title: Human herpesvirus 6-related pure red cell aplasia, secondary graft failure, and clinical severe immune suppression after allogeneic hematopoietic cell transplantation successfully treated with foscarnet.
abstract: Human herpesvirus 6 (HHV-6) is frequently detected after allogeneic hematopoietic cell transplantation (allo-HCT); however, the clinical interpretation of HHV-6 viremia in a transplant patient is challenging as it may signify asymptomatic reactivation, chromosomal integration of the virus genome in the donor or recipient with no clinical significance, or severe HHV-6 disease. Here we present a case of HHV-6 disease after allo-HCT presenting as pure red cell aplasia, secondary graft failure, and severe immunosuppression causing multiple severe bacterial super-infections. Examination of pre-transplant patient and donor samples as well as serial determination of HHV-6 DNA copy numbers after transplantation were necessary to definitively interpret HHV-6 viremia as active HHV-6 infection with a causative role in pancytopenia and immune suppression. Foscarnet treatment resulted both in viral load decline and disappearance of HHV-6-related bone marrow suppression and predisposition to severe infections. Clinicians should be aware of the wide array of clinical manifestations and the diagnostic pitfalls of post-transplant HHV-6 disease. These issues are extremely challenging, as they may result either in dangerous underestimation of HHV-6 disease or in the institution of unnecessary antiviral therapy. Late bone marrow aplasia and late severe infections after allo-HCT without other obvious causes may be HHV-6 related.
authors.affiliation: Department of Internal Medicine, Patras University Medical Center, Rio/Patras, Greece.
authors.forename: E D
authors.initials: ED
authors.lastname: Lagadinou
authors.forename: M
authors.initials: M
authors.lastname: Marangos
authors.forename: M
authors.initials: M
authors.lastname: Liga
authors.forename: G
authors.initials: G
authors.lastname: Panos
authors.forename: E
authors.initials: E
authors.lastname: Tzouvara
authors.forename: E
authors.initials: E
authors.lastname: Dimitroulia
authors.forename: M
authors.initials: M
authors.lastname: Tiniakou
authors.forename: A
authors.initials: A
authors.lastname: Tsakris
authors.forename: N
authors.initials: N
authors.lastname: Zoumbos
authors.forename: A
authors.initials: A
authors.lastname: Spyridonidis
mesh_terms: D000328:Adult; D000998:Antiviral Agents / Q000627:therapeutic use*; D017245:Foscarnet / Q000627:therapeutic use*; D006084:Graft Rejection; D018380:Hematopoietic Stem Cell Transplantation / Q000009:adverse effects*; D015654:Herpesvirus 6, Human / Q000302:isolation & purification*; D006801:Humans; D007108:Immune Tolerance; D008297:Male; D012010:Red-Cell Aplasia, Pure / Q000209:etiology* / Q000276:immunology; D019349:Roseolovirus Infections / Q000150:complications* / Q000188:drug therapy*; D014184:Transplantation, Homologous; D019562:Viral Load
chemical_list: D000998:Antiviral Agents; D017245:Foscarnet