CMV and Herpesviruses Michael Boeckh, M.D. Fred Hutchinson Cancer Research Center University of Washington Seattle, WA, USA.

CMV and Herpesviruses

Michael Boeckh, M.D.

Fred Hutchinson Cancer Research Center

University of Washington

Seattle, WA, USA

Human Cytomegalovirus

• Beta herpesvirus• Seroprevalence 50-95%• Establishes latency• Sites of latency

– Mononuclear cells– Polymorphonuclear cells– Tissue (e.g. lung )

CMV Seroprevalence in the US

Staras et al. Clin Inf Dis, 2006

Transmission of CMV

• Saliva– Toddlers

• Blood products• Transplanted organs• Breast milk• Trans-placental• Sexual contact

– Semen– cervical secretion

CMV Clinical Disease in Healthy Subjects

• Mononucleosis• Hepatitis• Meningoencephalitis• Myocarditis• Interstitial pneumonia

Impact of CMV in Immunocompromised Hosts

Stem Cell

TransplantDisease

(Pneumonia, GI Disease, Graft

Failure etc.)

Mortality

Hospitalization

Donor Pool

Other infections

? GvHD

Solid Organ

TransplantDisease

(Syndrome, Hepatitis,

Pneumonia etc.)

Other Infections

Hospitalization

Donor Pool

Rejection

HIVDisease

(Retinitis, GI, CNS etc.)

Hospitalization

Blindness

Mortality

Quality of Life

Treatment- or Prophylaxis-Related Adverse Events

Congenital CMV• Acquisition during pregnancy• 0.2-2.2% of life birth• Appr. 105 symptomatic• High morbidity of disease

– Leading cause of CNS maldevelopment in children• Hearing loss• Mental retardation• Jaundice• Microcephaly• Seizure• Long-term sequelae

CMV Pneumonia in HCT Recipients 1970s and early 1980s: CMV disease is the leading

infectious cause of death after HCT 85-90% fatality rate

Time to CMV Reactivation and Disease after HCT

Any CMV AG/DNA= Reactivation

CMV Disease

0 7 14 21 28 35 42 49 56 63 70-7

0

20

pp

65 A

G/D

NA

CM

V v

iral

load

Days after Transplantation

CMV Viral Load Endpoints

o

o

o

o

o

o o

10

40

30

50 peak

Area Under the Curve (AUC)

Initial Load(Any Reactivation)

Preemptive Antiviral Treatment

CMV Disease • Pneumonia• Gastrointestinal disease• Retinitis• Encephalitis• Hepatitis• Marrow suppression

