ABSTRACT
BACKGROUND: This paper describes the transmission of hepatitis A virus (HAV) to two blood recipients from a healthy donor that later presented to the blood bank with jaundice. METHODS: The RNA of HAV was detected by qualitative nested reverse transcription polymerase chain reaction (nested RT-PCR) and quantified by real-time RT-PCR. HAV RNA samples were genotyped by direct sequencing of PCR products. A sequence from a fragment of 168 bp from the VP1/2A HAV region was used to construct a phylogenetic tree. CASE REPORT: A 31-year-old male donor accepted for donation of a whole blood unit returned to the blood bank with clinical jaundice 20 days after donation. His serological and NAT tests were negative for HBV and HCV. Serological tests for HAV IgM and IgG were negative on donation sample but positive on follow-up sample, confirming donor's HAV acute infection. Both recipients of red blood cells (R1) and platelet concentrate (R2) from the same implicated donation were HAV IgM-negative and IgG-positive. Qualitative PCR was positive on samples from all three individuals and phylogenetic analysis of viruses proved HAV transmission to the two recipients of blood products. HAV viral load on donor follow-up sample and the platelet recipient was 1.3 and 1.5 × 10(3) IU/ml, respectively. The RBC recipient, also infected by HCV, was undergoing bone marrow transplantation and died from fulminant hepatitis, 26 days after the implicated HAV transfusion. CONCLUSION: The blood donor, a garbage collector, spontaneously returned to the blood bank when developing jaundice. This highlights the importance of donor education to immediately report to blood banks of any signs and symptoms related to infectious disease developed after blood donation. The fact that one immunocompromised patient with HCV infection died from fulminant hepatitis after receiving a HAV-contaminated platelet transfusion underpins the importance of a HAV vaccination program for these group of patients.
ABSTRACT
A infecção por citomegalovírus (CMV) é uma complicação freqüente no período pós-transplante de células-tronco hematopoéticas(TCTH); seu diagnóstico pode ser realizado por antignemia ou PCR. A infecção pelo CMV é definida como a presença do vírus circulante e a doença como a presença deste vírus associada à lesão tecidual e sintomatologia clínica. A doença pelo CMV tem elevadas taxas de mortalidade, sendo importante sua prevenção e tratamento. Há duas formas de prevenção da doença: a profilaxia e o tratamento preemptivo; a profilaxia se caracteriza pelo uso do ganciclovir até o dia 100 do TCTH e o tratamento preemptivo no início do antiviral a partir de uma documentação de infecção pelo CMV em um paciente assintomático. O CDC recomenda o trtamento preemptivo baseado em uma antigenemia ou dois PCRs positivos consecutivos para o DNA viral. A droga de escolha é o ganciclovir, por via intravenosa. A duração do tratamento preemptivo anti-CMV é variável. Alguns estudos sugerem que cursos curtos, de 2 a 3 semanas baseados em um marcador viral negativo ao final do tratamento seriam eficazes. Porém, nesses casos há um risco de reativação da infecção por CMV em 30% dos pacientes, que requerem, então, um novo curso de tratamento. O estudo visa determinar o valor da manutenção com ganciclovir na prevenção da reativação e da progressão para doença pelo CMV. Secundariamente este estudo visa determinar o valor do PCR na detecção da infecção pelo CMV e avaliar a toxicidade do ganciclovir. Trata-se de um ensaio clínico randomizado, comparando a manutenção com ganciclovir e a observação em pacientes preventivamente tratados com ganciclovir por infecção pelo CMV. De 15 de agosto de 2005 a 18 de abril de 2007, 29 pacientes foram recrutados pelo estudo. Foram realizadas antigenemias e PCRs para o CMV semanalmente em todos os pacientes. O tratamento preemptivo foi baseado em uma antigenemia positiva e realizado com ganciclovir por via intravenosa por 14 dias. Após este tratamento inicial os pacientes foram randomizados e acompanhados com dosagens de creatinina e hemograma com plaquetas 3 vezes por semana. Quinze dos 29 pacientes (51,7%) apresentaram reativação do CMV e foram randomizados: 5 para o grupo manutenção e 10 para o grupo observação. Quatro dos 15 tiveram uma segunda reativação da infecção pelo CMV ( 1 no grupo manutenção e 3 no grupo observação); um paciente do grupo observação desenvolveu cistite hemorrágica atribuída ao CMV e outro desenvolveu quadro de esofagite com biópsia positiva para o CMV(doença pelo CMV). Seis de dez pacientes no grupo observação e 4/5 no grupo manutenção desenvolveram neutropenia, com duração de 2 a 20 dias no grupo observação (mediana: 8,5) e 4 a 17 dias no grupo manutenção (mediana: 12); trombocitopenia ocorreu em 6/10 pacientes no grupo observação e em 5/5 no grupo manutenção. Oito pacientes desenvolveram infecção bacteriana, sendo 5/10 no grupo observação e 3/5 no manutenção. Um paciente em cada grupo apresentou infecção fúngica...
Cytomegalovirus infection is a frequent complication of hematopoietic stem cell transplantation (HSCT). It may be diagnosed by antigenemia or PCR. CMV infection is defined as circulating virus, and disease as the presence of virus causing organic lesion and symptoms. Given that CMV disease has great mortality, treatment and prevention of CMV infection is fundamental. There are two major forms of disease prevention: prophylaxis and preemptive treatment. Prophylaxis is defined as the use of ganciclovir until day 100 of HSCT; preemptive treatment is the treatment based on the detection of CMV infection in an asymptomatic patient. The CDC recommend preemptive treatment based on an antigenemia or two consecutive positive PCRs for CMV DNA. The drug of choice is intravenous ganciclovir. The duration of anti-CMV preemptive treatment is variable. Some studies suggest that shorter treatments based on a negative PCR test by the end of two or three weeks of treatment will be enough. However, in these cases, reactivation occurred in 30 percent of patients, who ultimately required additional treatment. The objective of this study is to determine the value of ganciclovir maintenance on the prevention of CMV reactivation and progression to disease. As a secondary objective, this study aimed to determine the value of PCR in preventing CMV disease and ganciclovir toxicity. It is a randomized clinical trial, comparing ganciclovir maintenance versus observation in patients preemptively treated for CMV infection. From august 15, 2005 until april 18, 2007, 29 patients were included in the study. Antigenemia and PCRs for CMV were done weekly in all patients. Preemptive treatment was started with intravenous ganciclovir for 14 days after one positive antigenemia. Thereafter, patients were randomized. All had creatinine levels and blood counts thrice a week. Fifteen of 29 patients (51.7%) had CMV reactivation and were randomized: 5 to the maintenance and 10 to the observational group. Four of 15 had a second CMV reactivation (1 in the maintenance and 3 in the observational group); one patient in the observational group developed hemorrhagic cystitis attributed to CMV and another had esophagitis with positive biopsy for CMV (CMV disease). Six of 10 patients in the observational group and 4/5 in the maintenance group developed neutropenia, with a duration of 2 to 20 days in the observational (median: 8.5) and 4 to 17 days in the maintenance group (median: 12); thrombocytopenia occurred in 6/10 patients in the observational and 5/5 in the maintenance group. Overall, 8 patients developed infectious complications: 3/5 in the maintenance and 5/10 in the observational group. One patient in each group had fungal infection. Creatinine levels varied from 1.0 to 2.44 times the baseline level in the observational (median: 1.59), versus 1.08 to 2.36 times the baseline level in the experimental group (median: 1.82). Resistance to ganciclovir was not observed...
