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Primary human herpesvirus 6 infection in liver transplant recipients
Primary human herpesvirus 6 infection in liver transplant recipients Tetsushi Yoshikawa, MD, Masaru Ihira, PhD, Kyoko Suzuki, MD, Sadao Suga, MD, Yoshizo Asano, MD, Katsuhiro Asonuma, MD, Koichi Tanaka, MD, and Yukihiro Nishiyama, MD We detected primary human herpesvirus 6 (HHV-6) infection in 5 infants who received living related liver transplantation from their HHV-6 seropositive mothers. Primary HHV-6 infection was confirmed by demonstrating the seroconversion of HHV-6 antibodies with an immunofluorescence assay, by the isolation of the virus, or both. Seroconversion of HHV-6 immunoglobulin G antibody was demonstrated in all 5 recipients. HHV-6 was isolated from 3 of the 5 recipients between 2 and 3 weeks after transplantation. Moreover, the virus genome was detected in plasma by polymerase chain reaction in 4 of the 5 recipients during the same period. Although the 5 recipients had pyrexia at the time of primary HHV-6 infection, none of the recipients had a skin rash after defervescence. Clinical symptoms disappeared without specific antiviral treatment in all but 1 of the recipients. (J Pediatr 2001;138:921-5)
Human herpesvirus 6 was discovered as a member of the human herpesvirus family in 1986.1 Primary infection with HHV-6 variant B causes exanthem subitum,2,3 which is a common febrile disease of infancy. In most children primary HHV-6 infection occurs between 6 months and 2 years of age.4,5 It has been reported that primary HHV-6 infection can cause severe manifestations6-9 including fatalities.10-13 However, it is thought that
the clinical features of primary infection of the virus in immunocompetent infants are generally benign and selflimited.14 In contrast to that in immunocompetent hosts, primary virus infection in an immunocompromised host generally is severe or fatal. Moreover, clinical features of primary cytomegalovirus infection in transplant recipients are generally more severe than those of reactivation or reinfection of the virus. Primary HHV-6 in-
From the Laboratory of Virology, Research Institute for Disease Mechanism and Control, Nagoya University School of Medicine, Nagoya, Aichi, Japan; the Department of Pediatrics, Fujita Health University School of Medicine, Toyoake, Aichi, Japan; and the Department of Transplantation and Immunology, Kyoto University School of Medicine, Kyoto, Japan.
Supported in part by grants from Fujita Health University, a grant from Japan Society for the Promotion of Science (JSPS-RFTF97L00703), and also by a Grant-in-Aid for Scientific Research, the Ministry of Education, Science and Culture, Japan. Submitted for publication July 19, 2000; revision received Oct 13, 2000; accepted Dec 4, 2000. Reprint requests: Tetsushi Yoshikawa, MD, Laboratory of Virology, Research Institute for Disease Mechanism and Control, Nagoya University School of Medicine, Tsurumai-cho, Showaku, Nagoya, 4668550 Japan. Copyright © 2001 by Mosby, Inc. 0022-3476/2001/$35.00 + 0 9/22/113622 doi:10.1067/mpd.2001.113622
fection has been reported in immunocompromised infants.15,16 Recently, we analyzed HHV-6 infection in a large number of recipients after living related liver transplantation and reported the incidence, time course, and clinical features of the virus infection.17 There were 5 recipients with primary HHV-6 infection in the subjects enrolled in the study. Here, we focus on the clinical features of the 5 infants with primary HHV-6 infection after liver transplantation. All 5 recipients had fever without rash at the time of the virus infection, and the symptom disappeared without specific antiviral treatment in 4 of the 5 recipients. CMV Cytomegalovirus HHV-6 Human herpesvirus 6 PCR Polymerase chain reaction
METHODS Sample Preparation EDTA peripheral blood was collected from the donor-recipient pairs at the time of transplantation and fortnightly from the recipients for 2 months after transplantation. Peripheral blood mononuclear cells and plasma were separated by density-gradient centrifugation (Ficoll-Paque; Amersham Pharmacia Biotech). Peripheral blood mononuclear cells were dedicated to virus isolation, and plasma was stored at –20°C for serologic assay and DNA extraction at a later time.