• Immunosuppressive effects• Rejection• GvHD

Late CMV Disease in HCTClinical Manifestations

IP

IP + GI

GI

Other

< Day 100 >Day 100RetinitisMarrow failureEncephalitisSinusitisCystitis

Boeckh & Marr 2002

CMV: Current IssuesTransplantation

Drug toxicity HCT > SOT

Survival disadvantage of seropositivepatients undergoing URD/TCD Tx Mainly HCT

Late Disease HCT = SOT

Drug resistance SOT > HCT

0 7 14 21 28 35 42 49 56 63 70-7

0.1

1

10

Gra

nu

locy

tes

Days after Transplantation

Prophylaxis

Pre-emptive

AntigenemiaDNA/RNA

Current Prevention Strategies

CMV

CMV Prevention Strategies

Prophylaxis Indirect Effects

Preemptive Therapy Direct Effects

CMV Prevention in HCT RecipientsHistory

ProphylaxisPreemptive

Therapy

1985 1990 1995 2000

Antiviral Drug

Time

Preemptive Therapy

PCR, pp65 AGPp67 mRNA

RTCGanciclovir +Foscarnet +Cidofovir not testedValganciclovir pilot study

Start of Ganciclovir

• Based on– Threshold correlating with disease– In vivo replication dynamics

• Highly immunosuppressed patients have a shorter replication time

Start of Ganciclovir

• Antigenemia: low/moderate risk

CMV D-/R-Autologous > 1 mg/kg 1/slide

Autologous < 1 mg/kg 5/slide

Viral Doubling Time in vivo relative to Degree of Immunosuppression

Weeks

Log10

CMV

Weeks

FastSlow

Viral Doubling Time in vivo relative to Degree of Immunosuppression

Weeks

Log10

CMV

Weeks

FastSlow

R+ or D+/R- allograft< 1 mg/kg steroids and no T cell depletion

All other allosCD34-s autos

Cord blood: very fast

CMV Viral Load Assay Variability

• Quantitative DNA assays have lower variability than antigenemia assay

• Coefficient of variation of most DNA assays < 0.3

• Viral load increases of > 0.5 log10

likely to indicate true increase

Preemptive TherapyThreshold Levels for Starting Therapy

Risk Threshold

Very High < day 100: Any level> day 100: 1000 copies/mL

High < day 100: 100 copies/mL*> day 100: 1000 copies/mL

Low < day 100 500 copies/mL*> day 100 1000 copies/mL

* Repeat after 2-3 days if less and treat if next value > 5x baseline

Other Key Points

• Stop of preemptive therapy:– One negative test

• Valganciclovir– After day 100: ok for induction– Before day 100: generally IV induction

Case

• 58 yo women, 9 months after NM PBSCT for ALL in 1st remission

• Early posttransplant complications– 2 episodes of CMV reactivation (+ one pre-Tx)– Acute GvHD– RSV URI

• Now severe GI GVHD, diagnosed 4 weeks ago – 1 mg/kg steroids, FK506 and beclomethasone

dipropionate

• Admitted with respiratory failure requiring intubation

Case – continued • CMV reactivation 7 weeks prior to admission:

– plasma PCR 1100 treated with valganciclovir, – switched to 450 mg/day after one week, – switched back to acyclovir prophylaxis a 2 days prior to

admission

• Lab: Crea 0.2, bili 23.4, AST 390• PCP prophylaxis:

– atovaquone 1500 mg/day, – acyclovir 800 mg BID, – fluconazole 400 mg

• Other medications– prednisone 2 mg/kg– beclomethasone dipropionate, FK506 for GI GVHD

Case – Questions

What would be your differential diagnosis?

1. PCP

2. CMV pneumonia

3. Respiratory virus pneumonia

4. Bronchiolitis obliterans

5. All of the above

Case – Questions

The patient was started on broadspectrum antibiotics (imipenem, vancomycin, gentamicin, levofloxacin). Which additional agents would you start empirically?

1. High-dose TMP-SMX2. Ganciclovir induction therapy3. Voriconazole4. Oseltamivir5. 1 and 26. All of the above

Case – Additional Information• Patient received TMP-SMX and ganciclovir empiricallyAdditional diagnostic

• IT aspirate: GPC, GPR, GNR (mixed flora), yeast• BAL:

– Gram stain: GPC, GNR– Viral DFA; negative for ADV, RSV, FLU, PIV, HMPV– PCP DFA: negative– CMV shell vial: pending– Respiratory 12-virus multiplex PCR: pending– Aspergillus GM: positive (index 2)– Aspergillus PCR: pending– Legionella: negative

• CMV PCR (plasma): 2 million copies/mL

Case – Interim Working Diagnosis

• Presumed CMV pneumonia– Drug resistance possible if not probable

• Pulmonary aspergillosis

• Bacterial pneumonia

Utility of Galactomannan Detection in BAL

Hematopoietic Cell Transplantation• Becker et al. Br J Haematol 2003• Musher et al. J Clin Microbiol 2004• Maertens et al. Clin Infect Dis 2009

Hematologic malignancies• Hsu et al. BMC Inf Dis 2010• Bergeron et al. Chest 2010

Lung transplantation• Husein et al. Transplantation 2007• Pascaloto et al. Transplantation 2010

Case – Questions

How would you adjust treatment?

• Switch to foscarnet

• Add foscarnet

• Add voriconazole

• Add both foscarnet and voriconazole

• No change

Foscarnet and voriconazole added

Ganciclovir Resistance against CMV

Prevalence 2010

SOT >>> HCT

Ganciclovir Resistance against CMV

Prevalence 2010

SOT >>> HCT

However…..

