switzerland]. / Fieber nach Zeckenstich: Klinik und Diagnostik von akuten Zeckenstich-assoziierten Infektionskrankheiten in der Nordostschweiz.

BACKGROUND: Different tick-borne infections can cause an acute febrile illness. The study objectives were to investigate the clinical manifestations and diagnosis of infections among patients who presented with fever after a tick-bite, and to detect newly described pathogens, including Ehrlichia, Babesia and Rickettsia helvetica, in North-Eastern Switzerland. PATIENTS AND METHODS: : We studied 75 patients (41 male, 34 female, median age 38 years, among them 10 children) who had fever within 3 weeks after a tick-bite. Paired sera were tested for antibodies to Borrelia burgdorferi, tick-borne encephalitis virus, Anaplasma (Ehrlichia) phagocytophila, Babesia microti, B. divergens, and Rickettsia helvetica. In addition, microscopy and polymerase chain reaction was used to detect Ehrlichia. Clinical data were obtained at baseline and at 1 and 2 year follow-up. RESULTS: Tick-borne infections were confirmed or possible in 36 (48 %) patients: 7 (9 %) Erythema migrans, 6 (8 %) other specific manifestations of Lyme borreliosis, 6 (8 %) Lyme borreliosis presenting as non-specific febrile illness, 8 (11 %) tick-borne encephalitis, 7 (10 %) granulocytic ehrlichiosis, 1 B. microti infection in a traveler from the US and 6 (8 %) dual infections. In 8 (11 %) patients serological findings were suggesting possible acute or past R. helvetica infection. CONCLUSION: Among patients with fever after a tick-bite, Lyme borreliosis was most frequently found. There was no evidence for babesiosis among the resident population. Serologic data suggest that human granulocytic ehrlichiosis and R. helvetica infections may be endemic in Switzerland. Among 50 % of the patients no tick-borne infections could be diagnosed.

Reliable detection of respiratory syncytial virus infection in children for adequate hospital infection control management.

By using a rapid test for respiratory syncytial virus (RSV) detection (Abbott TestPack RSV), a number of patients were observed, showing repeatedly positive results over a period of up to 10 weeks. A prospective study was initiated to compare the rapid test with an antigen capture enzyme immunoassay (EIA) and a nested reverse transcriptase PCR (RT-PCR) protocol for detection of RSV serotypes A and B. Only respiratory samples from children exhibiting the prolonged presence of RSV (> or =5 days) as determined by the rapid test were considered. A total of 134 specimens from 24 children was investigated by antigen capture EIA and nested RT-PCR. Using RT-PCR as the reference method, we determined the RSV rapid test to have a specificity of 63% and a sensitivity of 66% and the antigen capture EIA to have a specificity of 96% and a sensitivity of 69% for acute-phase samples and the homologous virus serotype A. In 7 (29%) of 24 patients, the positive results of the RSV rapid test could not be confirmed by either nested RT-PCR or antigen capture EIA. In these seven patients a variety of other respiratory viruses were detected. For general screening the RSV rapid test was found to be a reasonable tool to get quick results. However, its lack of specificity in some patients requires confirmation by additional tests to rule out false-positive results and/or detection of other respiratory viruses.

Polyclonal proliferation of large granular lymphocytes during cytomegalovirus primary infection in a human immunodeficiency virus-infected patient receiving antiretroviral therapy.

We report the first case of a patient infected with HIV in whom polyclonal CD8+/CD57- T lymphocyte large granular lymphocyte (LGL) proliferation was observed in association with cytomegalovirus primary infection. Because the differential diagnosis of an increased number of LGLs includes both monoclonal LGL leukemia and polyclonal proliferation of LGL, patients in whom LGL proliferation is detected always need close hematological and clinical observation to determine whether therapeutic intervention is necessary.

Dynamics of Epstein-Barr virus DNA levels in serum during EBV-associated disease.

A real-time polymerase chain reaction assay for quantitation of Epstein-Barr virus (EBV) DNA in serum was developed. This assay detected EBV DNA in 24 (89%) of 27 sera from patients with infectious mononucleosis, but only in 9 (18%) of 51 sera from EBV carriers (P < 0.001) and in none of the sera from 32 EBV-seronegative individuals. EBV DNA levels were higher in sera from infectious mononucleosis (median 8,000, range 1833-150,069 copies/ml) than from carriers (median < 2, range < 2-2980; P < 0.001). In sera of 36 children with infectious mononucleosis followed prospectively, EBV DNA levels correlated inversely with the duration of symptoms. Among 18 children with tumors including Hodgkin's disease (n = 7), non-Hodgkin's lymphoma (n = 6), Burkitt's lymphoma (n = 1), lymphoproliferative disorder (n = 4), and osteosarcoma (n = 1), EBV DNA was detected in serum from those 9 (100%) expressing EBV in the tumor (Hodgkin's disease, 3; non-Hodgkin's lymphoma, 2; lymphoproliferative disorder, 4), the levels peaking at diagnosis and correlating with disease activity. Quantitation of EBV DNA in serum may offer a simple means of monitoring patients at risk of EBV-associated lymphoproliferation.

