title: Clinically significant CMV (re)activation during or after radiotherapy/chemotherapy of the brain : Correlation with neurological deterioration and improvement upon antiviral treatment.
abstract: BACKGROUND
  For both patients with high-grade gliomas and multiple cerebral metastases, radio(chemo)therapy is the standard therapy. Neurological decline during treatment is rarely attributed to infections of the brain but to tumor progression or side effects of radiotherapy.
  
  
  METHODS
  We present 4 cases of cytomegalovirus (CMV) viremia associated with neurological deterioration, which occurred during or shortly after radiotherapy and/or chemotherapy of the brain (brain metastases 2, high-grade glioma 1, carcinoma infiltrating brain 1). In all cases, neurological decline was sudden and unexpected, and causes such as increased intracranial pressure or tumor progression could be excluded radiologically. Treatment with dexamethasone and mannitol had no or only very short-term effects. General infections were either excluded or receding before the neurological symptoms occurred. All patients presented with decreasing levels of thrombocytes. In all cases, CMV (re)activation could be proven using blood test for CMV-DNA. The anti-CMV-IgG status suggested reactivation rather than a primary infection. One patient died within 72 h of onset of the symptoms (results of CMV tests were received postmortem). Diagnosis of 3 patients allowed successful administration of antiviral treatment, which greatly improved the general and neurological conditions of the patients within 48 h.
  
  
  CONCLUSIONS
  Neurological deterioration during RT is hardly ever attributed to viral infections. These cases suggest that CMV reactivation and subsequent infection might actually be causative and has to be considered and treated.
  
  
  CONCLUSIONS
  Further prospective studies verifying and investigating this observation in terms of frequency and clinical relevance seem indicated.
authors.affiliation: Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 27, 91054, Erlangen, Germany. Nicole.Goerig@uk-erlangen.de.
authors.forename: N
authors.initials: N
authors.lastname: Goerig
authors.affiliation: Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 27, 91054, Erlangen, Germany.
authors.forename: S
authors.initials: S
authors.lastname: Semrau
authors.affiliation: Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 27, 91054, Erlangen, Germany.
authors.forename: B
authors.initials: B
authors.lastname: Frey
authors.affiliation: Institute of Clinical and Molecular Virology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.
authors.forename: K
authors.initials: K
authors.lastname: Korn
authors.affiliation: Institute of Clinical and Molecular Virology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.
authors.forename: B
authors.initials: B
authors.lastname: Fleckenstein
authors.affiliation: Institute of Clinical and Molecular Virology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.
authors.forename: K
authors.initials: K
authors.lastname: Überla
authors.affiliation: Institute of Neuroradiology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.
authors.forename: A
authors.initials: A
authors.lastname: Dörfler
authors.affiliation: Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 27, 91054, Erlangen, Germany.
authors.forename: F
authors.initials: F
authors.lastname: Putz
authors.affiliation: Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 27, 91054, Erlangen, Germany.
authors.forename: U S
authors.initials: US
authors.lastname: Gaipl
authors.affiliation: Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 27, 91054, Erlangen, Germany.
authors.forename: R
authors.initials: R
authors.lastname: Fietkau
mesh_terms: D000368:Aged; D000998:Antiviral Agents / Q000008:administration & dosage; D001932:Brain Neoplasms / Q000150:complications / Q000628:therapy*; D059248:Chemoradiotherapy / Q000009:adverse effects*; D003586:Cytomegalovirus Infections / Q000188:drug therapy* / Q000209:etiology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009422:Nervous System Diseases / Q000175:diagnosis / Q000209:etiology* / Q000517:prevention & control*; D016896:Treatment Outcome; D014766:Viremia / Q000175:diagnosis / Q000188:drug therapy / Q000209:etiology
chemical_list: D000998:Antiviral Agents
keywords: Encephalitis; Encephalopathy; Ganciclovir; Neurological manifestations; Opportunistic infections