Long-term valacyclovir suppressive treatment after herpes simplex virus type 2 meningitis: a double-blind, randomized controlled trial.

BACKGROUND: Herpes simplex virus type 2 (HSV-2) is a common cause of acute and recurrent aseptic meningitis. Our aim was to determine the impact of antiviral suppression on recurrence of meningitis and to delineate the full spectrum of neurological complications. METHODS: One hundred and one patients with acute primary or recurrent HSV-2 meningitis were assigned to placebo (n = 51) or 0.5 g of valacyclovir twice daily (n = 50) for 1 year after initial treatment with 1 g of valacyclovir 3 times daily for 1 week in a prospective, placebo-controlled, multicenter trial. The primary outcome was time until recurrence of meningitis. The patients were followed up for 2 years. RESULTS: The first year, no significant difference was found between the valacyclovir and placebo groups. The second year, without study drugs, the risk of recurrence of verified and probable HSV-2 meningitis was significantly higher among patients exposed to valacyclovir (hazard ratio, 3.29 [95% confidence interval, 10.06-10.21]). One-third of the patients experienced 1-4 meningitis episodes during the study period. A considerable morbidity rate, comprising symptoms from the central, peripheral, and autonomous nervous system, was found in both groups. CONCLUSIONS: Suppressive treatment with 0.5 g of valacyclovir twice daily was not shown to prohibit recurrent meningitis and cannot be recommended for this purpose after HSV meningitis in general. Protection against mucocutaneous lesions was observed, but the dosage was probably inappropriate for the prevention of HSV activation in the central nervous system. The higher frequency of meningitis, after cessation of active drug, could be interpreted as a rebound phenomenon.

Human herpes virus 6 or Epstein-Barr virus were not detected in Guthrie cards from children who later developed leukaemia.

To investigate if children who later developed acute lymphoblastic leukaemia (ALL) were prenatally infected with HHV-6 and/or EBV, Guthrie cards taken at birth were analysed by PCR. Guthrie cards from 54 patients with ALL and 47 healthy controls matched for age and birth place were tested negative for both HHV-6 and EBV DNA. All samples contained amplifiable DNA when tested by HLA-DQ PCR. Our negative findings suggest that childhood ALL is unlikely to be associated with an in utero infection with EBV or HHV-6.

Recognition of cytomegalovirus clinical isolate antigens by sera from cytomegalovirus-negative blood donors.

BACKGROUND: The most common way to prevent transmission of CMV by blood transfusion is to use blood products from seronegative donors. Screening of blood donors for CMV infection is usually based on detection of antigens obtained from the CMV laboratory strain AD 169. Recent evidence suggests that approximately up to 20 percent of CMV-negative blood donors may in fact be CMV-DNA positive by PCR analyses. STUDY DESIGN AND METHODS: In this study, sera from CMV-seronegative, CMV-seropositive, and CMV-DNA-positive/seronegative individuals, and from patients with acute and convalescent CMV infection for detection of CMV antibodies were analyzed. CMV antigens prepared from cells infected with CMV clinical isolates or the CMV laboratory strain AD 169 in ELISA and Western blot assays were used. RESULTS: All CMV-positive sera from blood donors were seropositive for the CMV antigens prepared from AD 169 (A2) or from a CMV clinical isolate (C6). Interestingly, whereas all CMV-negative blood donors were negative in tests for the CMV antigen A2, 36 percent were CMV seropositive using the CMV antigen C6 in ELISA. CONCLUSION: The data suggest that a substantial number of CMV-seronegative/CMV-DNA-positive serum samples contain antibodies that recognize CMV clinical isolate antigens.

A case of diffuse leptomeningeal oligodendrogliomatosis associated with HHV-6 variant A.

We describe a rare case of diffuse leptomeningeal oligodendrogliomatosis associated with the human herpes virus 6 variant A (HHV-6 A). A 2-year-old boy presented with progressive neurological symptoms and hydrocephalus. The patient had a VP shunt placement but did not fully recover. HHV-6 A was detected in both CSF and serum by nested PCR. His symptoms improved repeatedly, but temporarily, on antiviral treatment. An open brain biopsy, ten months after presentation, revealed leptomeningeal tumour as well as the presence of viral DNA in the tumour tissue. The role of HHV-6 A could be that of a reactivated opportunist. However, this case also raises the question whether this neurotropic virus, with malignant transforming properties in vitro, may have a role in pathogenesis in some cases of brain malignancy.

