Use of a novel virus detection assay to identify coronavirus HKU1 in the lungs of a hematopoietic stem cell transplant recipient with fatal pneumonia.

A 38-year-old female patient with systemic lupus erythematosus presented with pulmonary infiltrates and hypoxemia for several months following immunodepleting autologous hematopoietic stem cell transplantation. She was treated for influenza, which was isolated repeatedly from oropharynx and bronchoalveolar lavage (BAL) fluids, and later empirically for lupus pneumonitis, but died 6 months after transplant. Autopsy findings failed to show influenza in the lungs or lupus pneumonitis. A novel generic polymerase chain reaction (PCR)-based assay using degenerate primers identified human coronavirus (CoV) HKU1 RNA in BAL fluid at autopsy. CoV was confirmed by virus-specific PCRs of lung tissue at autopsy. Electron microscopy showed viral particles consistent with CoV HKU1 in lung tissue both at autopsy and from a previous biopsy. Although human CoV HKU1 infection is not usually severe, in highly immunocompromised patients, it can be associated with fatal pneumonia.

Production and persistence of specific antibodies in COVID-19 patients with hematologic malignancies: role of rituximab.

The ability of patients with hematologic malignancies (HM) to develop an effective humoral immune response after COVID-19 is unknown. A prospective study was performed to monitor the immune response to SARS-CoV-2 of patients with follicular lymphoma (FL), diffuse large B-cell lymphoma (DLBCL), chronic lymphoproliferative disorders (CLD), multiple myeloma (MM), or myelodysplastic/myeloproliferative syndromes (MDS/MPN). Antibody (Ab) levels to the SARS-CoV-2 nucleocapsid (N) and spike (S) protein were measured at +1, +3, +6 months after nasal swabs became PCR-negative. Forty-five patients (9 FL, 8 DLBCL, 8 CLD, 10 MM, 10 MDS/MPS) and 18 controls were studied. Mean anti-N and anti-S-Ab levels were similar between HM patients and controls, and shared the same behavior, with anti-N Ab levels declining at +6 months and anti-S-Ab remaining stable. Seroconversion rates were lower in HM patients than in controls. In lymphoma patients mean Ab levels and seroconversion rates were lower than in other HM patients, primarily because all nine patients who had received rituximab within 6 months before COVID-19 failed to produce anti-N and anti-S-Ab. Only one patient requiring hematological treatment after COVID-19 lost seropositivity after 6 months. No reinfections were observed. These results may inform vaccination policies and clinical management of HM patients.

Epstein-Barr virus-associated lymphoproliferative disease in non-immunocompromised hosts: a status report and summary of an international meeting, 8-9 September 2008.

BACKGROUND: Recently novel Epstein-Barr virus (EBV) lymphoproliferative diseases (LPDs) have been identified in non-immunocompromised hosts, both in Asia and Western countries. These include aggressive T-cell and NK-cell LPDs often subsumed under the heading of chronic active Epstein-Barr virus (CAEBV) infection and EBV-driven B-cell LPDs mainly affecting the elderly. DESIGN: To better define the pathogenesis, classification, and treatment of these disorders, participants from Asia, The Americas, Europe, and Australia presented clinical and experimental data at an international meeting. RESULTS: The term systemic EBV-positive T-cell LPD, as adopted by the WHO classification, is preferred as a pathological classification over CAEBV (the favored clinical term) for those cases that are clonal. The disease has an aggressive clinical course, but may arise in the background of CAEBV. Hydroa vacciniforme (HV) and HV-like lymphoma represent a spectrum of clonal EBV-positive T-cell LPDs, which have a more protracted clinical course; spontaneous regression may occur in adult life. Severe mosquito bite allergy is a related syndrome usually of NK cell origin. Immune senescence in the elderly is associated with both reactive and neoplastic EBV-driven LPDs, including EBV-positive diffuse large B-cell lymphomas. CONCLUSION: The participants proposed an international consortium to facilitate further clinical and biological studies of novel EBV-driven LPDs.

Ex situ conservation of plant genetic resources: global development and environmental concerns.

