lnt J Hematol (2008) 88: 145-148

DOlI0.1007/sJ2185-008-0126-z

Immune reconstitution complicated by CMV retinitisin a pediatric patient who underwent haploidenticalCD34+-selected hematopoietic stem cell transplantfor acute lymphoblastic leukemia

Simone Cesaro' Maria Paola Boaro • Marta Pillon .Elisabetta Calore . lvete Cermakova . Katia Perruccio .

Carlo Mengoli . Chiara Messina

Received: 30 April 2008/Revised: 22 May 20081 Accepted: 4 June 2008/Published online: 8 July 2008© The Japanese Society of Hematology 2008

Abstract We describe two episodes of CMV retinitis in apediatric patient who underwent a CD34+ selected graftfrom his haploidentical father. Both recipient and donorwere cytomegalovirus (CMV) seropositive. Both episodesoccurred late post-grafting during a phase of completeimmunological recovery with sufficient numbers of circu­lating CMV-specific clones. Antiviral treatment withfoscamet and ganciclovir was successful but prolongedtreatment was required to prevent relapses. We hypothesizethat this complication was more related to an immunereconstitution process than to an immune-deficient statepost-grafting. We conclude that CMV retinitis is a latecomplication of HSCT that can occur despite satisfactoryimmune reconstitution. Usually, it is responsive to antiviraltherapy. Dilated fundoscopic examination is essential bothfor examining patients with reduced visual acuity and forscreening asymptomatic patients.

S. Cesaro ([8]) . M. P. Boam . M. Pillon . E. Calore .C. Messina

Pediatric Hematology Oncology,Department of Pediatrics. University of Padova,Via Giustiniani 3. 35128 Padova, Italye-mail: simone.cesaro@unipd.it

1. Cermakova

Service of Pediatric Ophthalmology. Department of Pediatrics.University of Padova. Padova, Italy

K. Perruccio

Division of Hematology and Clinical Immunology,Department of Clinical and Experimental Medicine,lRCCS Foundation on Transplantation Biotechnologics,University of Perugia, Pcmgia, Italy

C. MengoliDepartmcnt of Histology, Microbiology and MedicalBiotcchnology, University of Padova, Padova. Italy

Keywords Cytomegalovirus retinitis .Haploidentical hematopoietic stem cell transplantation .Children

I Introduction

Cytomegalovirus (CMV) retinitis is a well-known sight­threatening complication in patients affected by acquiredimmune deficiency syndrome (AIDS) whilst it is morerarely reported in solid organ or haematopoietic stem celltransplant (HSCT) [1-4]. The incidence of this complica­tion is between 1.4 and 2.2% in HSCT patients, with anincreasing trend according to some recent reports [5-7].The main risk factors for CMV retinitis in allogeneic HSCTare CMV seropositivity of donor or recipient, CMV reac­tivation before day + 100,delayed lymphocyte engraftment,and chronic graft versus host disease (GVHD) [5].

Most of the data on CMV retinitis have been derived

from adult patients who received an unmanipulated HSCTusing an unrelated or mismatched donor as stem cell sourcewhilst cases after in vitro T-depletion or CD34+-positiveselection have been less frequently reported. especially inpediatric patients [8-10].

We describe a case of CMV retinitis after haploid enticalHSCT. which occurred despite the patient having had aprolonged period of treatment with anti-CMV therapy anddespite having received adoptive immunotherapy for per­sistent CMV reactivation.

2 Case report

A 14-year old boy, diagnosed with T-acute lymphoblasticleukemia (T-ALL), was urgently referred for allogeneicHSCT in view of an early neck lymph node relapse that

~ Springer

146

occurred during the reinduction phase, 4 months from thestart of chemotherapy. Lacking both a related and an unre­lated HLA matched donor, a peripheral blood stem cellcollection by leukapheresis was organized from his HLA­haploid entical father. The father was stimulated with gran­ulocyte-colony stimulating factor (2 x 300 ~lg/dayx 4 days,subcutaneously) whilst the stem cell collection wasT-depleted by CD34+ positive selection with CliniMACSsystem (Miltenyi Biotec. Calderara di Reno, Bologna, Italy).The recipient/donor (RID) CMV serostatus was pos.lpos.