Circulating soluble vascular cell adhesion molecule-1 and intercellular adhesion molecule-1 in immunocompetent and renal transplant patients: correlation with cytomegalovirus disease and renal function.

The plasma levels of the soluble adhesion molecules, soluble vascular cell adhesion molecule-1 (sVCAM-1) and intercellular adhesion molecule-1 (sICAM-1), were measured before and after transplantation in 26 renal transplant recipients, and in 173 longitudinally collected samples in 17 of the patients. The patients were carefully monitored for the presence of cytomegalovirus (CMV) infection and rejection. Forty healthy blood donors and 12 otherwise healthy subjects with symptomatic primary CMV infections served as controls. During CMV disease, plasma levels of sVCAM-1 and sICAM-1 were elevated in both renal transplant patients and otherwise healthy subjects with CMV disease. The sVCAM-1 levels were strongly elevated before transplantation in renal transplant recipients and correlated with creatinine levels. Increased sVCAM-1 levels were also registered during rejection episodes. CMV disease, per se, is associated with markedly increased levels of sVCAM-1 and sICAM-1. There is also a correlation of sVCAM-1 levels with serum creatinine levels. Thus, the presence of CMV infection and renal function are factors that must be considered in further studies of soluble adhesion molecules.

Sequence evolution and cross-reactive antibody responses to hypervariable region 1 in acute hepatitis C virus infection.

Hepatitis C virus (HCV) infection may result in acute resolving or chronic infection. Patients that clear the infection have a more vigorous cellular immune response and an early humoral response to the hypervariable region 1 (HVR1) of the E2 envelope protein. To analyse further the properties of the early anti-HVR1 response, cross-reactivity of anti-HVR1 responses was assessed in five patients with acute HCV infection, who were infected by the same virus strain during a nosocomial outbreak. The sequence evolution of HVR1 was examined in sequential serum samples up to 37 months post infection. Peptides were synthesised corresponding to the obtained HVR1 sequences and unrelated HVR1 sequences, and antibody reactivity to the peptides in sequential sera was investigated by ELISA. The results suggest an association between specific gaps in humoral immunity and the HVR1 sequence evolution during early infection. Possible interpretations of this phenomenon include immune escape mechanisms or suppression of specific anti-HVR1 antibodies.

Evaluation of the Abbott AxSYM cytomegalovirus (CMV) immunoglobulin M (IgM) assay in conjunction with other CMV IgM tests and a CMV IgG avidity assay.

The measurement of the avidity of cytomegalovirus (CMV) immunoglobulin G (IgG) antibodies has been shown by several investigators to be useful in identifying and excluding primary CMV infections in pregnant women. In this work, we examined the diagnostic utility of reflex testing of CMV IgM-positive specimens from pregnant women by using a CMV IgG avidity assay. The utility of this approach was directly dependent on the sensitivity of the CMV IgM assay employed during the initial screen. The higher initial reactivity rate of the AxSYM CMV IgM assay was necessary in order to detect CMV IgM in specimens containing low-avidity CMV IgG antibodies, indicative of a primary CMV infection, which other CMV IgM assays (Behring, Vidas, Captia, and Eurogenetics) fail to detect in some cases. The use of the AxSYM CMV IgM assay, followed by an avidity test, should result in more accurate diagnosis of CMV infection in pregnant women.

Sequence analysis of UL54 and UL97 genes and evaluation of antiviral susceptibility of human cytomegalovirus isolates obtained from kidney allograft recipients before and after treatment.

The frequency of infections caused by drug-resistant cytomegalovirus (CMV) in solid-organ transplant recipients is not known. Only a few resistant strains have been described in transplant recipients. Antiviral susceptibility to ganciclovir (GCV) and foscarnet (PFA) of CMV isolates from 24 renal transplant patients with CMV viremia and CMV disease before and after therapy were investigated by a solid phase ELISA. The CMV DNA polymerase (UL54) and viral phosphotransferase (UL97) genes were also sequenced. Ten patients did not receive antiviral treatment; five and nine patients were treated with PFA and GCV, respectively. No appearance of drug-resistant viruses was observed in the present study, but one isolate showed a reduced sensitivity to PFA after treatment with GCV. This finding could not be explained by the presence or development of mutations that have been associated with drug resistance in UL54. We found no evidence that short-term treatment of CMV with PFA- or GCV-induced resistance.