Virologic Examinations of HHV-6 The procedures for isolation and identification of HHV-6 from periph921
YOSHIKAWA ET AL
THE JOURNAL OF PEDIATRICS JUNE 2001
Table. Summary of virologic findings and clinical features of the patients with primary HHV-6 infection and biliary atresia
Donor’s antibody titers
Days after operation
Isolation of HHV-6
HHV-6 PCR
7/M
64
7/F
128
7/F
32
8/F
256
9/F
128
0 14 28 0 14 42 0 14 28 42 0 14 21 28 42 0 14 28 42
— Yes — — — — — — — — — — Yes — — — Yes — —
— P P — — — — P — — — — P — — — P — —
Age (mo)/Sex
HHV-6 Antibody titers
Clinical remarks (days after operation)
IgG
IgM
Fever*
<8 8 64 <8 16 256 <8 8 8 32 <8 64 64 32 32 <8 32 128 128
<8 8 128 <8 <8 <8 <8 <8 8 8 <8 8 8 8 16 <8 <8 16 8
10-13
Treatments
9,10 21-24 5-12
GCV 9-15
16,17
15-18
Pulse therapy 15
Ig, Immunoglobulin; BA; biliary atresia, GCV; gancyclovir, P; positive. *>38.0°C and unknown cause.
eral blood mononuclear cells have been described elsewhere.3 HHV-6 isolation was confirmed by detection of specific immunofluorescence staining with monoclonal antibodies to HHV-6 (kindly provided by Dr T. Okuno, Department of Microbiology, Hyogo Collage of Medicine, Hyogo, Japan) in cultured cells. Antibody titers to HHV6 were measured by an indirect immunofluorescence assay, which has been described.4 A negative result was obtained if the titer was <1:8.
Extraction and Amplification of HHV-6 DNA From Plasma DNA was extracted from 200 µL of plasma with the use of a High Pure Viral Nucleic Acid Kit (Boeringer Mannheim) according to the manufacturer’s instructions. Nested polymerase chain reaction for HHV-6 DNA used 2 primer sets (A/C, HS6AE/HS6AF) as described previously.18 Aliquots of 922
TE buffer were processed as a negative control, and appropriate precautions were taken during sample preparation and performance of the PCR to avoid cross-contamination.
Case Reports and Results Five infants received living related liver transplantations from their mothers at Kyoto University Hospital. Patient characteristics are summarized in the Table. Immunosuppressive therapy was based on tacrolimus (FK506) and lowdose corticosteroid administration as described elsewhere.19 OKT-3 was not used in these recipients. As a prophylaxis for post-transplant infection, each recipient received several antimicrobial agents including antibiotics for 4 days after the operation, myconazole gel for 1 month after the operation, and trimethoprim-sulfamethoxiazole for 12 months after the operation. Acyclovir was also administered orally (10 mg/kg/d) for 6
months after the operation. Screening for the presence of the early antigen of CMV (with the HRP-C7 method) was used for the early detection of CMV antigenemia.20 This method detects the pp65 antigen of CMV in patients’ leukocytes. Gancyclovir treatment was started after positive results in the HRP-C7 test were obtained. The results of virologic examinations, plasma PCR, and clinical features of the recipients are summarized in the Table. All donor mothers were seropositive for HHV-6. All infants had fever, usually 1 to 2 weeks after transplantation; seroconversion to HHV-6 was documented. In addition, 3 children had virus isolated from blood, and 4 had positive PCR assays. One child received gancyclovir therapy because of persistent fever. One child had a rejection episode concurrent with fever. Although all recipients had fever during the time of primary
YOSHIKAWA ET AL
THE JOURNAL OF PEDIATRICS VOLUME 138, NUMBER 6 HHV-6 infection, none had skin rash. During the observation period, no recipient had CMV disease on the basis of antigenemia assay.
