Management of human cytomegalovirus infection and disease after allogeneic bone marrow transplantation.
OBJECTIVE
Human cytomegalovirus (HCMV) infection and disease remain a major cause of morbidity and mortality after bone marrow transplantation. HCMV disease, especially pneumonitis, may be treated with ganciclovir and immunoglobulin but even so the outcome is poor with mortality rates of 30-70%. It is therefore imperative to treat HCMV infection before it develops into disease. The aim of this article is to describe the main strategies used to prevent HCMV infection and to improve the survival after CMV disease in bone marrow transplant recipients.


METHODS
In the present review, we examined personal papers in this field and articles published in journals covered by the Science Citation Index and Medline.


BACKGROUND
Major advances have been made in preventing HCMV infection and disease through two different approaches, both of which reduce HCMV induced morbidity and mortality: In pre-emptive therapy, patients are given ganciclovir when HCMV infection is first identified and this is continued 3-4 months after transplantation; in prophylactic therapy ganciclovir is given to all patients at risk of HCMV disease from engraftment up to 3-4 months post transplantation. Each strategy has advantages and disadvantages and there is no evidence for the superiority of one over the other since the overall survival is the same and the incidence of death from HCMV disease is similar.


CONCLUSIONS
The use of more sensitive tests such as HCMV PCR or antigenemia may improve the outcome but probably will not eradicate all HCMV disease. Future possible strategies could include adoptive transfer of CD8+ HCMV-specific cytotoxic T lymphocytes clones derived from the donor marrow or boosting donor or patient immunity using subunit anti-HCMV vaccines such as gB or pp65.
Stocchi
R
R
Department of Medical and Morphological Research, University Hospital, Udine, Italy. ematologia@drmm.uniud.it
Ward
K N
KN
Fanin
R
R
Baccarani
M
M
Apperley
J F
JF
D000212:Acyclovir / Q000627:therapeutic use; D000293:Adolescent; D000328:Adult; D000956:Antigens, Viral / Q000097:blood; D000998:Antiviral Agents / Q000627:therapeutic use*; D016026:Bone Marrow Transplantation / Q000009:adverse effects*; D002648:Child; D002675:Child, Preschool; D003587:Cytomegalovirus / Q000187:drug effects / Q000254:growth & development / Q000302:isolation & purification; D003586:Cytomegalovirus Infections / Q000175:diagnosis / Q000188:drug therapy* / Q000209:etiology / Q000517:prevention & control / Q000635:transmission; D017245:Foscarnet / Q000627:therapeutic use; D015774:Ganciclovir / Q000627:therapeutic use; D006412:Hematopoietic Stem Cells / Q000821:virology; D006801:Humans; D016867:Immunocompromised Host; D016756:Immunoglobulins, Intravenous / Q000627:therapeutic use; D016219:Immunotherapy, Adoptive; D007223:Infant; D011024:Pneumonia, Viral / Q000188:drug therapy / Q000209:etiology; D012307:Risk Factors; D012680:Sensitivity and Specificity; D013602:T-Lymphocytes, Cytotoxic / Q000637:transplantation; D019172:Transplantation Conditioning; D014184:Transplantation, Homologous / Q000009:adverse effects*; D014765:Viral Vaccines / Q000627:therapeutic use; D014766:Viremia / Q000175:diagnosis; D014775:Virus Activation
D000956:Antigens, Viral; D000998:Antiviral Agents; D016756:Immunoglobulins, Intravenous; D014765:Viral Vaccines; D017245:Foscarnet; D015774:Ganciclovir; D000212:Acyclovir