[Cytostatic therapy reduces the immune defense. Children treated for leukemia have impaired immunity against measles and rubella]. / Cytostatikaterapi sänker immunförsvaret. Leukemibehandlade barn förlorar sin immunitet mot mässling och röda hund.

A study is summarized analyzing the levels of serum antibodies against vaccination antigens in 43 children treated for acute lymphoblastic leukemia. Two different therapeutical regimens were used. All children had been immunized against measles and rubella before being diagnosed with leukemia. Eight of the 24 children treated 1986-1991 lacked protective levels of antibodies against measles; four of the 24 children lacked antibodies against rubella. In the second cohort of children (n = 16) treated from 1992 and onwards, nine lacked protective levels of antibodies against measles, eight lacked antibodies against rubella.

Sequence variation within three important cytomegalovirus gene regions in isolates from four different patient populations.

We determined the nucleotide (nt) and amino acid (aa) heterogeneities of three distinct regions of the human cytomegalovirus (CMV) genome for 46 low-passage CMV isolates from four different patient populations (congenitally infected infants, children attending day-care centers, renal transplant recipients, and human immunodeficiency virus-infected individuals) and for two laboratory strains (CMV Ad169 and Towne). The gene regions for the major immediate-early (MIE) exon 4 gene (nt positions 1702 to 1982, aa positions 152 to 244), the DNA polymerase gene (nt positions 2797 to 3046, aa positions 713 to 795), and the glycoprotein B (gB) gene (nt positions 1698 to 1884, aa positions 567 to 628) were sequenced. The sequence information was used to design sets of nested PCR primers directed against the most highly conserved regions identified. MIE was the most variable gene region compared to the variability of the DNA polymerase and gB gene regions. Comparison of the sequences of all 46 isolates with that of Ad169 revealed nt and aa sequence homologies of 87.9 and 87.2%, respectively, within the MIE gene compared to 92.8 and 100% homologies, respectively, within the DNA polymerase gene and 93 and 95.2% homologies, respectively, within the gB gene. Within the MIE gene, compared to the Ad169 nt sequence the homology at the nt level among isolates obtained from children attending day-care centers was high (96.4%), while it was lower (90%) among isolates obtained from the other three patient populations. Preliminary results of a nested PCR with oligonucleotide primers selected from the DNA polymerase gene region with a low level of nt sequence variation indicates that primers selected from this region might be more powerful for use in PCR than primers selected from the MIE gene region.

Potential public health benefits from testing with Chlamydia trachomatis PCR technique on first void urine in men.

Urine samples from 467 men living in the Stockholm area were tested with the polymerase chain reaction (PCR), Roche Amplicor, and with an enzyme-linked immunosorbent assay, Syva MicroTrak EIA, for detection of Chlamydia trachomatis. The predictive value of urine versus urethral samples was subsequently compared on a second urethral sample from 25 C. trachomatis-positive cases. The urethral samples were in addition cultured for C. trachomatis. C. trachomatis was found more often in urine by Roche Amplicor than by Syva MicroTrak, 9.9% and 7.9%, respectively. Nine urine samples, positive only by Amplicor, could be confirmed as true positives by complementary testing. C. trachomatis was detected with the same frequency in urine and urethral samples. The sensitivity was highest for PCR, 88% and 92%, and lowest for EIA, 76% and 80%, on urethral and urine samples, respectively. Urine sampling, offering a non-invasive procedure, was found suitable for the diagnosis of C. trachomatis in men, with the use of Roche Amplicor.

The prevalence of hepatitis B in Sweden; a statistical serosurvey of 3381 Swedish inhabitants.