DISCUSSION According to epidemiologic analyses, primary HHV-6 infection occurs between 6 months and 2 years of age in most children.4,5 The 5 recipients described in this report were infants between 7 and 9 months of age. Seroconversion to HHV-6 after transplantation was observed in these recipients. Moreover, 3 of the 5 recipients had HHV-6 viremia, and in 4 of the 5 recipients active virus replication was indicated by the detection of the virus genome in plasma21 approximately 2 to 3 weeks after transplantation. These results indicate that primary HHV-6 infection occurred in these 5 recipients. It is thought that cell-mediated immunity plays an important role in controlling virus replication in the host. It is also well known that primary varicella zoster virus infection in immunocompromized children is severe and sometimes fatal. Ward et al22 described the first adult case of primary HHV-6 infection after liver transplantation, in which the patient had pyrexia, convulsion, and hepatitis. Moreover, Lau et al16 reported an infant with primary HHV-6 infection after bone marrow transplantation caused by bone marrow transfusion from a patient with exanthem subitum. The patient had fever, skin rash, hepatitis, and bone marrow suppression and was treated with gancyclovir because of severe marrow suppression. Although only case 3 in this report received gancyclovir to manage persistent fever, clinical symptoms disappeared without specific antiviral treatment in the other 4 cases. Moreover, we previously reported15 that an infant with acute lymphoblastic leukemia had pyrexia for 9 days as a result of primary HHV-6 infection, and that the symptoms were
tolerable and disappeared without specific antiviral treatment. These results suggest that primary HHV-6 infection in immunocompromised patients including organ transplant recipients is not always severe. However, the severity of clinical manifestations in such patients may vary depending on impairment of the host immunity. There are no reports of randomized clinical studies comparing antiviral agents; accumulating reports in vitro and in organ transplant recipients suggest efficacy of gancyclovir or foscarnet.23-28 The pathogenesis of skin eruption in exanthem subitum, a clinical feature of primary HHV-6 infection in immunocompetent infants, has not been elucidated. The frequency of the typical exanthem subitum in the patients with primary HHV-6 infection is >70% in Japan.14 It is almost comparable with that reported from Sweden29 but higher than that found in United States.30 Although the reason for this discrepancy is unknown, most Japanese children with primary HHV-6 infection have skin rash after subsidence of fever. All 5 infants in this report had pyrexia at the time of HHV-6 infection, without skin rash after the subsidence of fever. The infant with primary HHV-6 infection during an induction therapy for acute lymphoblastic leukemia also had fever without rash.15 These findings suggest that host immunity against HHV-6 may play an important role in the pathogenesis of skin eruption in exanthem subitum. In contrast to our cases, the infant reported by Lau et al16 had fever and skin rash 18 days after bone marrow transplantation. Moreover, the virus antigen was detected in a cell infiltrating into a skin biopsy specimen. It has been suggested that HHV-6 infection causes fever and skin rash, which is similar to acute graft versus host disease, approximately 2 to 4 weeks after bone marrow transplantation.31,32 Therefore the pathogenesis of skin eruption after bone marrow transplantation, which occurs at the time of HHV-6 infection,
may be different from that of skin eruptions observed in patients with exanthem subitum. HHV-6 infection can cause several complications after liver transplantation such as unexplained fever,17,33,34 encephalitis,23 bone marrow suppression,23 skin rash,23 hepatic dysfunction,35 and rejection.35,36 In addition to unexplained fever, case 5 had rejection confirmed by pathologic examination at the time of HHV-6 infection. Several reports have suggested that HHV-6 infection after liver transplantation is associated with graft rejection,35,36 and so the virus infection might be involved in the rejection in this case. Further studies including in vitro analysis are required to explore an association between HHV-6 infection and graft rejection. HHV-6 infection occurred at 2 to 3 weeks after transplantation in the 5 cases we have presented and in the patient reported by Ward et al.22 The incubation period of primary HHV-6 infection is approximately 2 weeks.37 All donors in this report had evidence of past infection with HHV-6. Taken together with these observations, it is likely that HHV-6 is transmitted by donor graft. It has been suggested that residual mononuclear cells latently infected with HHV-6 in donor liver graft may play an important role as a source of infection.38 Another possible route of the virus transmission is blood transfusion. Molecular epidemiologic analysis of the viruses obtained from donors and recipients will clarify epidemiology. Takeda Chemical Industries, Ltd, Osaka, Japan, kindly supplied recombinant human interleukin-2.
