Standard treatment–refractory cytomegalovirus encephalitis unmasked by immune reconstitution inflammatory syndrome and successfully treated with virus‐specific hyperimmune globulin. Issue 11 (17th November 2020)

• Record Type: Journal Article
• Authors: Maximova, Natalia; Marcuzzi, Annalisa; Del Rizzo, Irene; Zanon, Davide; Maestro, Alessandra; Barbi, Egidio; Sala, Roberto
• Is Part Of: Clinical & translational immunology. Volume 9:Issue 11(2020)
• Page Start: n/a
• Page End: n/a
• Publication Date: 2020-11-17
• Subjects: cerebrospinal fluid CMV antibodies -- CMV‐hyperimmune globulin -- cytomegalovirus (CMV)‐related encephalitis -- IL‐6 -- immune reconstitution inflammatory syndrome (IRIS); Immunologic diseases -- Periodicals; Immunology -- Periodicals; Clinical medicine -- Periodicals; Immune System Diseases -- therapy; Immunotherapy; Immunologic Factors -- therapeutic use; Translational Medical Research; Molecular Targeted Therapy; Clinical medicine; Immunologic diseases; Immunology; Periodicals; Periodicals; Fulltext; Internet Resources; Periodicals; 616.079
• DOI: 10.1002/cti2.1201
• Languages: English
• ISSNs: 2050-0068

Abstract

Abstract: Objectives: Cytomegalovirus (CMV)‐related encephalitis is a rare but potentially life‐threatening complication of CMV infection in immunocompromised patients. The high mortality rate is associated with deficient immune system reconstitution after hematopoietic stem cell transplant (HSCT) and poor bioavailability of antiviral drugs in cerebrospinal fluid (CSF). CMV‐related central nervous system (CNS) infection may occur with aspecific symptoms, without evidence of either blood viral load or magnetic resonance imaging (MRI) signs of encephalitis. Methods: Here, we describe a 10‐year‐old girl who underwent an allogeneic HSCT and subsequently developed CMV encephalitis. Because of the absence of CMV antigen in the blood, the diagnosis of encephalitis was proposed only after a delay, following the onset of immune reconstitution inflammatory syndrome (IRIS). Two months of combined dual antiviral therapy with ganciclovir and foscarnet proved ineffective against CMV and caused significant bone marrow and renal toxicity. To avoid further toxicity, the girl was given daily treatment with CMV‐hyperimmune globulins alone. Results: After three weeks, the CSF viral load dropped significantly and was undetectable within three more weeks. In the meantime, the renal impairment resolved, and there was a complete bone marrow recovery. Conclusion: We suggest that this patient succeeded in achieving CMV CSF clearance with high dose of CMV‐hyperimmune globulin, given alone, because of the ability of immunoglobulins to penetrate the blood–brain barrier (BBB). Abstract : This case describes the high‐dose anti‐cytomegalovirus (CMV) hyperimmune globulin treatment of CMV‐induced encephalitis after allogeneic hematopoietic stem cell transplant. After two months of combined dual antiviral therapy with ganciclovir and foscarnet, the CSF viral load remained very high; meanwhile, the patient, a 10‐year‐old girl, developed severe bone marrow and renal toxicity. Complete CSF clearance was obtained with high doses of anti‐CMV hyperimmune globulins given alone. We suggest this treatment succeeded because of the ability of immunoglobulins to penetrate the blood–brain barrier.