Conservation of plant genetic resources is achieved by protection of populations in nature (in situ) or by preservation of samples in gene banks (ex situ). The latter are essential for users of germplasm who need ready access. Ex situ conservation also acts as a back-up for certain segments of diversity that might otherwise be lost in nature and in human-dominated ecosystems. The two methods are complementary, yet better understanding of this interrelation and the role of ex situ conservation in global environmental considerations is needed. Inclusion of ex situ conservation efforts within current environmental policies conserving global diversity would focus greater international attention on the safeguarding of these efforts.

The biology of Epstein-Barr virus: lessons learned from the virus and the host.

Recent studies indicate that a large proportion of cytotoxic T cells are directed towards the Epstein-Barr virus (EBV) during both acute infection and convalescence. The virus, in turn, has usurped cellular pathways to promote proliferation of infected cells and has pirated cellular genes into its genome to modulate the immune system to allow lifelong infection of humans. Analysis of the immune response to the virus is leading to novel therapies for EBV-associated malignancies, including the use of virus-specific cytotoxic T cell infusions.

Cell type specific repression of the varicella zoster virus immediate early gene 62 promoter by the cellular Oct-2 transcription factor.

The cellular transcription factor Oct-2.1 has previously been shown to repress the transactivation of the varicella zoster virus (VZV) immediate early gene promoter by viral transactivators but not to inhibit its basal activity. In the case of the related virus herpes simplex virus (HSV), the effect of Oct-2 on the IE promoters has been shown to be cell type specific and to differ between the different alternatively spliced forms of Oct-2. Here we show that as well as Oct-2.1, the Oct-2.4 and 2.5 isoforms which are expressed in neuronal cells can inhibit transactivation of the VZV immediate early promoter regardless of the cell type used. In contrast, all the isoforms of Oct-2 can inhibit basal activity of the VZV promoter in neuronal cells but not in other cell types indicating that this effect is cell type specific. These effects are discussed in terms of the differential regulation of latent infections with HSV or VZV in dorsal root ganglia.

Streptokinase therapy of pulmonary emboli with heparin-associated thrombocytopenia.

A 59-year-old man developed pulmonary emboli with heparin-associated thrombocytopenia. He was treated simultaneously with intravenous streptokinase and oral warfarin sodium. He responded with complete resolution of perfusion defects on lung scan and did not have any hemorrhagic or thrombotic problems. Although optimal therapy for patients with heparin-associated thrombocytopenia and thrombosis is unknown, fibrinolytic therapy may be useful despite thrombocytopenia, provided appropriate resources are available for careful patient monitoring and transfusion therapy.

Resolution of factor X deficiency in primary amyloidosis following splenectomy.

A 57-year-old man with primary amyloidosis was initially seen with hematuria, cutaneous bleeding, and hepatosplenomegaly. Factor X was determined to be 10% to 16% of normal plasma values. Administration of vitamin K-dependent factor concentrate transiently improved in vitro clotting tests but did not alter the clinical course. Following a splenectomy, bleeding ceased and factor X levels returned to normal, remaining so despite discontinuation of factor concentrate infusion. Amyloid fibrils extracted from the patient's spleen were determined to be derived from lambda V1 light chains. The importance of splenectomy as an effective therapeutic modality is discussed.

Epstein-Barr virus lymphoproliferative disease associated with acquired immunodeficiency.