REFERENCES 1. Salahuddin SZ, Ablashi DV, Markham PD, Josephs SF, Sturzenegger S, Kaplan M, et al. Isolation of a new virus, HBLV, in patients with lymphoproliferative disorders. Science 1986;234:596-601. 923
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2. Yamanishi K, Okuno T, Shiraki K, Takahashi M, Kondo T, Asano Y, et al. Identification of human herpesvirus-6 as a causal agent for exanthem subitum. Lancet 1988;1:1065-7. 3. Asano Y, Yoshikawa T, Suga S, Yazaki T, Hata T, Nagai T, et al. Viremia and neutralizing antibody response in infants with exanthem subitum. J Pediatr 1989;114:535-9. 4. Yoshikawa T, Suga S, Asano Y, Yazaki T, Kodama H, Ozaki T. Distribution of antibodies to a causative agent of exanthem subitum (human herpesvirus-6) in healthy individuals. Pediatrics 1989; 84:675-7. 5. Okuno T, Takahashi K, Balachandra K, Shiraki K, Yamanishi K, Takahashi M, et al. Seroepidemiology of human herpesvirus 6 infection in normal children and adults. J Clin Microbiol 1989;27:651-3. 6. Yoshikawa T, Nakashima T, Suga S, Asano Y, Yazaki T, Kimura H, et al. Human herpesvirus-6 DNA in cerebrospinal fluid of a child with exanthem subitum and meningoencephalitis. Pediatrics 1992;89:888-90. 7. Suga S, Yoshikawa T, Asano Y, Kozawa T, Nakashima T, Kobayashi I, et al. Clinical and virological analyses of 21 infants with exanthem subitum (roseola infantum) and central nervous system complications. Ann Neurol 1993;33:597-603. 8. Asano Y, Yoshikawa T, Suga S, Hata T, Yamazaki T, Yazaki T. Simultaneous occurrence of human herpesvirus 6 infection and intussusception in three infants. Pediatr Infect Dis J 1991;10: 335-7. 9. Yoshikawa T, Asano Y, Kobayashi I, Nakashima T, Yazaki T. Exacerbation of idiopathic thrombocytopenic purpura by primary human herpesvirus 6 infection. Pediatr Infect Dis J 1993;12: 409-10. 10. Asano Y, Yoshikawa T, Suga S, Yazaki T, Kondo K, Yamanishi K. Fatal fulminant hepatitis in an infant with human herpesvirus-6 infection. Lancet 1990; 355:862-3. 11. Huang LM, Lee CY, Lin KH, Chuu WM, Lee PL, Chen RL, et al. Human herpesvirus-6 associated with fatal haemophagocytic syndrome. Lancet 1990;336:60-1. 12. Prezioso PJ, Cangiarella J, Lee M, Nuovo GJ, Borkowsky W, Orlow SJ, et al. Fatal disseminated infection with human herpesvirus-6. J Pediatr 1992; 120:921-3. 13. Asano Y, Yoshikawa T, Kajita Y, 924
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14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
Ogura R, Suga S, Yazaki T, et al. Fatal encephalitis/encephalopathy in primary human herpesvirus-6 infection. Arch Dis Child 1992;120:921-3. Asano Y, Yoshikawa T, Suga S, Kobayashi I, Nakashima T, Yazaki T, et al. Clinical features of infants with primary human herpesvirus 6 infection (exanthem subitum, roseola infantum). Pediatrics 1994;93:104-8. Yoshikawa T, Kobayashi I, Asano Y, Nakashima T, Yazaki T, Kojima S, et al. Clinical features of primary human herpesvirus-6 infection in an infant with acute lymphoblastic leukemia. Am J Pediatr Hematol Oncol 1993; 15:424-6. Lau YL, Peiris M, Chan GCF, Chan ACL, Chiu D, Ha SY. Primary human herpesvirus 6 infection transmitted from donor to recipient through bone marrow infusion. Bone Marrow Transplant 1998;21:1063-6. Yoshikawa T, Ihira M, Suzuki K, Suga S, Iida K, Saito Y, et al. Human herpesvirus 6 infection after living related liver transplantation. J Med Virol 2000;62:52-9. Suga S, Yoshikawa T, Kajita Y, Ozaki T, Asano Y. Prospective study of persistence and excretion of human herpesvirus 6 in patients with exanthem subitum and their parents. Pediatrics 1998;102:900-4. The US multicenter FK506 liver study group. A comparison of tacrolimus (FK506) and cyclosporin for immunosuppression in liver