The prevalence of hepatitis B virus markers in the adult Swedish population was investigated according to age, sex, origin and demographic stratum. Sera were collected from 3382 persons in 1990-1. The sera were selected on a statistical basis considered to be representative of the Swedish population from adults aged > or = 18 years. Two of the sera (0.06%) were found to be hepatitis B surface antigen positive. The two hepatitis B carriers were of non-Scandinavian origin as were (8.9%) of those tested. A total of 90 persons had a marker of previous, hepatitis B virus infection, i.e. antibodies against hepatitis B core antigen. Of these, 66 (2.0%) were of Scandinavian origin and 24 (18.1%) from highly endemic areas. The overall hepatitis B virus marker prevalence was 2.7%. The highest age-specific prevalence of hepatitis B markers in those of Scandinavian origin was in those born in 1939 and earlier. In this age-group, women had a significantly higher prevalence (3.6%) than males (1.9%). The lowest prevalence was found in those born in 1970 and later. No significant, age-related differences between younger or older persons, or between men and women, could be found in persons of non-Scandinavian origin. The results showed significant differences in exposure to hepatitis B virus among the indigenous population, compared with those of non-Scandinavian extraction. The results do not support the proposal to include hepatitis B vaccination in the Swedish immunization schedule.

Hepatitis A immunity in the Swedish population. A study of the prevalence of markers in the Swedish population.

After a 20-year interval, the prevalence of seroimmunity to Hepatitis A (HA) was again investigated in a statistical sample of the adult Swedish population. Sera from 3382 of the 4800 originally selected persons were tested. The prevalence of antibodies to HA had not changed since the 1960s when only the Scandinavian population was considered. In the oldest population born at the beginning of this century, the presence of antibodies amounted to 69%. It gradually declined to 6% in those born in the 1940s. In the population born after 1950, the percentage of seropositive individuals was only 2%. A slightly higher prevalence was seen in the big cities, compared with the rural areas (13% vs 9%). Persons of non-Scandinavian origin showed a different pattern. Those from other European countries showed a prevalence of about 70% in all the age-groups investigated. Among the young adults of Arabic or Asiatic origin, the figure was > 90%. The conclusion is that the native Swedish population has a low natural exposure to HA, which has not changed during the last 20 years. Prophylaxis before going to countries where the disease is endemic is strongly recommended.

Patients infected with the same hepatitis C virus strain display different kinetics of the isolate-specific antibody response.

The antibody response to the hypervariable region of the E2 protein (HVR1) of hepatitis C virus (HCV) was studied in 5 patients who were infected by a common virus strain during an outbreak in a hemodialysis unit. Two patients resolved the infection, while 3 developed chronic HCV infection. For studying the antibody response to HVR1 during the early phase of infection, a Western blot assay using recombinant phage displaying HVR1 was developed. The 2 patients with resolving infection had a more rapid antibody response to HVR1 than did the patients developing chronic infection. Anti-HVR1 antibodies were repeatedly absent in 1 of the chronically infected patients. Antibodies to recombinant E2 protein occurred later than the anti-HVR1 antibodies and did not correlate with resolution of the infection. Thus, the present results suggest that early appearance of antibodies to the HVR1 may predict clearance of HCV infection.

Growth failure, encephalopathy, and endocrine dysfunctions in two siblings, one with 5-oxoprolinase deficiency.

UNLABELLED: Two female siblings, born to consanguineous parents, presented with a similar phenotype characterized by severe growth and developmental failure, dysmorphic features, thyroid and gonadal dysfunction, autistic traits and hand stereotypes resembling Rett syndrome. In the elder patient, analysis of urinary organic acids disclosed a very high excretion of 5-oxoproline (4.2 to 8.1 mol/mol creatinine) and enzyme assays of leucocyte extracts revealed a profound deficiency of 5-oxoprolinase. However, normal urinary organic acid profiles were found in the younger child. In view of their distinct dysmorphic features and severe growth deficiency, these siblings cannot be considered as Rett Syndrome variants. The Dubowitz and carbohydrate-deficient glycoprotein syndromes were also excluded clinically and biochemically respectively. We conclude that these patients suffer from a hitherto undescribed autosomal recessive disorder, unrelated to the 5-oxoprolinase deficiency of the elder sib. CONCLUSION: The present findings give evidence that 5-oxoprolinase deficiency is not associated with a distinct morbid phenotype.

A prospective study of rapid methods of detecting cytomegalovirus in the blood of renal transplant recipients in relation to patient and graft survival.