Low immune status• Drug induced• Severe IS (e.g. TCD,

HD steroids)• D+/R-• CD4 count

Subclinical CMV load Low drug levels

Prolonged

Adminstration

Resistance

Ganciclovir ResistanceNot one single factor is

responsible

+

+

+ +

+ +

CMV Drug Resistance High Risk Situation

ViralLoad

Months after Transplantation

Ganciclovir

Ganciclovir

• Ganciclovir-experienced patient (prophylaxis, preemptive therapy, pre-transplant use), especially with low doses• Increase of viral load > 2 weeks • High risk transplant setting

• Lung, K-P transplant (D+/R-)• HCT (severe TCD or immunosuppression, e.g. haplo Tx)

CMV Drug Resistance Low Risk Situation

ViralLoad

Months after Transplantation

Ganciclovir

•Ganciclovir-naïve patient•Increase of viral load during the first 2-3 weeks of therapy•Low risk setting (R+, kidney Tx, liver Tx, heart Tx, HCT)

CMV Drug Resistance Mutation Map: UL97 and UL54

Chou S, Rev Med Virol 2008

UL97

UL54

CMV Drug ResistanceDiagnosis

• Increases of viral load as surrogate marker for resistance

– drug-naïve subjects, early during treatment, low risk setting (R+):

• drug resistance unlikely

• increases most likely due to the underlying immunosuppression

– after significant exposure (especially low-dose), high risk setting

• More likely

• True viral load increase: > 0.5 log10 (> 3x baseline)

• Testing: direct genotypic testing if resistance is suspected

– UL97 gene: CMV, maribavir

– UL 54 gene: foscarnet, cidofovir, ganciclovir (high level)

CMV Drug ResistanceManagement Strategies

• Switch to alternative drug

– Ganciclovir Foscarnet

Cidofovir (some cross-resistance)

– Foscarnet Ganciclovir

Cidofovir

• Reduce immunosuppression (if possible)

CMV Drug ResistanceManagement Strategies

In refractory situations (viral load increases, clinical deterioration):

– Reduce immunosuppression if feasible

– Consider dose increase if possible (West P et al. Transplant Infect Dis 2008)

– Consider combination therapy

• Continue ganciclovir in addition to foscarnet (Emery et al. PNAS 2008)

CMV Drug ResistanceManagement Strategies

In refractory situations – continued :

– Consider alternative agents (alone or in combination) CASE REPORTS ONLY – NO CONSISTENT EVIDENCE

• Leflunomide (Avery RK et al. BMT 2004; Battiwalla M et al. TID 2007)

• Artesunate (Shapira et al., CID, 2008; Effert et al. CID, 2008) – not available everywhere

– Consider alternative immunosuppressive agents

• Sirolimus (Chou S, Rev Med Virol, 2008)

CMV Drug ResistanceManagement Strategies

In refractory situations – continued : – Consider experimental drugs if available:

• High dose maribavir

– Alone

– In combination with foscarnet or cidofovir (not ganciclovir)

• CMX-001 (lipid cidofovir)

Summary: CMV Drug Resistance

• Increases of viral load as surrogate marker for resistance

– drug-naïve subjects, early during treatment, low risk setting:

• Drug resistance unlikely, increases most likely due to the underlying immunosuppression

– after significant exposure (especially low-dose), high risk setting

• More likely, true increase: > 0.3 log10

• Testing: direct genotyping if resistance is suspected

• Alternative treatment while awaiting results

Case – Follow-up

• Final BAL results:– Aspergillus GM and PCR positive– CMV SV positive, UL97 mutation detected– Pseudomonas aeruginosa (> 104 cfu/ml)– No evidence of

• Respiratory virus disease• PCP• Legionellosis• Mycobacterial disease

• Patient died of refractory respiratory failure

Nakamae et al. ASH 2007 abstract

Ganciclovir-related Neutropenia Not Reduced after Non-myeloablative

Conditioning

Adj. HR 1.1, P=0.52

Reduction of GCV or VGCV-related Neutropenia

Strategies

• Limit use of marrow-toxic drugs – Hold/replace concomitant medications (e.g. TMP-SMX,

MMF, Imatinib)

• Preemptive use of G-CSF– Studied in HIV-infected patients (Dubreuil-Lemaire et al.

Eur J Haematol 2000, Kuritzkes et al. AIDS 1998)

• Foscarnet (Reusser et al. Blood 2002)– Equivalent to IV GCV for CMV disease-free survival– Less neutropenia

• Cidofovir: no randomized trials

Diagnostic Test Ganciclovir/FSC(e.g. PCR> 1000 copies/mL)

0 200 days100 days

Prevention of Late CMV DiseaseCurrrent Strategies

•Duration of monitoring: until 6-12 m after HCT–Detectable CMV-specific T cell function–No or minimal systemic immunosuppression

•No or minimal systemic steroids•No anti-T cell agents•No DLI

–Several negative surveillance assays

Control of CMVFuture Strategies

• Novel anti-CMV drugs – Maribavir

• T cell therapy

• Vaccination strategies

Summary• Current anti-CMV strategies have reduced

the incidence of CMV disease but– A mortality disadvantage persists in high-risk

seropositive recipients– Breakthrough disease continues to occur– Toxicity remains a problem.