Community-acquired pneumonia in children due to Mycoplasma pneumoniae: diagnostic performance of a seminested 16S rDNA-PCR.

A 16S rDNA-PCR assay for Mycoplasma pneumoniae applied to nasopharyngeal secretion (NPS) or pharyngeal swab (PS) from children with community-acquired pneumonia (CAP) was prospectively compared to serological tests including complement fixation (CF) test, a mu-capture enzyme immuno assay (EIA) for the detection of specific IgM, and an EIA for the detection of specific IgG. During a 24-months-period diagnosis of active M. pneumoniae infection was established in 32 (12.6%) of 253 patients for whom paired sera were available. In the acute phase, the sensitivities of PCR from NPS and PS, CF test, IgM EIA, and IgG EIA were 90.0%, 79.3%, 46.9%, 78.1%, and 59.4%, respectively. The corresponding specificities were 98.1%, 98.6%, 97.6%, 87.1%, and 72.4%, respectively. Thus, the 16S rDNA-PCR assay provides a highly sensitive and accurate tool for the rapid diagnosis of M. pneumoniae infection in children with CAP.

Phase I clinical trial with HIV-1 gp160 plasmid vaccine in HIV-1-infected asymptomatic subjects.

The aim of the study was to investigate the safety of an HIV-1 gp160 plasmid vaccine. Four asymptomatic HIV-1-infected subjects with CD4+ lymphocyte counts >500/microl were injected with four times 400 microg of HIV-1 modified gp160 env and rev coding DNA vaccine at 0, 4, 10 and 28 weeks. Safety parameters, including autoimmune antibodies as well as CD4+/CD8+ cell counts and HIV-1 plasma concentrations, were monitored for 52 weeks after the first vaccine application. Follow-up data for more than 3 years are now available. The DNA vaccine proved to be safe and, specifically, did not induce anti-DNA autoimmune antibodies. Vaccination had no long-term effects on the CD4+/CD8+ lymphocyte counts, plasma HIV-1 RNA concentrations or disease progression. The present data supplement published data from Philadelphia, USA, where a dose-escalating study (30-300 microg) with the same HIV-1 DNA vaccine was performed.

[Diagnosis and course of myocarditis: a survey in the medical clinics of Zurich University Hospital 1980 to 1998]. / Diagnose und Verlauf bei Myokarditis: eine Erhebung in den Medizinischen Kliniken des Universitätsspitals Zürich im Zeitraum von 1980 bis 1998.

The clinical picture of myocarditis/myopericarditis is of importance in differential diagnosis, especially in younger patients with suspected myocardial infarction. Myocarditis/myopericarditis commonly presents with chest pain, and the diagnosis is usually established on clinical grounds. However, endomyocardial biopsy is necessary to confirm the diagnosis. We evaluated the characteristics of acute myocarditis over the years 1980-1998 in 54 patients of the Department of Medicine of the University Hospital, Zurich. Two to 6 patients per year were hospitalised with this diagnosis. In most cases the diagnosis was established by a combination of criteria, such as a preceding infection of the upper respiratory tract, thoracic pain, ST segment elevations in different precordial leads followed by T wave inversions, arrhythmias, elevation of cardiac enzymes, reversible hypokinesia by echocardiography and normal coronary arteries. At least 3 of 5 criteria were requested. In a first step we analysed retrospectively all patients with acute myocarditis/myopericarditis in the years 1980-1993. Among 30 cases of acute myocarditis/myopericarditis the following causes could be identified: one influenza B, one Toxoplasma gondii infection, 2 Epstein-Barr infections and one bacterial myocarditis with gram-negative rods. The aetiology of the other 25 cases remained unknown. The majority of myocarditis/myopericarditis healed without complications. One patient with Epstein-Barr myocarditis and one with Toxoplasma gondii infection died. Two patients developed dilated cardiomyopathy. In a second phase we analysed prospectively all cases with acute myocarditis/myopericarditis over the period 1994-1998: 24 patients with acute myocarditis/myopericarditis were hospitalised. At that time coronary angiography and endomyocardial biopsies were performed more frequently. We found 2 patients with giant cell myocarditis and 2 with Toxoplasma gondii infection and HIV, all of whom died. In addition, there were 2 patients with eosinophilic myocarditis, one with Lyme carditis, one with Epstein-Barr myocarditis, one with myopericarditis after Campylobacter enteritis and one histologically proven myocarditis after pneumonia with Haemophilus influenzae. The aetiology of the remaining 13 cases with myocarditis/myopericarditis could not be established. Three patients with probable viral myocarditis developed cardiogenic shock requiring intraaortic balloon pump, and fully recovered. The patient with Lyme carditis manifested with total atrioventricular block and was treated with a temporary pacemaker. One patient with lymphocytic myocarditis required heart transplantation because of terminal heart failure and one female patient with histologically proven diffuse lympho-monocytic myocarditis died of cardiogenic shock. All the other cases healed without complications. Serologies are of little diagnostic value and should be restricted to serologies with therapeutic implications. We believe that the apparent increase in myocarditis/myopericarditis in recent years is a result of better diagnostic tools, such as more specific cardiac enzyme tests, coronary angiography and endomyocardial biopsies. In most cases the therapy remains symptomatic. In elected, severe cases steroids and other immunosuppressive drugs are sometimes used.