transplantation. N Engl J Med 1994;331:1110-5. Eizuru Y, Minematsu T, Minamishima Y, Ebihara K, Takahashi K, Tamura K, et al. Rapid diagnosis of cytomegalovirus infection by direct immunoperoxidase staining with human monoclonal antibody against an immediate early antigen. Microbiol Immunol 1991;35:1015-22. Secchiero P, Carrigan DR, Asano Y, Benedetti L, Crowley RW, Komaroff AL, et al. Detection of human herpesvirus 6 in plasma of children with primary infection and immunosuppressed patients by polymerase chain reaction. J Infect Dis 1995;171:27380. Ward KN, Gray JJ, Efstathiou S. Brief report: primary human herpesvirus 6 infection in a patient following liver transplantation from a seropositive donor. J Med Virol 1989; 28:69-72. Singh N, Carrigan DR, Gayowski T, Singh J, Marino IR. Variant B human
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
herpesvirus 6 associated febrile dermatosis with thrombocytopenia and encephalopathy in a liver transplant recipient. Transplantation 1995;60: 1355-7. Rosenfeld CS, Rybka WB, Weinbaum D, Carrigan DR, Knox KK, Andrews DF, et al. Late graft failure due to dual bone marrow infection with variant A and B of human herpesvirus-6. Exp Hematol 1995;23:626-9. Mookerjee BP, Vogelsang G. Human herpesvirus-6 encephalitis after bone marrow transplantation: successful treatment with ganciclovir. Bone Marrow Transplant 1997;20:905-6. Cole PD, Stiles J, Boulad F, Small TN, O’Reilly RJ, George D, et al. Successful treatment of human herpesvirus 6 encephalitis in a bone marrow transplant recipient. Clin Infect Dis 1998;27:653-4. Rieux C, Gautheret-Dejean A, Challine-Lehmann D, Kirch C, Agut H, Vernant JP. Human herpesvirus-6 meningoencephalitis in a recipient of an unrelated allogeneic bone marrow transplantation. Transplantation 1998; 65:1408-11. Burns WH, Sanford GR. Susceptibility of human herpesvirus 6 to antivirals in vitro. J Infect Dis 1990;162:634-7. Linnavouri K, Peltola H, Hovi T. Serology versus clinical signs or symptoms and main laboratory findings in the diagnosis of exanthem subitum (roseola infantum). Pediatrics 1992;89: 103-6. Pruksananonda P, Hall CB, Insel RA, McIntyre K, Pellet PE, Long CE, et al. Primary human herpesvirus 6 infection in young children. N Engl J Med 1992;326:1445-50. Asano Y, Yoshikawa T, Suga S, Nakashima T, Yazaki T, Fukuda M, et al. Reactivation of herpesvirus type 6 in children receiving bone marrow transplants for leukemia. N Engl J Med 1991;324:634-5. Yoshikawa T, Suga S, Asano Y, Nakashima T, Yazaki T, Sobue R, et al. Human herpesvirus-6 infection in bone marrow transplantation. Blood 1991;78:1381-4. Yoshikawa T, Ihira M, Furukawa H, Suga S, Asonuma K, Tanaka K, et al. Four cases of human herpesvirus 6 variant B infection after pediatric liver transplantation. Transplantation 1998; 65:1266-9. Chang FY, Singh N, Gayowski T, Wagener MM, Marino IR. Fever in liver
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THE JOURNAL OF PEDIATRICS VOLUME 138, NUMBER 6 transplant recipients: changing spectrum of etiologic agents. Clin Infect Dis 1998;26:59-32. 35. Lautenschlager I, Hockerstedt K, Linnavouri K, Taskinen E. Human herpesvirus infection after liver transplantation. Clin Infect Dis 1998;26:702-7.
36. Lautenschlager I, Hockerstedt K, Linnavouri K, Taskinen E. Human herpesvirus 6 infection increase adhesion molecule expression in liver allografts. Transplant Proc 1998;31:479-80. 37. Kemp CH, Shaw EB, Jackson JR, Silver HK. Studies on etiology of ex-
anthem subitum (roseola infantum). J Pediatr 1950;37:561-8. 38. Yoshikawa T, Suzuki K, Ihira M, Furukawa H, Suga S, Iwasaki T, et al. Human herpesvirus 6 latently infects mononuclear cells but not liver tissue. J Clin Pathol 1999;52:65-7.