• New strategies include– Novel drugs, e.g. maribavir– Combined virologic and immunologic

monitoring– T cell therapy– Vaccination

Herpesviruses 2010Transplantation

• VZV HCT: Long-term acyclovir works No issues with drug resistance Long-term adherence is a problem When to stop prophylaxis?

SOT: Zoster also occurs in approximately 8-12% no general recommendation for ACV use

Varicella Zoster Virus

Courtesy of Galvin and D’Alessandro

VZV after HCT Disseminated and Visceral Disease

• Dissemination in 36%, mainly during the 1st year• Visceral VZV: appr. 1/250 seropositive recipients

– Symptoms– RUQ or back pain– Sometimes vomiting, diarrhea, bloody emesis– NO SKIN LESIONS at onset (may occur after 24-

96 h, maybe rare, always disseminated)– Hallmark: rapidly rising LFT’s (transaminitis >

1000)– Diagnosis: VZV DNA by PCR in plasma, biopsy– Management: empiric use of high-dose IV acyclovir– Outcome: often fatal even with early treatment

0

5

10

15

20

25

30

96 97 98 99 00 01 02 03 Year of Transplantation

A

0

5

10

15

20

25

30

96 97 98 99 00 01 02 03Year of Transplantation

B

Introduction of Acyclovir prophylaxis

Autologous Transplant Recipients

Allogeneic Transplant Recipients

Introduction of Acyclovir prophylaxis

V Erard et al. Blood 2007

VZV Disease after HCT

Acyclovir 800 mg twice daily

Acyclovir ProphylaxisExtended during IS

P

robabili

ty

months

Group 0 Group 1 Group 2

0 3 6 9 12 15 18 21 24

0.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35

0.40

No ACV (N=932)

1 yr ACV (N=1117)

1 yr + ACV (N=586)

P<0.001P<0.001

P=0.01

V Erard et al. Blood 2007

Acyclovir ProphylaxisExtended during IS: No Rebound VZV

P

robabili

ty

months

Group 0 Group 1 Group 2

0 3 6 9 12 15 18 21 24

0.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35

0.40

No ACV (N=932)

1 yr ACV (N=1117)

1 yr + ACV (N=586)

P<0.001P<0.001

P=0.01

V Erard et al. Blood 2007

VZV ProphylaxisHow long is enough ?

• Thomson et al. BMT 2005– 200 mg BID until d/c of IS

and CD4 count > 200/uL– Breakthrough during

prophylaxis: 1/247 (0.4%)– 26/64 (40%) developed

herpes zoster a median of 135 after d/c (range 116-959)

– 93% dermatomal

After HCT

After d/c of ACV

Herpesviruses 2010Transplantation

• HHV-6 HCT: High complication rate in cord blood recipients Encephalitis Other disease endpoints not well defined

Drug toxicities with currently available agents

SOT: rarely a problem

HHV-6• Most recipients seropositive• Variant A < B (PBL) but high frequency of A in plasma• Early reactivation (first month)• Viremia occurs in 30-70%• Clinical manifestations

– CNS disease (encephalitis): best evidence– Marrow suppression

• Delayed platelet engraftment

– Rash, fever, sinusitis– Interstitial pneumonia ?

• Association with GvHD, rejection ?• Impact on mortality ?

Risk Factors

• Age

• Underlying Disease

• Cord blood transplantation

• HLA match of transplantation

• Sex match of transplantation

• Anti-CD3 monoclonal antibodies

• Glucocorticoids

HHV-6 & Clinical Endpoints

Subsequent Events

HR (95% CI)

p-value

Adjusted

HR (95% CI)

Adjusted

p-value

Platelet engraftment 0.4 (0.19, 0.97) 0.03 0.5 (0.2, 1.1) 0.05

All Cause Mortality 2.9 (1.1, 7.5) 0.03

CNS dysfunction 8.5 (0.7, 103) 0.06

Grade 3-4 GVHD 5.6 (1.6, 19) 0.01 4.9 (1.5, 16) 0.02

CMV antigenemia 1.9 (0.9, 4.0) 0.07

Zerr et al. CID 2006

HHV-6 and Encephalitis Following HCT

• >100 cases described in literature

• Clinical criteria– Delirium +/- seizures– HHV-6 DNA detected in CSF +/- viremia– No other identified etiology