Rapid detection of Mycoplasma pneumoniae in clinical samples by real-time PCR.

M. pneumoniae is a common causative agent of community-acquired pneumonia in children. The diagnosis of such infections is usually based on serology using complement fixation or, more recently, enzyme-immuno assays. PCR has been shown to be a promising alternative. We have evaluated a real-time PCR assay targeting the P1 adhesion protein gene and compared it to a conventional semi-nested PCR assay with the 16S rDNA as target. Comparison of 147 specimens from 48 patients showed an overall agreement of 97.4%. Real-time PCR proved to be of equal value on clinical specimens as conventional PCR regarding sensitivity and specificity, but is clearly advantageous regarding speed, handling and number of samples that can be analyzed per run.

Detection and quantification of cell-free Epstein-Barr virus by polymerase chain reaction and subsequent DNA enzyme immunoassay.

Amplification by polymerase chain reaction and subsequent DNA enzyme immunoassay (DEIA) were employed to determine the number of genome equivalents of cell-free Epstein Barr virus (EBV) DNA in peripheral blood. The assay detected cell-free EBV DNA in the serum of 14 out of 18 patients with primary, productive EBV infection (sensitivity 77.7%) but not in healthy EBV carriers with latent infection (specificity 100%). Our assay has the potential for a clinical diagnostic tool to monitor patients at risk for EBV reactivation and productive infection with subsequent EBV-induced lymphoproliferative diseases.

Two-centre study comparing DNA preparation and PCR amplification protocols for herpes simplex virus detection in cerebrospinal fluids of patients with suspected herpes simplex encephalitis.

In a two-centre study, the routine DNA preparation and PCR amplification protocols were compared for herpes simplex virus (HSV) detection in cerebrospinal fluids (CSFs) of 43 patients with suspected herpes simplex encephalitis (HSE). The combined clinical, radiological and laboratory results indicated HSE in 6/43 (14%) patients. Discrepant PCR results between the two centres were obtained in 8 (18%) cases consisting of 5 false-positive and 3 false-negative results. Seven out of 8 (88%) discrepant results were associated with the method of CSF preparation using protease K digestion followed by heat inactivation. In contrast, CSF digestion with proteinase K followed by DNA purification on silica spin columns was better yielding discrepant PCR results in only 1 of 78 analyses (1.3%). The results point to the need for standardization and inter-laboratory quality control for routine clinical work.

[Clinical evaluation of impression cytology in diagnosis of superficial viral infections]. / Klinische Evaluation der Impressionszytologie zur Diagnostik viraler Oberflächeninfektionen.

BACKGROUND: Impression cytology is a non invasive technique for the diagnosis of external eye disease. As infected epithelial cells are losing their adhesion to neighbouring cells they are an ideal target for impression cytology. Despite its diagnostic potential impression cytology has not yet become a routine diagnostic tool because of technical inconvenience in use of conventional membranes. The aim of this study was to evaluate a practicable technique of impression cytology for the rapid diagnosis of superficial viral eye disease. MATERIAL AND METHODS: 52 patients with suspected viral conjunctivitis or keratitis underwent impression cytology with a Biopore membrane device. After air fixation immunologic detection tests using either peroxidase antiperoxidase or fluorescent techniques were performed directly on the membrane. RESULTS AND CONCLUSIONS: 21 of 38 patients with suspected Herpes-simplex-virus (HSV), 3 of 4 patients with suspected Varicella-Zoster-virus (VZV) and 2 of 10 patients with suspected Adenovirus infection had a positive result on the impression cytology membrane. These results were confirmed by virus cultures or polymerase chain reactions (PCR) a few days later. No patient with a negative impression cytology had a positive culture result. Using impression cytology and an immunodetection test results became available within 1 to 4 hours. CONCLUSIONS: Impression cytology combined with immunologic detection tests is a rapid, sensitive and practicable diagnostic test for superficial viral eye diseases.