Epstein-Barr virus (EBV) lymphoproliferative disease is seen in patients with both congenital and acquired immunodeficiencies. Lymphoproliferative disease has been reported in 1 to 3% of renal transplant recipients. Most patients presented with solid tumor masses, rather than an infectious mononucleosis-like syndrome. About one third of cases had involvement of the renal allograft with tumor; the small intestine or central nervous system was also frequently affected. About half of the patients survived. The most frequent therapy used for survivors was decreasing the dose of immunosuppressive therapy and surgical resection of lymphoproliferative lesions. Compared with fatal cases, survivors more often had evidence of active EBV infection (primary or reactivated), received cyclosporine as the major immunosuppressive agent, had polyclonal lesions, and had B-cell hyperplasia rather than lymphoma. Lymphoproliferative disease has been described in 5 to 13% of heart transplant recipients. In our review, the cardiac allograft was not involved by disease in any patient; however, the lungs were involved in more than half of the cases. The soft tissues were frequent sites of lymphoproliferative disease. All patients had lymphoma or immunoblastic sarcoma on pathology and all had monoclonal lesions. While only 8% of patients survived, about half died from causes unrelated to lymphoproliferative disease. EBV lymphoproliferative disease has been reported in 9% of heart-lung transplant recipients. Most of the patients presented with pulmonary symptoms and the pulmonary allograft was involved in 80% of cases. The large and small intestine were frequently affected. About 60% of patients survived; survivors were treated with acyclovir and decreases in the dose of immunosuppressive drugs. Lymphoproliferative disease has been described in 2% of liver transplant recipients. In our review, the hepatic allograft was involved in one third of cases; the tonsils, kidneys, and small intestine were frequently affected. Half of the patients survived; survivors were most often treated with reduction in immunosuppressive therapy and surgical resection of lesions. Compared with fatal cases, survivors had fewer organs involved and fewer monoclonal lesions. Lymphoproliferative disease has been reported in 1 to 2% of bone marrow transplant recipients. Use of T-cell depleted bone marrow and infusion of anti-T-cell antibodies to prevent graft-versus-host disease increased the risk of EBV lymphoproliferative disease. In our review, the bone marrow was involved by lymphoproliferative disease in one third of cases; the liver, spleen, kidney, and lungs were frequently affected. About 16% of patients survived; 2 survivors were treated with infusions of monoclonal anti-B-cell antibodies and 1 received interferon alpha.(ABSTRACT TRUNCATED AT 400 WORDS)

Cytomegalovirus infection in the normal host.

CMV mononucleosis often resembles EBV infectious mononucleosis; however, certain features of the history and physical may help to distinguish CMV from EBV. While CMV mononucleosis is usually self-limited, certain laboratory abnormalities may persist for months or years after the patient has recovered. Previous reports on CMV in the non-immunocompromised host have rarely described systemic complications. We have reviewed 10 cases of CMV with systemic manifestations at one institution over a 15-year period. These patients had prolonged fevers (often greater than three weeks) and the diagnosis was often unsuspected during the early part of the illness. While two patients required mechanical ventilation, all patients had self-limiting disease and survived. When CMV is suspected and diagnosed early in the course, numerous diagnostic (and potentially dangerous) tests can be avoided in a viral illness in which prolonged fever is common.

Extra-intestinal manifestations of salmonella infections.

While salmonellosis is often considered to affect primarily the gastrointestinal tract, infection at other sites may occur, producing characteristic clinical syndromes. We reviewed cases from our institutions and the literature on focal manifestations of salmonella infections. In the past, most extra-intestinal salmonella infections were caused by S. choleraesuis; however, we found S. typhimurium to be the predominant serotype. The mortality rate for patients in our series was considerably lower than the rate described for focal infections in other reviews. This may in part be due to lower proportion of infections due to S. choleraesuis, improved microbiologic and diagnostic techniques, increased use of ampicillin, and improved surgical techniques. Salmonella endocarditis usually occurs in patients with preexisting heart disease. Unlike other salmonella infections, S. choleraesuis is the most frequent serotype. Salmonella endocarditis is often very destructive, with a fatality rate of 70%. Nonvalvular (mural) endocarditis occurs in one-fourth of patients and survival has not been reported. While antibiotic therapy should be tried initially, if response is not prompt the clinician should look for an associated site of infection (intra- or extra-cardiac abscess), which will often require surgery. Salmonella pericarditis often presents with cardiac or pulmonary symptoms, but typical signs of pericardial disease (pulsus paradoxus, friction rub) or characteristic electrocardiographic changes (low voltage, elevated ST segments) are uncommon. Early diagnosis, before infection involves other areas of the heart, is crucial for survival. In addition to antibiotic therapy, pericardiocentesis or pericardiectomy is required. Salmonella may infect the peripheral or visceral arteries, but the abdominal aorta is the most frequent site of vascular infection. Most patients are men over age 50 with preexisting atherosclerosis of the aorta who do not have a previous history of gastroenteritis. About one-fourth of patients have associated lumbar osteomyelitis. No patients have been reported to survive with medical therapy alone. Specific guidelines for surgical removal of infected aneurysms have been proposed and these (in addition to increased use of ampicillin) may be responsible for higher survival rates in recent years. Due to the high incidence of relapses, postoperative blood cultures should be done routinely. Arterial infection should be considered in any elderly patient with salmonella bacteremia especially with prolonged fever or bacteremia after an "adequate course" of antibiotic therapy.(ABSTRACT TRUNCATED AT 400 WORDS)

