Incidence of bronchiolitis obliterans syndrome unaffected by absence of cytomegalovirus

170

Abstracts

The Journal of Heart and Lung Transplantation February 2001

Purpose: To prospectively define the epidemiology, clinical manifestations and acute sequelae of community acquired respiratory viruses (CRV) in a lung transplant (LTx) cohort. Procedures: From November 1999 to May 2000 we performed prospective viral surveillance on LTx patients (n⫽93) at our institution. Weekly telephone symptom surveys were performed by two nurses for upper (URI) or lower (LRI) respiratory symptoms. Patients who developed URI signs/symptoms (s/s) (rhinorrhea, sore throat or cough) underwent nasal washes (NW); those with s/s of LRI (wheezing, shortness of breath or hypoxia) underwent bronchoalveolar lavage (BAL). Infection was documented by positive rapid antigen (EIA) or rapid shell vial culture (RSVC). All pts received the influenza vaccine prior to November. A total of 96 NW and 48 BAL were performed in 72 symptomatic pts. All documented infections were LRI, except 1 RSV and 2 influenza A which were URIs. Summary: Isolates RSV Parainfluenza Influenza A Any virus Multiple viruses

# pts 11 7 10 28 4

# episodes 13 9 11

incidence 11.8% 7.5% 10.9% 30.1% 3.7%

Twenty-five episodes of biopsy-proven acute rejection developed within 90d. Fourteen episodes of superinfection occurred within 13d in 9 pts. Pneumococcus, Pseudomonas and aspergillus were the isolated pathogens. Conclusions: There was a significant incidence of CRV in symptomatic LTx. CRV LRI is commonly associated with AR in ⬍ 90d and bacteria and fungi superinfection. Prospective screening and early treatment may impact the acute and chronic sequelae of CRV in lung transplant recipients. 62 DIRECT FLUORESCENT ANTIBODY TESTING IN THE DIAGNOSIS OF INFLUENZAE INFECTION IN LUNG TRANSPLANT RECIPIENTS P.M. Hopkins, St. Vincent’s Hospital, Sydney, Australia Introduction: Rapid and reliable diagnosis of respiratory viral infections (RVI) in lung transplant recipients is essential in order to differentiate these from acute rejection or CMV infection which may have overlapping clinical manifestations. Traditional techniques of serology and viral culture are limited by delay in diagnosis and lack of antibody response. Aim: To examine the clinical utility of direct fluorescent antibody (DFA) testing (cost $25 AUD) in lung transplant patients with suspected RVI who presented from August-September 2000. Methods: Nasopharyngeal and throat (NPT) swabs were undertaken to sample epithelial cells followed by the application of monoclonal antibody to adenovirus, RSV, parainfluenza 1-3 and influenza A,B. The Bartels Respiratory Kit was used with all specimens sent to a reference laboratory for MDCK shell culture. Results: 7 of 17 subjects tested positive for influenza - 6 DFA positive (2 of these culture negative) and 1 DFA negative but culture positive. Of influenza subjects (6 type A, 1 B) the average age was 40.5 years, time post-transplantation 36 months, duration of illness 4 days, percentage decline in lung function 26% or absolute volume 510 ml and 6 of 7 patients were hospitalised. All results were available within 24 hours. Conclusions: 1. DFA of a NPT swab is a rapid cost effective non-invasive test of high sensitivity compared with culture in the

