Marburg haemorrhagic fever in returning travellers: an overview aimed at clinicians.

Marburg virus haemorrhagic fever (MARV HF) is a dramatic disease that can occur in a traveller returning from an area where the virus is endemic. In this article, we provide an overview of MARV HF as an imported infection with an emphasis on clinical aspects. Although late features such as rash, signs of haemorrhagic diathesis and liver necrosis may point to the diagnosis, the initial clinical picture is non-specific. If in this early phase the patient's epidemiological exposure history is compatible with MARV HF, the patient should be isolated and managed according to viral haemorrhagic fever protocol and RT-PCR should be performed on the patient's blood as soon as possible to rule out MARV HF (or other possible viral haemorrhagic fevers). In severe cases, direct electron microscopy of blood in specialized centres (e.g. Bernhard-Nocht Institute in Hamburg, Germany) may be considered if the result of the RT-PCR is not readily available. Adequate diagnostics and empirical treatment for other acute life-threatening illnesses should not be withheld while test results are awaited, but all management and diagnostics should be weighed against the risks of nosocomial transmission.

[Measles after MMR-vaccination]. / 'De mazelen' na bmr-vaccinatie.

BACKGROUND: The Dutch national vaccination program provides vaccination for mumps, measles and rubella (MMR vaccine) for all children. After vaccination with live attenuated viruses, the virus replicates on a limited scale. Replication may lead to mild symptoms occurring 5-14 days after MMR-vaccination, including fever, conjunctivitis and rash. Symptoms are comparable to those of a wildtype measles infection. CASE DESCRIPTION: A 14-month-old boy was admitted to the hospital with an impressive rash 13 days after MMR-vaccination. Diagnostic tests were positive for measles. This test result caused the mother to doubt further vaccination. CONCLUSION: Within 14 days after MMR-vaccination, a child can present with symptoms very similar to a wildtype measles virus infection. The low incidence of wildtype measles infection strongly suggests that these symptoms will likely be a reaction to vaccination. Elaborate diagnostic procedures may cause the parents a lot of stress and therefore offering reassurance to parents may be more appropriate.

Disease burden of congenital cytomegalovirus infection at school entry age: study design, participation rate and birth prevalence.

Congenital cytomegalovirus infection (cCMV) may lead to symptoms at birth and long-term consequences. We present a nationwide, retrospective cohort study on the outcome of cCMV up to age 6 years. For this study we identified cCMV, using polymerase chain reaction, by analysing dried blood spots, which are taken shortly after birth for neonatal screening. The group of children with cCMV were compared to a group of children who were cCMV negative at birth. Data were collected about their health and development up to age 6 years. Parents of 73 693 children were invited to participate, and 32 486 (44·1%) gave informed consent for testing of their child's dried blood spot for CMV. Of the 31 484 dried blood spots tested, 156 (0·5%) were positive for cCMV. Of these, four (2·6%) children had been diagnosed with cCMV prior to this study. This unique retrospective nationwide study permits the estimation of long-term sequelae of cCMV up to the age of 6 years. The birth prevalence of cCMV in this study was 0·5%, which is in line with prior estimates. Most (97·4%) children with cCMV had not been diagnosed earlier, indicating under-diagnosis of cCMV.

Cytomegalovirus infection in the Netherlands: seroprevalence, risk factors, and implications.

BACKGROUND: Cytomegalovirus (CMV) infections occur worldwide and are usually asymptomatic in healthy individuals. In fetuses and immunocompromised persons, they can cause severe disease and disabilities. OBJECTIVE: To determine the CMV seroprevalence and risk factors for CMV infection in the Netherlands. STUDY DESIGN: In a cross-sectional population-based study (PIENTER-2, 2006-2007), sera and questionnaire data were collected from 6386 individuals. Sera were tested for CMV-specific IgG antibodies using enzyme-linked immunosorbent assay (ELISA). RESULTS: The CMV seroprevalence in the general population (6 months-79 years) was 45.6%. Age and country of origin were the most prominent independent risk factors. The seroprevalence was significantly lower in native Dutch and Western individuals (41.5%) than in non-Western individuals (76.7%). Multivariable logistic regression analysis showed that age, lower educational level, first-generation migrancy, and among native Dutch/Western individuals, female gender and having contact with young children, were independently associated with CMV seropositivity. The geometric mean concentrations of antibodies increased with age and were higher in women than in men. CONCLUSION: CMV seroprevalence in the Netherlands is relatively low compared to other countries. This is in line with our finding of a higher seroprevalence among migrants compared to the native population. The higher seroprevalence in women and individuals who have contact with young children is especially important for women of reproductive age. Preventing CMV infection in these women, through counseling on hygiene or possible future vaccination, may lead to a decrease of congenital CMV infections.