The patient received a myeloablative conditioning reg­imen with total body irradiation, 12 Gy, thiothepa, 10 mg/kg, and etoposide, 40 mg/kg. Standard prophylaxis withacyclovir (3 x 500 mg m-2 day-I) was used as preventionof herpes virus infection (HSV. CMV). GVHD prophylaxisconsisted of administration of antithymocyte serum (Gen­zyme Polyclonals, Marcy L'Etoile, France) at a cumulativedose of 15 mg/kg before the stem cell infusion, andT-depletion of the graft by CD34+ positive selection[11, 12]. The tota] number of CD34+ and CD3+ cellsinfused was 3.13 x 106 and 1.6 x 104 kg-I, respectively.Pre-engraftment toxicity was limited to WHO grade IIImucositis whilst polymorphonuclear (PMN) and platelet(PLT) engraftment occurred at day + 13 and day + 14,respectively.

Despite the absence of any sign of acute or chronicGVHD, frequent CMV reactivations (detected by bloodpp65 antigenemia or CMV-DNAemia) were diagnosedstarting from day +20. The patient received multiplecourses of pre-emptive treatment with foscarnet, ganci­clovir or cidofovir until day +241 [13, 14]. Given theknown delayed immune-reconstitution following T-deple­ted grafts, adoptive immunotherapy was also used toimprove CMV virus specific immunity. Two infusions ofpaternal-derived CMV-specific CD4+ lymphocyte weregiven at day +74 and +117, 0.125 x lO6 and 1 x 106kg-I, respectively [15].

On day +252, 12 days after the last administration offoscarnet, he complained of a reduction in visual acuityfrom IOII0 to 2II 0 in his right eye. Ophthalmologicinvestigation showed diffuse corneal endothelial deposits,anterior uveitis, vitreal thickening, vitreitis, white retinalperivascular sheath and pelipheral necrosis. At that time,the absolute number of lymphocytes and of CD4+ cellswas 1.3 x lO9 and 0.36 x !O9 L-I, respectively. Theaqueous humor, obtained by fine needle aspiration of theanterior chamber, tested positive for CMV-DNA. Thesefindings were consistent with a diagnosis of CMV eyedisease. Therapy with foscarnet (120 mg/kg for 14 days)and then with cidofovir (3-5 mg/kg for four doses) wasresumed and a complete regression was obtained after 4weeks. Maintenance anti-CMV treatment with foscarnet

(90 mg/kg) or ganciclovir (lO mg/kg thrice or twice-a-

<g) Springer

S. Cesaro et aJ.

week) was continued for a further 7 months making a totalof 180 days of treatment.

A second relapse of CMV retinitis occurred 3 monthsafter stopping anti-CMV therapy and was characterized bya reduction of visual acuity to 5II 0 in the tight eye and thereappearance of uveitis, vitreal thickening, and retinitis atophthalmoscopic examinaton. At that time, his lymphocyteand CD4+ count were 2.9 x lO9 and 1.04 x 109 L-I,

respectively. The patient was started on foscarnet (90 mg/kg) for 2 weeks and then switched to maintenance withvalgancycIovir (2 x 450 mg/day, orally) for 3 months. Thetreatment resulted in a complete regression of activelesions in a month with an improvement in visual acuity.The patient continued the treatment with valgancyclovir450 mg/day for a further 2 months.

Figure I shows the timing of CMV reactivation asdetennined by CMV-DNAemia in the post-engraftmentperiod, the timing of CMV eye-disease and the immuno­logical recovery with regard to lymphocyte and CD4+ cellcount.

As of March 31st, 2008, 24 months from HSCT, the

patients was alive and well. His Karnofsky score was 100and the visual acuity in his right eye was 6-8/10 withoutand !OlIO with lens correction. On fundoscopic examina­tion a moderate vitreal thickening remained.

3 Discussion

CMV remains a major cause of morbidity and mortality inimmunocompromised patients who have undergone HSCT[3]. Nowadays, CMV disease has become less frequentwith the pre-emptive use of anti-CMV drugs in asymp­tomatic high-risk patients [13, 14]. In contrast to AIDSpatients, CMV retinitis is a rare complication after HSCTbut may represent up to 5-25% of CMV disease occurringafter day +100 [5-7, 13].

