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Case Reports
. 2020 May 7;135(19):1619-1629.
doi: 10.1182/blood.2019000956.

How I treat CMV reactivation after allogeneic hematopoietic stem cell transplantation

Hermann Einsele  1 , Per Ljungman  2   3 , Michael Boeckh  4   5   6
Affiliations
Case Reports

How I treat CMV reactivation after allogeneic hematopoietic stem cell transplantation

Hermann Einsele et al. Blood. .

Abstract

Cytomegalovirus (CMV) reactivation remains one of the most common and life-threatening infectious complications following allogeneic hematopoietic stem cell transplantation, despite novel diagnostic technologies, several novel prophylactic agents, and further improvements in preemptive therapy and treatment of established CMV disease. Treatment decisions for CMV reactivation are becoming increasingly difficult and must take into account whether the patient has received antiviral prophylaxis, the patient's individual risk profile for CMV disease, CMV-specific T-cell reconstitution, CMV viral load, and the potential drug resistance detected at the time of initiation of antiviral therapy. Thus, we increasingly use personalized treatment strategies for the recipient of an allograft with CMV reactivation based on prior use of anti-CMV prophylaxis, viral load, the assessment of CMV-specific T-cell immunity, and the molecular assessment of resistance to antiviral drugs.

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Conflict of interest statement

Conflict-of-interest disclosure: P.L. reports personal fees from AiCuris and grants from Astellas, Oxford Immunotech, Takeda (Shire), and MSD outside of the submitted work. M.B. reports grants and personal fees from Merck, Takeda/Shire, Gilead Sciences, and VirBio; grants from Astellas and Chimerix; personal fees, including options to acquire equity from Helocyte and EvrysBio; and personal fees from GlaxoSmithKline, Moderna, and AlloVir, outside of the submitted work. H.E. declares no competing financial interests.

Figures

None
Graphical abstract
Figure 1.
Figure 1.
Case 1: engraftment, viral reactivation, antiviral prophylaxis, treatment, and other relevant clinical data of a 37-year-old woman with high-risk multiple myeloma.
Figure 2.
Figure 2.
Case 2: engraftment, viral reactivation, antiviral prophylaxis, treatment, and other relevant clinical data of a 62-year-old man with ALL in remission.
Figure 3.
Figure 3.
Viral load thresholds for starting preemptive therapy. Adapted from CMV Prevention: Prophylaxis, Surveillance, and Preemptive Therapy in Hematopoietic Stem Cell Transplant Recipients Guidelines.
Figure 4.
Figure 4.
Case 3: engraftment, viral reactivation, antiviral prophylaxis, treatment, and other relevant clinical data of a 52-year-old woman with Philadelphia-positive ALL in CR.
Figure 5.
Figure 5.
Case 4: engraftment, viral reactivation, antiviral prophylaxis, treatment, and other relevant clinical data of a 55-year-old man with AML in CR.
Figure 6.
Figure 6.
Case 5: engraftment, viral reactivation, antiviral prophylaxis, treatment, and other relevant clinical data of a 28-year-old man with high-risk AML in CR.
See this image and copyright information in PMC

References

    1. Zaia JA, Gallez-Hawkins GM, Tegtmeier BR, et al. . Late cytomegalovirus disease in marrow transplantation is predicted by virus load in plasma. J Infect Dis. 1997;176(3):782-785. - PubMed
    1. Teira P, Battiwalla M, Ramanathan M, et al. . Early cytomegalovirus reactivation remains associated with increased transplant-related mortality in the current era: a CIBMTR analysis. Blood. 2016;127(20):2427-2438. - PMC - PubMed
    1. Ljungman P, Schmitt M, Marty FM, et al. . A mortality analysis of letermovir prophylaxis for cytomegalovirus (CMV) in CMV-seropositive recipients of allogeneic hematopoietic-cell transplantation [published online ahead of print 8 Jun 2019]. Clin Infect Dis. doi:10.1093/cid/ciz490. - PMC - PubMed
    1. Fuji S, Einsele H, Kapp M. Cytomegalovirus disease in hematopoietic stem cell transplant patients: current and future therapeutic options. Curr Opin Infect Dis. 2017;30(4):372-376. - PubMed
    1. Chemaly RF, Chou S, Einsele H, et al. ; Resistant Definitions Working Group of the Cytomegalovirus Drug Development Forum . Definitions of resistant and refractory cytomegalovirus infection and disease in transplant recipients for use in clinical trials. Clin Infect Dis. 2019;68(8):1420-1426. - PMC - PubMed

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