Genetic and antigenic structural characterization for resistance of echovirus 11 to pleconaril in an immunocompromised patient.

Pleconaril is a capsid inhibitor used previously to treat enterovirus infections. A pleconaril-resistant echovirus 11 (E11) strain was identified before pleconaril treatment was given in an immunocompromised patient. The patient was also treated with intravenous Ig (IVIg) for a long period but remained unresponsive. The pleconaril-resistant strains could not be neutralized in vitro, confirming IVIg treatment failure. To identify the basis of pleconaril resistance, genetic and structural analyses were conducted. Analysis of a modelled viral capsid indicated conformational changes in the hydrophobic pocket that could prevent pleconaril docking. Substitutions (V117I, V119M and I188L) in the pleconaril-resistant viruses were found in the pocket region of VP1. Modelling suggested that V119M could confer resistance, most probably due to the protruding sulfate side chain of methionine. Although pleconaril resistance induced in vitro in a susceptible E11 clinical isolate was characterized by a different substitution (I183M), resistance was suggested to also result from a similar mechanism, i.e. due to a protruding sulfate side chain of methionine. Our results showed that resistant strains that arise in vivo display different markers from those identified in vitro and suggest that multiple factors may play a role in pleconaril resistance in patient strains. Based on IVIg treatment failure, we predict that one of these factors could be immune related. Thus, both IVIg and capsid inhibitors target the viral capsid and can induce mutations that can be cross-reactive, enabling escape from both IVIg and the drug. This could limit treatment options and should be investigated further.

Nucleoside plus nucleotide analogs and cessation of hepatitis B immunoglobulin after liver transplantation in chronic hepatitis B is safe and effective.

BACKGROUND: After orthotopic liver transplantation (OLT) in chronic hepatitis B (HBV), adequate prophylaxis for recurrence of HBV in the graft is mandatory. OBJECTIVES: Evaluate safety of HBV prophylaxis with tenofovir and emtricitabine (TDF/FTC) after cessation of hepatitis B immunoglobulin (HBIG) after OLT in chronic HBV. STUDY DESIGN: In 17 consecutive patients after OLT in chronic HBV we started TDF/FTC after cessation of HBIG. All had received HBIG >6 months. 15/17 were HBsAg negative and 16/17 had undetectable HBV-DNA. RESULTS: After mean follow-up of 2 years 16/17 patients were alive, one died due to urosepsis. All 16 with undetectable HBV-DNA remained HBV-DNA negative. From 15 HBsAg negative patients at start, in one seroconversion to positive HBsAg occurred, without detectable HBV-DNA. Liver biochemistry remained within the normal ranges. There were no cases of drug discontinuation. No major side effects were reported. TDF/FTC use saves €16,262/year over standard-of-care (HBIG+LAM). This prospective follow-up study shows that in liver transplantation for chronic hepatitis B, after initial treatment including HBIG for at least 6 months combined with or followed by (dual) nucleos(t)ide analog therapy, TDF/FTC provides adequate prophylaxis against recurrent HBV infection without major side effects and leads to substantial cost savings over a regimen with HBIG. CONCLUSION: Combined prophylaxis with TDF/ETV nucleoside plus nucleotide analogs and cessation of immunoglobulin after liver transplantation in chronic hepatitis B is safe and effective.

Viral loads and antiviral resistance of herpesviruses and oral ulcerations in hematopoietic stem cell transplant recipients.

Ulcerative oral mucositis and infection are frequent complications in hematopoietic stem cell transplant (HSCT) recipients. The aim of this study was to investigate the relationship between oral ulcerations and HSV-1, EBV and CMV excretion and the presence of aciclovir-resistant HSV-1 strains in HSCT recipients. This prospective observational study included 49 adult patients who underwent allogeneic HSCT. In total, 26 patients received myeloablative and 23 received non-myeloablative conditioning. Ulcerations on non-keratinized and keratinized oral mucosa were scored and oral rinsing samples were taken twice weekly. Viral loads were determined by real-time PCR. Samples from patients remaining HSV-1 positive despite antiviral treatment were studied for resistance to antivirals. Having an HSV-1 or EBV DNA-positive sample was a significant predictor for ulceration of keratinized mucosa. HSV-1 was a significant predictor for ulcerations on non-keratinized mucosa as well. Persistent HSV-1 infection occurred in 12 of 28 patients treated with antiviral medication and aciclovir-resistant HSV-1 was found in 5 persistent infections. In conclusion, HSV-1 is a predictor of ulcerations on non-keratinized as well as keratinized oral mucosa following HSCT. The role of EBV deserves further study. Persistent HSV-1 replication despite antiviral treatment is common and is due to resistance in 18% of treated patients.