In the setting of unmanipulated allogeneic HSCT, Crippaet al. showed that the main risk factors associated with the

development of CMV retinitis were CMV-seropositivity ofdonor or recipient, CMV reactivation before day +100,delayed lymphocyte engraftment (lymphocyte count <0.3x 109L-I), and chronic GVHD. The role of these factorshas been confirmed in a recent report by Xhaard et aI. [7]. Inparticular, the combination of CMV-seronegative donor andCMV-seropositive recipient resulted in a cumulative inci­dence of CMV retinitis of 6.3%. The increasing proportionof unrelated donor sources for HSCT pelformed in the lastdecade is advocated to explain the increased incidence ofCMV retinitis compared to the past [5-7].

CMV retinitis in children has previously been describedin case reports or limited case series, mostly in the settingof unmanipulated HSCT with the administration of

2000

1000

1500

CMV retinitis and pediatric HSCT

Fig. 1 Timetable of CMVevents (reactivation and

retinitis), therapy and timing oflymphocyte and CD4+ cellsrecovery

«zc,>:EU

13500

12000

10500

9000

7500

4500

3000

1500

1.35

1.20

.. ~ 1.05'"""'~',.~ i ...J

....;. ! 01••••••• 0.90'~. ~0., ! <r-

-.; LymPhO~ -+ ~ 0.75

.: . + 060..,. .

g 0.450.30

0.15

147

4500

4000 .­..J

3500 mo3000 T'"

)(2500 -;

>-uo.s::Co[..J

500

123456

t ta 9 10 11 11 13 14 15 16 tl 18 Ie 20 21 n n 24

months

O.j. 0

CMV - specific CD4+ infusion

Legend

:227ff~ CMV retinitis

•••••••••••••••. Lymphocyte

CMV - DNA

*t

CD 4+

CD 4 Anti CMV specific (x 1061L)

CMV - specific CD4+ infusion

antithymocyte globulin as part of the conditioning regimen[4-7, 16, 17]. In some reports, the most important differ­ences with respect to adults were the timing of diagnosis ofCMV retinitis, the occurrence being as early as day +42,+63, and +81 post-grafting in pediatric patients, and thetemporal association with CMV reactivation or CMV dis­ease involving other organs [J7, 18J.

Despite the recent development of efficient proceduresfor T-depletion of grafts by CD34+ positive selection [11,12], CMV retinitis has been rarely reported in suchpatients. In this setting, some authors have shown that thiscomplication occurs as early as day + 10, day +42, day+64, and day + I07 post-grafting, whilst the patient isseverely Iymphopenic and CMV is actively replicating [8­10]. Accordingly, it has been demonstrated that the adop­tive transfer of donor-derived CMV-specific CD8+ orCD4+ cytotoxic T lymphocytes is protective against thedevelopment of CMV disease in recipients of an allogeneicHSCT and has the potential for clearing CMV viremia [19].

In contrast to above-mentioned reports, our patientdeveloped CMV retinitis late after HSCT during a phase ofcomplete immunological recovery, the lymphocyte andCD4+ cell count being greater than 1.0 and 0.2 x 109L-I,respectively, i.e. the conventional thresholds for defining astatus of severe immunocompromission. Moreover, neitherepisode was associated with concurrent CMV replication.

In our patient, we hypothesize that the retinal tissue wasa site of CMV latent infection and that viral replication wasinitially not detected by the immune system because oflymphopenia and, possibly, the difficulties of effector cellsmigrating into the eye through the vascular endothelium.We demonstrated that the patient had CMV-specific clonescirculating before both episodes of CMV retinitis, so it is

conceivable to think that the clinical onset of retinitis was

possibly related to a reaction of these clones to subclinicalor latent ocular infection. CMV retinitis in this case seems

more a consequence of an immune-reconstitution processrather than as a result of an immune-deficient status.

We conclude that CMV retinitis is a late complication ofHSCT that can occur despite satisfactory immune recon­stitution both for unmanipulated and T-depleted grafts.Usually, it is responsive to antiviral therapy but a pro­longed course of treatment may be required. Dilatedfundoscopic examination is essential both for patients withreduced visual acuity post-HSCT and for screeningasymptomatic patients with chronic GVHD.

Acknowledgments We would like to thank Maria Vitloria Gazzola,Ph.D., and Roberta Destro, Ph.D., for graft processing; JudithKingston, M.D., for the kind revision of English style of manuscript,and Andrea Velardi. Prof., M.D. for CMV adoptive immunotherapyand the useful comments.

References

1. Jabs DA, Van Natta ML, Kempen JH, et a1. Characteristics ofpatients with cytomegalovirus retinitis in the era of highly activeantiretroviral therapy. Am J Ophthalrno1. 2002;133:48-61.