diagnosis of influenza infection 2. Routine viral culture of specimens may not be necessary after an initial positive DFA 3. Influenza A may produce significant clinical manifestations in LT recipients and occur in solated mini-epidemics late in the winter season 4. Negative viral culture may reflect in-vitro viral instability or suboptimal specimen handling. 63 TREATMENT OF RESPIRATORY SYNCYTIAL VIRAL AND PARAINFLUENZA LOWER RESPIRATORY TRACT INFECTION IN LUNG TRANSPLANT PATIENTS T.N. Hodges, F.P. Torres, M.R. Zamora, University of Colorado Health Sciences Center, Denver, CO, USA Lower respiratory infections (LRI) due to paramyxoviruses (PMV), respiratory syncytial virus (RSV) and parainfluenza (PIV), are associated with graft dysfunction and mortality following lung transplantation (LTx). RSV hyperimmune globulin (RSVIG), used for prevention and treatment of severe RSV infections may contain high titers against other PMV. We retrospectively reviewed our experience with PMV LRI and therapy with nebulized ribavirin (RV) and RSVIG to determine if this approach attenuates the effects of PMV LRI. From Feb 1992 to Oct 2000 34 episodes of PMV LRI (17 RSV and 17 PIV) in 28 pts were confirmed by direct fluorescent antibody and/or rapid shell vial culture of bronchoalveolar lavage. Onset was seasonal (Sept to May) occurring 511⫹182d post-LTx (range 16-2056). PMV LRI was not related to indication for LTx, recipient age or augmented immunosuppression. Six pts were treated with bronchodilators and steroids (group 1); 18 pts were treated with RV 2gms tid x 5d and RSVIG .75-1.5 gms/kg Ivx1 (Group 2). Solumedrol 5-10mg/kgx3d was given for biopsy proven acute rejection (AR) or clinical bronchiolitis. Follow-up has been 1295⫹/-506d (range 517-2107d) and 683⫹/-275d (range 547697d) for grps 1 and 2, respectively. No deaths occurred in either group. Ten episodes of AR occurred in grp 1, 10 episodes in grp 2 within 90d post-viral infection. Bronchiolitis obliterans syndrome (BOS) occurred in 6/6 pts in grp 1 (onset 142⫹/-105d) vs 1/18 pts in grp 2 (onset 119d). Four pts with prior BOS were excluded. Viral clearance was documents at end of treatment in group 2 pts. No adverse events were attributable to either drug. Combination therapy with aerosolized RV and RSVIG and appears to prevent the progression to bronchiolitis obliterans syndrome in symptomatic PMV LRI in lung transplant patients. 64 INCIDENCE OF BRONCHIOLITIS OBLITERANS SYNDROME UNAFFECTED BY ABSENCE OF CYTOMEGALOVIRUS H. Luckraz, L.D. Sharples, K. McNeil, J. Wallwork, Papworth Hospital NHS Trust, Cambridge, United Kingdom Background: Previously, we reported that prophylaxis against cytomegalovirus (CMV) infection did not influence the incidence of bronchiolitis obliterans syndrome (BOS) at 2 years. The effect of CMV presence without infection, on BOS is still not well understood. Moreover, the incidence and risk factors for BOS in CMV negative matched lung transplants has not been described. Aim: To determine the incidence of BOS in lung transplant patients with CMV negative (-) donors (D) and recipients (R) and evaluate the risk factors that predispose to BOS in this subgroup.

The Journal of Heart and Lung Transplantation Volume 20, Number 2 Method and Results: A retrospective study of data from the transplant database of the centre was carried out. All single lung (SL), double lung (DL) and heart-lung block (HL) transplant patients who survived over 2 years post transplant were included in the study group. They were grouped as follows: A ⫽ D-/R(n⫽102), B ⫽ D-/R⫹ (n⫽70), C ⫽ D⫹/R- (n⫽33) and E ⫽ D⫹/R⫹ (n⫽92). The respective incidence of BOS in the different groups was 43.1%, 45.7%, 51.5% and 47.8% (p⫽0.32). The 3-year BOS free survival was 65%, 56%, 58% and 67% respectively (p⬎0.05). In group A, the significant risk factors for developing BOS were three or more episodes of acute rejection (p⫽0.02) and non-CMV pulmonary infection (p⫽0.03). The mean number of acute rejection episodes per 100 patients days within the first six months were 1.28 (group A), 1.06 (group B), 0.50 (group C) and 1.11 (group E) [p⬍0.05]. Conclusion: Although CMV has been shown to be a risk factor for BOS, its absence did not preclude lung transplant patients from developing BOS. Moreover, absence of CMV was associated with an increase in the number of acute rejection episodes within the first transplant year. However, this could be accounted for by changes in frequency of acute rejection over time. Moreover, this may also reflect the non-uniformity of the pathological processes that are grouped as BOS. 65 BRONCHIOLITIS OBLITERANS WITH ORGANIZING PNEUMONIA: POSSIBLE ASSOCIATION WITH HUMAN HERPES VIRUS-7 INFECTION AFTER LUNG TRANSPLANTATION D.J. Ross1, R.C. Chan2, B. Kubak1, A. Ardehali1, H. Laks1, W.S. Nichols2, 1University of California at Los Angeles, Los Angeles, CA; 2Cedars-Sinai Medical Center, Los Angeles, CA, USA INTRODUCTION: The clinical significance of ‘atypical’ respiratory infections and their potential role in allograft dysfunction and inflammation is unclear after lung transplantation [LT]. Using polymerase chain reaction techniques, we analyzed for DNA of Chlamydia pneumoniae [CP] and human herpesvirus types 6 and 7 [HHV-6, HHV-7] in 53 serial BAL specimens with concurrent histopathology from 19 LT recipients. RESULTS: Overall, CP was detected in 7.5%, HHV-6 in 9.4%, and HHV-7 in 36.2% of specimens. Coinfection with cytomegalovirus was only sporadically observed. When analyzing the histologic findings on transbronchoscopic biopsies, ‘diffuse alveolar damage’ and ‘acute cellular rejection’ only rarely were associated with these atypical infections. In contrast, all seven episodes of ‘bronchiolitis obliterans with organizing pneumonia’ [BOOP-like reaction] were associated with DNA for HHV-7. These episodes were detected 1.6⫾0.4 months after LT, subsequent to cytolytic induction immunosuppression, and despite patients receiving herpesvirus chemoprophylaxis. CONCLUSION: Although we cannot conclusively link causally the presence of HHV-7 with these BOOP-like reactions after LT, we believe that further evidence should be explored regarding a putative role of HHV-7 in lung allograft dysfunction. 66 CHLAMYDIA PNEUMONIAE IS ASSOCIATED WITH GRAFT DYSFUNCTION AFTER LUNG TRANSPLANTATION A.R. Glanville, St Vincent’s Hospital, Sydney, Australia