Squamous cell carcinoma of the pharyngeal walls treated with radiotherapy.

PURPOSE: To assess the impact of fractionation schedule, chemotherapy, and tumor location on local control and survival in patients treated with definitive irradiation for carcinoma of the pharyngeal walls. METHODS AND MATERIALS: Between May 1971 and December 1991, 74 patients with previously untreated squamous cell carcinoma of the pharyngeal walls (excluding nasopharynx, tonsil, and pyriform sinus) were treated with radical megavoltage irradiation with or without chemotherapy at Oregon Health Sciences University. RESULTS: Two-year local control rates by stage were: T1: 100%, T2: 55%, T3: 31%, and T4: 29% . Twice-a-day irradiation improved local control rates as compared with once-a-day irradiation for patients with Stage T3 lesions, with 5 out of 7 (71.4%) vs. 4 out of 19 (21%) patients controlled at 2 years (p = 0.015). No improvement was seen in 2-year local control of all stages when chemotherapy was used in conjunction with once-a-day fractionation; however, six of eight patients (75%) treated with twice-a-day irradiation combined with either induction or concurrent chemotherapy had local control. The 2-year local control rate of 100% (6 out of 6) for the group of patients treated with concurrent chemotherapy and b.i.d. irradiation (all with Stage T3 and T4 tumors) is a dramatic improvement over the 2-year local control rate of 30% (10 out of 33) for our entire group of patients with Stage T3 and T4 tumors. Local control rates did not differ by tumor location on the pharyngeal walls. Adjusted disease-specific survival rates by stage were: 1: 100%, II: 85%, III: 58%, IV: 40%. Overall survival rates by stage were: I: 75%, II: 67%, III: 33%, IV: 30%. CONCLUSION: We advocate radical irradiation as the primary therapy for pharyngeal wall carcinomas with the use of twice-a-day fractionation for Stages T2-T4. Our preliminary results with concurrent chemotherapy and b.i.d. irradiation for advanced T3 and T4 tumors appear to be comparable to reported results with hyperfractionated radiation alone. The relative contribution of chemotherapy to b.i.d. irradiation cannot be determined from this small retrospective series; however, in view of the relatively poor results for patients with advanced stage disease, we feel this treatment combination deserves further investigation.

Chronic pancreatitis: long-term surgical results of pancreatic duct drainage, pancreatic resection, and near-total pancreatectomy and islet autotransplantation.

Severe abdominal pain was the major indication for operation in 85 patients with chronic pancreatitis. Preoperative endoscopic retrograde cholangiopancreatography (50 patients) or intraoperative pancreatic ductograms (44 patients) demonstrated dilated or obstructed major pancreatic ducts in 50 patients (59%), nonvisualization of the distal duct in 10 patients (12%), and normal or small sized ducts in 34 patients (40%). Operative procedures, tailored according to duct morphology, included pancreatic duct drainage (46 patients), subtotal (40% to 80%) pancreatectomy (21 patients), near-total (85% to 95%) pancreatectomy alone (eight patients), and near-total or total pancreatectomy and intrahepatic islet autotransplantation (10 patients). Pancreatic duct drainage resulted in pain relief in 37/46 patients (80%) followed for 6 years. However, 20/46 patients (43%) had continued loss of pancreatic function after duct drainage as measured by the development of insulin-dependent diabetes (16 patients) or steatorrhea (seven patients). Seven years after subtotal pancreatectomy, pain relief was partial in 9/21 patients (43%) and complete in five patients (24%). A higher incidence of hypoglycemic or ketoacidotic complications was noted in patients treated by subtotal pancreatectomy (three patients, 14%) than by duct drainage (one patient, 2%). Near-total pancreatectomy was the most effective surgical procedure in relieving pain, but late sequelae in three patients (38%) included one hypoglycemic death and two ketoacidotic episodes. Five years after near-total pancreatectomy and islet autotransplantation, one patient remained permanently insulin independent; three patients were insulin independent for 4, 5, and 15 months, respectively, but subsequently developed nonketosis-prone diabetes (tested by insulin withdrawal) and require 15 to 30 U of insulin daily; three patients had immediate insulin requirements and currently need 20 to 30 U of insulin per day but are nonketosis prone; and two patients are ketosis prone and require 30 to 60 U of insulin daily. Our analysis suggests that 5-year survival of patients undergoing operation for chronic pancreatitis is similar after treatment by duct drainage, subtotal pancreatectomy, or near-total pancreatectomy, regardless of duct morphology. Five years after duct drainage or subtotal pancreatic resection, a high incidence of diabetes (59% and 48%) and/or continued pain (20%) and (35%) can be expected.(ABSTRACT TRUNCATED AT 400 WORDS)