Diagnostic and therapeutic management for suspected neonatal herpes simplex virus infection.

BACKGROUND: Neonatal herpes simplex virus (HSV) is a rare disease associated with high mortality and morbidity rates. HSV infection can be subdivided into 3 clinical manifestations: isolated skin, eye and mouth (SEM) disease, central nervous system (CNS) disease and disseminated disease. Consensus guidelines for diagnostic and therapeutic management are not available. OBJECTIVES: To evaluate the diagnostic work-up and therapeutic management in neonates with suspected or proven HSV infection. STUDY DESIGN: Retrospective study of diagnostic and therapeutic management in all neonates with suspected HSV infection admitted to our neonatal nursery between January 2005 and July 2010. RESULTS: A total 53 neonates with suspected HSV infection were included in the study and classified as SEM disease (n=2), CNS disease (n=41) or disseminated disease (n=10). None of the included infants tested positive for HSV infection. Correct and complete diagnostic work-up was performed in only 11% (6/53) of the cases. All neonates were treated with intravenous acyclovir. CONCLUSIONS: None of the neonates with suspected HSV tested positive. Diagnostic management in neonates with suspected HSV infection was often improper and incomplete. Consensus guidelines to identify low-risk infants in whom HSV testing and acyclovir treatment is not warranted, are urgently needed.

Is routine TORCH screening and urine CMV culture warranted in small for gestational age neonates?

BACKGROUND: congenital infections are associated with a wide variety of clinical symptoms, including small for gestational age (SGA). AIMS: to determine the co-occurrence of SGA and congenital TORCH infections, as diagnosed by TORCH serologic tests and/or cytomegalovirus (CMV) urine culture. STUDY DESIGN: we performed a retrospective study of all neonates admitted to our neonatal intensive care unit from January 2004 to February 2010 in whom SGA was diagnosed and TORCH serologic tests and/or CMV urine cultures were performed. RESULTS: TORCH serologic tests (in neonatal or maternal serum) and/or a CMV urine culture were performed in 112 neonates with SGA. None of the neonates tested positive for Toxoplasma gondii, Rubella, and Herpes simplex virus. Positive CMV urine culture was detected in 2% (2/112) of neonates, but their CMV IgM titers were negative. CONCLUSIONS: the co-occurrence of TORCH congenital infection in infants with SGA is rare. Routine TORCH screening in neonates with isolated SGA does not seem warranted and should be limited to CMV urine cultures.

Routine TORCH screening is not warranted in neonates with subependymal cysts.

BACKGROUND: Congenital infections are associated with a wide variety of clinical symptoms, including subependymal cysts (SEC). OBJECTIVE: To determine the co-occurrence of SEC and congenital infections, as diagnosed by TORCH serologic tests and/or cytomegalovirus (CMV) urine culture. METHODS: We performed a retrospective study of all neonates admitted to our neonatal intensive care unit from 1998 to 2009 in whom SEC were detected on cranial ultrasound and TORCH serologic tests and/or CMV urine cultures were performed. RESULTS: Fifty-nine neonates fulfilled the inclusion criteria. TORCH serologic tests were performed in 69% (41/59) of cases. Urine CMV culture was performed in 68% (40/59) of cases. None of the neonates tested positive for IgM Toxoplasma gondii, Rubella and Herpes simplex virus. Positive CMV IgM titers and/or a positive urine CMV culture were detected in 2% (1/59) of neonates. CONCLUSION: The co-occurrence of TORCH congenital infections in infants with SEC is rare. Routine TORCH screening in neonates with SEC does not seem warranted.

Is routine TORCH screening warranted in neonates with lenticulostriate vasculopathy?