2. Dy Lin, Warren JF, Lazzeroni LC, Wolitz RA, Mansour SE.Cytomegalovirus retinitis after initiation of highly active anti­

retroviral therapy in HIV infected patients: natural history andclinical predictors. Retina. 2002;22:268-77.

3. Nichols GN, Bocckh M. Recent advances in the therapy andprevention of CMV infections. J Clin Viral. 2000;16:25-40.

4. Chung H, Kim KH, Kim JG, Lee SY, Yoon YH. Retinal com­plications in patients with solid organ or bone marrowtransplantations. TranspJantation. 2007;83:694-9.

5. Crippa F, Corey L, Chuang EL, Sale G, Boeckh M. Virological,clinical and ophthalmogic features of cytomegalovirus retinitis

~ Springer

148

after hematopoietic stem cell transplantation. CJin Infect Dis.2001;32:214-9.

6. Larsson K, Lonnqvist B, Ringden 0, Hedquist B, Ljungman P.CMV retinitis after allogeneic bone marrow transplantation: areport of five cases. Transpllnfect Dis. 2002;4:75-9.

7. Xhaard A. Robin M, Scieux C, et al. Increased incidence of

cytomegalovirus retinitis after allogeneic hematopoietic stem celltransplantation. Transplantation. 2007;83:80-3.

8. Miyoshi H, Tanaka-Taya K, Nagae Y, et al. Cytomegalovirusretinitis after transplantation of positively selected CD 34+ cellsfrom HLA mismatched donors. Ped Infect Dis J. 1998;]7:345-8.

9. Miyamoto T, Gondo H, Miyoshi Y, et al. Early viral complica­tions following CD34-selected autologous peripheral blood stemcell transplantation for non-Hodgkin's lymphoma. Br J Haematol.1998: I00:348-50.

10. Ohta H, Matsuda Y, Tokimasa S, et al. Foscarnet therapy forganciclovir-resistant cytomegalovirus retinitis after stem celltransplantation: effective monitoring of CMV infection byquantitative analysis of CMV mRNA. Bone Marrow Transplant.2001 ;27: 1141-5.

II. Aversa F, Tabilio A. Velardi A, et al. Hematopoietic stem celltransplantation from alternative donors for high-risk acute leu­kemia: the haploidentical option. Curr Stem Cell Res Ther.2007;2: 105-12.

12. Aversa F, Terenzi A. Tabilio A, et al. Full haplotype-mismatchedhematopoietic stem-ceJI transplantation: a phase II study inpatients with acute leukemia at high risk of relapse. J Clin Oncol.2005;23:3447-54.

~ Springer

S. Cesaro et al.

13. BoeckJl M, Gooley TA, Myerson D, Cunnigham T, Schonch G,Bowden RA. Cytomegalovirus pp65 antigenemia-guided earlytreatment with ganciclovir versus ganciclovir at engraftment afterallogeneic marrow transplantation: a randomized double-blindstudy. Blood. 1996;88:4063-71.

14. Reusser P. Einsele H, Lee J. et al. Infectious diseases workingparty of the European group for blood and marrow transplanta­tion. Randomized multicenter trial of [oscarnet versus ganciclovirfor pre-emptive therapy of cytomegalovirus infection after allo­geneic stem cell transplantation. Blood. 2002;99(4): 1159-64.

15. Perruccio K, Tosti A. Burichelli E, et al. Transferring functionalimmune response to pathogens after haploidentical haemato­poietic transplantation. Blood. 2005;106(l3);4397-406.

16. Suzuki N, Kudoh T, Mizue N, et al. CMV retinitis after cessation

of ganciclovir therapy for CMV antigenemia in a unrelated BMTrecipient. Bone Marrow Transplant. 1998;22:931-2.

17. Kuriyama K, Todo S, lkishima S, et al. Risk factors for cyto­megalovirus retinitis following bone marrow transplantation fromunrelated donors in patients with severe aplastic anemia ormyelodisplasia. Int J Hematol. 200 I;74:455-60.

18. Ghosh F, Hansson LJ, Bynke G, Bekassy A. lntravitreal sus­tained-release ganciclovir implants for severe bilateral

cytomegalovirus retinitis after stem cell transplantation. ActeOphthalmol Scand. 2002;80:101-4.

19. Einsele H, Kapp M, Grigoleit GU. CMV-specific T cell therapy.Bllod Cells Mol Dis. 2008;40:7]-5.