Mutagenesis of the varicella-zoster virus genome: lessons learned.

The varicella-zoster virus (VZV) genome encodes at least 70 genes. We have developed a cosmid based system to inactivate individual viral genes or to insert foreign genes into the genome. We have shown that many VZV genes are not required for replication of the virus in cell culture. Several of these genes, including VZV ORF61, ORF47, and ORF10, have unexpected phenotypes in cell culture and differ from their homologs in the better studied herpes simplex virus (HSV). We have also used the Oka strain of VZV as a live virus vaccine vector. Guinea pigs vaccinated with recombinant VZV expressing HSV-2 glycoprotein D and challenged with HSV-2 have reduced severity of primary genital herpes and reduced mortality compared to animals receiving parental VZV. Recently we have inserted the human immunodeficiency virus (HIV) and simian immunodeficiency virus (SIV) glycoprotein 160 genes into the Oka strain of VZV and have shown that these proteins are expressed in recombinant virus-infected cells. Thus, directed mutagenesis of the VZV genome is providing new insights into viral pathogenesis and may provide new candidate vaccines.

Varicella-zoster virus. The virus.

Varicella-zoster virus (VZV) causes chickenpox and herpes zoster. After acute infection the virus becomes latent in dorsal root and trigeminal ganglia for the lifetime of the individual. The viral genome encodes about 70 proteins, at least three of which are thought to be expressed during latency in humans. VZV grows in cell culture, but is very cell-associated; it is relatively difficult to obtain high titers of cell-free virus.

Epstein-Barr Virus Gene Expression in Lymphoproliferative Disease.

Epstein-Barr virus (EBV) is associated with Burkitt lymphoma, nasopharyngeal carcinoma, and lymphoprolifcrative disease in patients with congenital or acquired immunodeficiencies. B lymphocytes in tissues from these patients often contain EBV genomes. Expression of the EBV genes EBNA-1, EBNA-2, and LMP and the B cell genes CD23, ICAM-1, and LFA-3 has been demonstrated in lymphoblastoid cells in vitro and in B lymphocytes in tissues from patients with lymphoproliferative disease. In contrast, B cells in tissue from patients with Burkitt lymphoma usually show expression of EBNA-1, but not the other viral or B cell genes. Expression of EBNA-1 with variable expression of LMP has been reported in tissue from patients with nasopharyngeal carcinoma. The different patterns of viral and cellular gene expression in these diseases have important implications for their treatment.

Use of the radial forearm microvascular free-flap graft for cranial base reconstruction.