Abstracts

171

Background: Chlamydia pneumoniae is established as a frequent cause of both upper and lower respiratory tract infection and has been implicated as a cofactor in asthma, chronic airflow limitation and atherosclerosis. Postoperative pneumonia and late inflammatory airway disease are important causes of morbidity and mortality after lung transplantation (LTX). Aim: To analyse the putative role of C.pneumoniae as a pulmonary pathogen after LTX. Methods: 50 LTX recipients underwent bronchoscopy with bronchoalveolar lavage (BAL) ⫾ transbronchial lung biopsy for surveillance of rejection/infection or where clinically mandated. A total 130 BAL samples were centrifuged and nested PCR performed retrospectively on the cell pellet. Results: BAL was PCR positive for C.pneumoniae in 19 patients (35%); 3 had repeated positive BAL samples, all of whom died of airway disease within the first postoperative year. C.pneumoniae was detected in BAL in 8/22 (36%) patients studied within 2 days of LTX but cleared from BAL within 4 weeks. 10 patients had C.pneumoniae ⬎1month post transplant, 5/10 had acute rejection and 4/10 progressive loss of graft function with Bronchiolitis Obliterans Syndrome (BOS). Conclusion: Our data support the notion that C.pneumoniae may be donor acquired. Persistent infection (whether de novo or reactivation) appears deleterious to graft function and is associated with both rejection and airway disease (BOS). (Funded in part by a Research Grant from Aventis Pharma.) 67 ENDOTHELIAL-CELL SELECTIVE CTL ARISE FROM LIMITED PRECURSOR SUBSETS OF ALLOREACTIVE CD8ⴙ T CELLS AND SHOW REDUCED CLONAL EXPANSION T.J. Dengler1, D.R. Johnson2, J. Pober2, 1Medinische Universitaetsklinik, Heidelberg, Germany; 2BCMM, New Haven, CT, USA Endothelial cell (EC)-selective cytotoxic T lymphocytes (CTL) may mediate alloimmune vascular injury. In a coculture system of human CD8⫹ T cells EC cause alloactivation of memory CD8⫹ T cells, which differentiate into EC-selective CTL that retain high surface expression of the early activation markers CD69, CD25 and CD62L. Following stimulation with corresponding B lymphoblastoid cells (BLC), CTL are generated from naive and memory CD8⫹ T cells, displaying a more mature phenotype (low CD69, CD25, and CD62L). We now show that the numbers of alloreactive CTL following stimulation with EC were always markedly lower than in BLC-stimulated cultures, accounting mainly for the reduction of measurable cytotoxicity in EC-activated microcultures. Using a newly developed method of limiting dilution analysis based on CFSE labeling, precursor frequencies for EC-stimulated CTL were shown to be 5 to 40-fold (mean: 7.5-fold) lower compared to BLC-stimulated CTL (p ⬍ 0.01). The average number of CTL in single precursor cultures (clonal expansion) were significantly smaller in cultures stimulated with EC, primarily due to the occurrence of some very large clone sizes exclusively with BLC stimulation. The intracellular expression of interferon-␥ in CTL arising from either type of stimulation was comparable, but EC-selective CTL displayed significantly lower intracellular perforin levels. Cyclosporine inhibited CTL expansion to a similar degree in both EC- and BLCstimulated cultures, but did not affect the phenotype of emerging CTL. Regulatory or suppressor CD8 cells could not be demon-