Eighty-five renal transplant recipients were prospectively monitored for CMV infection up to 4 months post-transplantation by virus isolation from leukocytes, CMV antigen detection (pp65) in peripheral blood leukocytes (PBL), polymerase chain reaction (PCR) of alkaline treated plasma (P-PCR), PCR of extracted DNA from PBL (L-PCR) and serology. Additionally univariate and multivariate analyses of risk factors for patient and graft survival up to 4 yr post-transplantation were performed. The incidence of CMV infection was 78% and of CMV disease 33%. Antigen detection in PBL was positive before or at onset of symptoms in 23/24 (96%) evaluable patients with CMV disease. The corresponding figures for virus isolation were 22/24 (92%), P-PCR 21/24 (88%) and for L-PCR 18/24 (75%). The percentage of negative samples in patients without CMV disease was 89% for the antigen test, 92% for L-PCR and 83% for virus isolation and P-PCR. One rapid test (antigen test, P-PCR or L-PCR) was positive at a median of 16 d before the onset of symptoms. The antigen test was generally the first rapid test to become positive. CMV disease did not affect graft survival in the multivariate analysis but was associated with decreased patient survival.

Cytomegalovirus (CMV) DNA amplification from plasma compared with CMV pp65 antigen (ppUL83) detection in leukocytes for early diagnosis of symptomatic CMV infection in kidney transplant patients.

BACKGROUND: Rapid laboratory methods for the early detection of cytomegalovirus (CMV) are needed for the prevention of CMV disease in transplant recipients. These methods should not only be able to detect the virus but also be highly predictive for CMV disease. OBJECTIVE: The clinical value of a simple and rapid nested plasma polymerase chain reaction (PCR) was evaluated by comparing the results with CMV pp65 antigen detection in leukocytes (CMV antigenemia assay), virus isolation from leukocytes, CMV IgG and IgM antibody response and clinical data. STUDY DESIGN: A total of 471 EDTA blood samples were collected from 85 kidney transplant patients during a 3-4 month period after transplantation. CMV DNA was amplified directly from 10 microliters of plasma while 150000 separated leukocytes were stained for CMV pp65 antigen by each of two monoclonal antibodies. A total of one million leukocytes were used for virus isolation. The PCR protocol used in the present study involves a simple alkaline lysis technique for isolating DNA directly from plasma which is easy and rapid to perform. RESULTS: Twenty-eight patients developed symptomatic CMV infection while asymptomatic infection occurred in 29 patients. CMV pp65 antigen detection had a 75% sensitivity and a 57% positive predictive value for CMV disease development, compared with 64% and 79% sensitivity and 49% and 46% positive predictive value for CMV DNA and viremia, respectively. The median time until detection of CMV in patients with symptomatic CMV infection was 26 days after transplantation, compared with 49 days in asymptomatic patients by any of the methods used. Early appearance (within 8 weeks) of CMV pp65 antigen and CMV DNA had high predictive values for symptomatic infection; repeated detection of pp65 antigen and CMV DNA were more common in symptomatic patients. CONCLUSIONS: CMV antigenemia assay and plasma PCR can be used for pre-symptomatic diagnosis of CMV infection. Virus isolation and CMV serology in most cases provide a post-symptomatic diagnosis. The best marker for monitoring kidney transplant patients might be the quantitative CMV antigenemia assay.

Young women with symptoms of urinary tract infection. Prevalence and diagnosis of chlamydial infection and evaluation of rapid screening of bacteriuria.

OBJECTIVE: To estimate the prevalence of chlamydial infection among young women with UTI symptoms. To evaluate chlamydia diagnostics with the aid of enzyme immuno assay (EIA) on first-void urine. To evaluate rapid screening of bacteriuria, including low concentrations of common pathogens. DESIGN: EIA for detection of Chlamydia trachomatis antigen and confirmation with immunofluorescence test (DFA) in urine, cervical and urethral chlamydia culture, nitrite and granulocyte esterase test, urine sediment, chamber count, dipslide and conventional urine culture were performed. SETTING: Primary health care (PHC). PATIENTS: 217 women aged 15-35 years attending PHC for dysuria or urgency-frequency. MAIN OUTCOME MEASURES: Frequency of chlamydial infections. Sensitivity, specificity, predictive values of EIA and bacteriuria screening tests, respectively. RESULTS: The frequency of chlamydial infection was 3.7%. In spite of a high specificity of the EIA test (0.94 without DFA) the number of false positives exceeded the number of true positives. No single bacteriuria test showed sufficient diagnostic efficiency. CONCLUSIONS: Routine chlamydia testing in young women with UTI symptoms is recommended. EIA test on urine is of little use. Assessing diagnosis of UTI symptoms requires insight into the use of several rapid tests and a dialogue with the patient.