BACKGROUND: Congenital infections are associated with a wide spectrum of clinical symptoms, including lenticulostriate vasculopathy (LSV). OBJECTIVE: To determine the relationship between LSV and congenital infections, as diagnosed by TORCH serology and viral culture for cytomegalovirus (CMV). METHODS: All neonates with LSV admitted to our neonatal intensive-care unit from 2004 to 2008 were included in the study. Results of maternal and neonatal TORCH testing were evaluated. RESULTS: During the study period, cranial ultrasound scans were performed in 2,088 neonates. LSV was detected in 80 (4%) neonates. Maternal and/or neonatal serological TORCH tests were performed in 73% (58/80) of cases. None of the mothers or infants (0 of 58) had positive IgM titres for Toxoplasma, rubella, CMV or herpes simplex virus. Additional urine culture for CMV was performed in 38 neonates. None of the infants (0 of 38) had a positive CMV urine culture test. CONCLUSIONS: Routinely applied efforts to diagnose congenital infections in cases presenting with LSV have a poor yield. Routine TORCH screening in neonates with LSV cases should only be regarded as mandatory once well-designed studies demonstrate a clear diagnostic benefit.

DECIBEL study: Congenital cytomegalovirus infection in young children with permanent bilateral hearing impairment in the Netherlands.

BACKGROUND: A significant number of asymptomatic newborns infected with congenital cytomegalovirus (CMV) will present with permanent childhood hearing impairment (PCHI) during early childhood. OBJECTIVES: To investigate the role of congenital CMV infection in causing PCHI in the Netherlands, and assess the efficacy of two different hearing screening strategies and the developmental outcome following each strategy. STUDY DESIGN: We included 192 children with PCHI at the age of 3-5 years, who were offered hearing screening in their first year of life. Dried blood spots from 171 children were available for CMV detection using real-time PCR. The results of eight previously tested samples were also available. Clinical baseline characteristics were collected from medical records and the Child Development Inventory was used to investigate the developmental outcome. RESULTS: The rate of congenital CMV among the 179 children was 8% (14/179) and 23% (9/39) among children with profound PCHI. Two of eight CMV-positive children with PCHI at the age of 3-5 years had passed the newborn hearing screening (NHS) test. Developmental outcome measures showed a significantly greater delay in language comprehension in children with both PCHI and congenital CMV infection (the largest in symptomatic children) than in the children with PCHI without congenital CMV infection. CONCLUSIONS: Congenital CMV infection is important in the etiology of PCHI. Universal NHS is not a guarantee of normal hearing and development in childhood for children with congenital CMV infection. This is a problem which might be solved by universal congenital CMV screening.

Awareness of congenital cytomegalovirus among doctors in the Netherlands.

BACKGROUND: Because of limited treatment options for congenital cytomegalovirus (CMV) infection, preventive strategies are important. Knowledge and awareness are essential for the success of preventive strategies. OBJECTIVES: To investigate the knowledge of congenital CMV among doctors involved in mother and child care in the Netherlands. STUDY DESIGN: A questionnaire on CMV infection was sent to doctors by snowball sampling. Knowledge concerning epidemiology, transmission, symptoms and signs of CMV infection in adults and children, and treatment options were evaluated. RESULTS: The questionnaire was completed by 246 doctors involved in mother and child care. The respondents estimated a prevalence of congenital CMV varying between 0.1 and 500 per 1000 live-born infants. The mean knowledge scores regarding transmission and postnatal symptoms increased with a more advanced career stage (i.e. older age). Gender and parenthood did not contribute to knowledge, but the field of expertise did. Respondents in the field of pediatrics had the highest mean score on postnatal symptoms and long-term effects. Respondents working in the field of gynecology and obstetrics were unaware of the precise transmission route of CMV. More than one-third of the respondents assumed that treatment was readily available for congenital CMV infection. CONCLUSIONS: The knowledge of CMV infection among doctors in the Netherlands contained several gaps. Increasing knowledge and awareness is expected to enhance the prevention of transmission, to improve recognition, and to stimulate diagnostic investigations and follow-up programs.

A pitfall in screening with decoy cells after simultaneous pancreas kidney transplantation.

In this report, we describe a bladder-drained simultaneous pancreas-kidney transplant (SPKT) recipient with a polyoma virus-associated nephropathy (PVAN) in whom the urine cytology failed to detect decoy cells despite repeated attempts. Several tests were performed to confirm our hypothesis that pancreatic enzymes can degrade decoy cells and granulocytes. This case illustrates an important pitfall in the urinary screening for PVAN with cytology and for urinary tract infections with urine sediment in bladder-drained SPKT recipients.