OBJECT: Reconstruction of the cranial base after resection of complex lesions requires creation of both a vascularized barrier to cerebrospinal fluid (CSF) leakage and tailored filling of operative defects. The authors describe the use of radial forearm microvascular free-flap grafts to reconstruct skull base lesions, to fill small tissue defects, and to provide an excellent barrier against CSF leakage. METHODS: Ten patients underwent 11 skull base procedures including placement of microvascular free-flap grafts harvested from the forearm and featuring the radial artery and its accompanying venae comitantes. Operations included six craniofacial, three lateral skull base, and two transoral procedures for various diseases. Excellent results were obtained, with no persistent CSF leaks, no flap failures, and no operative infections. One temporary CSF leak was easily repaired with flap repositioning, and at one flap donor site minor wound breakdown was observed. One patient underwent a second procedure for tumor recurrence and CSF leakage at a site distant from the original operation. CONCLUSIONS: Microvascular free tissue transfer reconstruction of skull base defects by using the radial forearm flap provides a safe, reliable, low-morbidity method for reconstructing the skull base and is ideally suited to "low-volume" defects.

Selective neck dissection and the management of the node-positive neck.

OBJECTIVE: To assess the oncologic effectiveness of the selective neck dissection (SND) in patients with both clinically and pathologically proven regional metastases. METHODS: A 4-year retrospective medical chart review was conducted in an academic tertiary care referral center. Twenty-nine patients with a newly diagnosed upper aerodigestive tract squamous cell carcinoma, and both clinically and histologically proven cervical metastases who underwent 36 SND, had their records reviewed. Minimum follow-up was 2 years. RESULTS: Regional metastasis were staged N1 in 13 patients, N2A in 1, N2B in 8, and N2C in 7. Seventeen supraomohyoid and 19 lateral neck dissections were performed. Extracapsular spread of tumor was present in 11 patients. Postoperative radiation therapy was administered to 20 patients. Actuarial disease-specific survival at 4 years was 47% overall, 67% in N1 patients, and 41% in N2 patients. Only 1 failure in the treated neck occurred for a 4-year actuarial regional failure rate of 4%. The actuarial local failure and distant metastasis rate were 36% each. CONCLUSIONS: In carefully selected patients with clinically and histologically apparent regional metastases, the selective neck dissection can be an oncologically effective procedure.

Use of the radial forearm free tissue flap to treat persistent stricture after esophagogastrectomy.

BACKGROUND: Persistent stricturing or anastomotic leakage at the cervical esophagogastric anastomosis can be a troublesome complication of gastric pull-up procedures. When the stricture is the result of ischemia of the stomach, the strictures are long and often not responsive to dilatation and require large operations such as jejunal interposition or replacement with colonic pull-up. In this report we describe the use of a radial forearm flap to patch strictures. METHODS: The radial forearm flap is a fascia cutaneous flap taken from the forearm and based on the radial artery and its venae comitantes. The advantages of this flap are that it is thin and pliable, conforms easily, has excellent reliability due to the size of the feeding vessels, and has a relatively long pedicle. The vascular anastomosis can be made to several arteries and veins within the neck. The epithelial component can be made in sizes up to 10 by 20 cm. RESULTS: We have used the radial forearm flap to patch strictures in 6 patients with persistent complex strictures in the cervical region after esophagectomy. Results were excellent in 4 patients (able to eat liquids and solids without problems) and good in 1 patient (liquids okay, some problem with solids), and 1 patient died postoperatively. Follow-up is 4 months to 7 years. CONCLUSIONS: The radial forearm flap is an excellent option for handling persistent stricture after esophagogastrectomy. In many instances, this flap can be used in lieu of a jejunal interposition flap and obviates a laparotomy to harvest jejunum. The flap fits easily into the neck and conforms to the space.

An external landmark for the anterior commissure.

OBJECTIVE: The ability to predict the level of the true vocal cords based on external landmarks is crucial to the success of many laryngeal surgical procedures. This study examines the reliability of one such landmark on the thyroid cartilage. METHODS: Twenty-four cadaver larynges were examined. A pin was placed through the landmark, best described as a small diamond shaped area of color change and surface depression along the anterior midline of each thyroid cartilage through which travels a very small unnamed artery. The endolaryngeal position of the pin was checked with a flexible nasopharyngoscope. RESULTS: In all 24 cadavers, the pin entered the larynx at the anterior commissure, just above or at the level of the true vocal cords. CONCLUSIONS: This external landmark reliably predicts the position of the true vocal cords. It serves as a useful adjunct to existing external landmarks used to direct thyroid cartilage cuts in laryngeal procedures.