HHV-6 Encephalitis

• Allogeneic• Present median D +24 (12-39)• Delirium characterized by:

– Short–term memory loss – Confusion – Disorientation – Depressed consciousness

• Seizures in 50%

HHV-6 Encephalitis

• CSF findings: – pleocytosis uncommon – elevated protein >50%

• MRI abnormal in 9/12 – 7 mesial temporal lobes/hippocampus

(*short term memory loss*)

• All treated with FSC +/- ganciclovir

HHV-6 Encephalitis (1998-2003): Outcomes

• 4 (29%) died within 1 month

• 10 (71%) survived >1 month– 8 Persistent cognitive deficits

Self report: memory/concentration issues

Severe cognitive impairment

HHV-6 Treatment

• Drugs with antiviral activity– Foscarnet – Ganciclovir– Cidofovir

HHV-6Take Home Points

• HHV-6 reactivation occurs in appr. 40% of patients

• HHV-6 is associated with – Encephalitis– Possibly also with delayed platelet engraftment

and GvHD

• Long-term sequelae of CNS disease are common

Herpesviruses 2010Transplantation

• EBV PTLD in high-risk patients» HCT: T cell depletion» SOT: seromismatch, anti T cell ABs

HCT: » Surveillance and preemptive therapy with rituximab

(non-randomized)» T cell therapy (non-randomized)

• HSV No real issue: no increase of drug resistance with long-term acyclovir (if the dose is high enough)

• HHV-7 No confirmed disease association• HHV-8 Rarely Kaposi sarcoma

HSV Infection after HCTTake Home Points

• HSV reactivation is common

• ACV prophylaxis now commonly applied– Minimum 30d– At FHCRC: minimum

100 days, > 1 year if VZV positive

– Highly effective, eliminates wildtype and ACV-resistant HSV

– Therapy of resistant disease: IV foscarnet (renal toxicity)

Pro

bab

ility

2yr-probability of HSV disease HCT recipientsmonths

Group 0 Group 1Group 2

0 6 12 18 24

0.00

0.05

0.10

0.15

0.20

0.25

0.30

Pro

bab

ility

2yr-probability of HSV disease HCT recipientsmonths

Group 0 Group 1Group 2

0 6 12 18 24

0.00

0.05

0.10

0.15

0.20

0.25

0.30

Cohort 2

Cohort 1

Cohort 3

Cohort 2

Cohort 1

Cohort 3

Pro

bab

ility

2yr-probability of HSV resistant disease in HCT recipientsmonths

Group 0 Group 1Group 2

0 6 12 18 24

0.00

0.00

0.00

0.01

0.01

0.01

0.01

0.01

0.02

Pro

bab

ility

2yr-probability of HSV resistant disease in HCT recipientsmonths

Group 0 Group 1Group 2

0 6 12 18 24

0.00

0.00

0.00

0.01

0.01

0.01

0.01

0.01

0.02

V Erard et al. JID 2007

All HSV disease

ACV-resistant HSV disease

Cidofovir Lipid Conjugates

• Lipid esters under development as oral therapy for smallpox virus– Also have activity vs. human

herpesviruses, adenovirus, BKV

• In vitro activity enhanced 2o 100-fold increases in intracellular levels– Rapid association with

membrane phospholipids (vs. pinocytosis for CDV)

Ciesla SL et al. Antiviral Res 2003;59:163

N

N

NH2

O

O P

HO

O

O-Na+

O O(CH2)15CH3

CMX001 – Chimerix, Inc.

CMX001 Potency against dsDNA Viruses

Virus Cell Line

Cidofovir CMX001Enhanced

Activity EC50 (µM) EC50 (µM)

Variola major Vero 76 27.3 0.1 271

Vaccinia Virus HFF 46 0.8 57

HCMV(AD169) MRC-5 0.38 0.0009 422

BK Virus WI-38 115.1 0.13 885

HSV-1 MRC-5 15 0.06 250

HHV-6 HSB-2 0.2 0.004 50

Adenovirus HFF 1.3 0.02 65

HPV 18 HeLa 516 0.42 1229

HPV 11 A431 716 17 42

EBV Dardi >170 0.04 >4250

Provided by Chimerix Inc.