Hepatitis B immunoglobulins inhibit dendritic cells and T cells and protect against acute rejection after liver transplantation.

The efficacy of anti-viral intravenous immunogobulins (anti-HBs Ig and anti-CMV Ig) in preventing acute rejection after liver transplantation was assessed in a retrospective analysis, and correlated to their effects on immune cells in vitro. HBs Ag-positive liver graft recipients (n = 40) treated prophylactically with anti-HBs Ig had a significantly lower incidence of acute rejection compared with recipients without viral hepatitis (n = 147) (12% vs. 34%; p = 0.012), while the incidence of rejection in HCV-positive recipients (n = 29) was similar to that in the control group. Treatment with anti-CMV Ig (n = 18) did not protect against rejection. In vitro, anti-HBs Ig suppressed functional maturation of and cytokine production by human blood-derived dendritic cells (DC) at concentrations similar to the serum concentrations reached during anti-HBs Ig treatment of liver graft recipients. In addition, anti-HBs Ig inhibited allo-antigen- and lectin-stimulated proliferation of peripheral T cells. Anti-CMV Ig suppressed functional DC-maturation and alloantigen-stimulated T-cell proliferation, but not lectin-driven T-cell proliferation. In conclusion, anti-HBs Ig protects against acute rejection after liver transplantation, probably by functional inhibition of the two principal immune cells involved in allograft rejection, DC and T cells.

Unusual presentation of herpes virus infections in renal transplant recipients exposed to high mycophenolic acid plasma concentrations.

Viral infections constitute an important problem for transplant recipients and their physicians. Often the balance between adequate and over-immunosuppression is hard to find and therapeutic drug monitoring might be a welcome adjunct in the management of transplant patients. We report four renal transplant recipients with extra-ordinary presentations of viral disease who were all treated with mycophenolate mofetil and in whom high mycophenolic acid (MPA) trough levels were found. High MPA levels may reflect over-immunosuppression resulting in infectious complications.

Passive immunization of chronic hepatitis B patients on lamivudine therapy: a feasible issue?

In view of the limited efficacy of lamivudine monotherapy for chronic hepatitis B (HBV) infection, combination with other drugs seems logical. Intravenous neutralization of circulating HBsAg by specific hepatitis B immunoglobulin (HBIg) has been shown to protect hepatocytes against (re-)infection with HBV in the setting of liver transplantation and postexposure prophylaxis. Large controlled vaccination trials have revealed that HBV can be prevented by HBIg therapy in the majority of newborns after perinatal infection. A benefit of anti-HBs in HBV patients has so far only been investigated in three small studies. In this pilot study we investigated the effects of polyclonal i.v. HBIg (HepatectR, Biotest) administration in HBV-infected patients. Six liver biopsy-proven HBV-infected patients, all on lamivudine treatment and HBV DNA negative by PCR, were investigated. Pre-treatment HBsAg levels varied between 120 and 9760 ng/mL. On day 1, 10.000 IU HBIg was given, followed by 10.000 IU once, twice or three times on day 29. Long-term follow-up lasted at least 4 months. HBsAg and anti-HBs were measured quantitatively by standard MEIA and also by an experimental EIA. In vitro neutralization of HBsAg by Hepatect was mimicked in an 'inhibition in solution assay'. Complete neutralization of HBsAg by HBIg in vitro was possible, 50% inhibition concentrations varied between 100 and 250 IU/L HBIg with HBsAg levels of 68 and 120 ng/mL. No HBIg-related side-effects were observed. In two patients with low pretreatment HBsAg levels HBsAg reached levels below the detection limit of the assay, which persisted a maximum of 31 and 7.5 h, respectively. Peak anti-HBs concentrations were 5100 and 4648 IU/L. In the other four patients, with higher pretreatment HBsAg levels, HBsAg concentrations in serum hardly changed. For the whole population, the drop in HBsAg did not reach statistical significance. However, in four of the six patients a further decrease in HBsAg [18%-66%] was observed. In conclusion, HBIg was well tolerated; however, efficacy was limited due to high HBsAg levels in spite of maximum inhibition of virion production. 'Neutralization' was achieved only in two patients with low HBsAg levels. Passive immunization in HBV-DNA negative patients is not a feasible option. This strategy seems only feasible if agents inhibiting both the production of viral proteins and Dane particles more selectively, become available.