50 Years Ago in The Journal of Pediatrics THE EFFECT OF ALLERGY MANAGEMENT ON GROWTH AND DEVELOPMENT OF ALLERGIC CHILDREN Welsh JB. J Pediatr 1951;38:571-5 In this article, written 5 decades ago, Welsh made an important observation that continues to be of great interest to those of us who treat children with allergies today. He demonstrated that children with allergic disease tend to have poor growth, which improves with treatment of their allergies. His study was based on an initial report by Cohen and Abrams,1 who demonstrated that growth delay in allergic children was 2.5 times higher than expected. In that report from Cleveland, two case histories were presented, which indicated improvement in growth when the patient’s allergic symptoms were treated. Welsh examined 34 children with a variety of allergic disorders, including seasonal and perennial allergic rhinitis and allergic asthma. They were followed up to determine whether initiation of treatment would improve their growth parameters. Patients were counseled on allergen avoidance or given specific immune desensitization after screening with a panel of skin tests with 240 antigens. Growth progress was determined in the children after initiation of therapy, based on weight and height compared with age and developmental level (Wetzel grids). The key finding of Welsh’s study was that appropriate management of the allergic diseases in many of these children normalized their growth, eliminating the expected growth failure increase described by Cohen and Abrams.1 It is interesting that the allergy testing techniques described by Welsh vary little from what is done in allergy clinics today and have changed little since they were described by Blackley in 1865 and Schloss in 1912. Also, although current pharmacologic options for the treatment of allergies are diverse, allergen avoidance and specific immune desensitization remain two of the pillars of allergy control 50 years after the publication of this work. Today, we continue to struggle with issues of growth in children with allergic disorders. Authors of recent published reports have reviewed growth in children treated with corticosteroids for allergic symptoms; these reports demonstrate our ongoing need to understand how allergic disease, and its treatment, affect the growth of the patients for whom we provide care. Dr Welsh closes with an insightful comment on the state of asthma management that is as true now as when written: “Although present-day allergy management is not without limitations, most authorities agree that the increasing progress of allergic manifestations can be arrested and severe asthma definitely minimized or eliminated in 75 to 85 percent of cases. In this way, certain predisposing factors to chronic respiratory infection or malformation may be minimized in susceptible individuals.” Michael O. Daines, MD Gurjit K. Khurana Hershey, MD, PhD Children’s Hospital Medical Center Division of Pulmonary Medicine, Allergy, and Clinical Immunology Cincinnati, OH 45229-3039 9/37/115892 doi:10.1067/mpd.2001.115892
REFERENCE 1. Cohen MB, Abrams JE. Growth patterns of allergic children. J Allergy 1948;19:165.
925
Human herpesvirus 6 was discovered as a member of the human herpesvirus family in 1986.1 Primary infection with HHV-6 variant B causes exanthem subitum,2,3 which is a common febrile disease of infancy. In most children primary HHV-6 infection occurs between 6 months and 2 years of age.4,5 It has been reported that primary HHV-6 infection can cause severe manifestations6-9 including fatalities.10-13 However, it is thought that
the clinical features of primary infection of the virus in immunocompetent infants are generally benign and selflimited.14 In contrast to that in immunocompetent hosts, primary virus infection in an immunocompromised host generally is severe or fatal. Moreover, clinical features of primary cytomegalovirus infection in transplant recipients are generally more severe than those of reactivation or reinfection of the virus. Primary HHV-6 in-
From the Laboratory of Virology, Research Institute for Disease Mechanism and Control, Nagoya University School of Medicine, Nagoya, Aichi, Japan; the Department of Pediatrics, Fujita Health University School of Medicine, Toyoake, Aichi, Japan; and the Department of Transplantation and Immunology, Kyoto University School of Medicine, Kyoto, Japan.
Supported in part by grants from Fujita Health University, a grant from Japan Society for the Promotion of Science (JSPS-RFTF97L00703), and also by a Grant-in-Aid for Scientific Research, the Ministry of Education, Science and Culture, Japan. Submitted for publication July 19, 2000; revision received Oct 13, 2000; accepted Dec 4, 2000. Reprint requests: Tetsushi Yoshikawa, MD, Laboratory of Virology, Research Institute for Disease Mechanism and Control, Nagoya University School of Medicine, Tsurumai-cho, Showaku, Nagoya, 4668550 Japan. Copyright © 2001 by Mosby, Inc. 0022-3476/2001/$35.00 + 0 9/22/113622 doi:10.1067/mpd.2001.113622
fection has been reported in immunocompromised infants.15,16 Recently, we analyzed HHV-6 infection in a large number of recipients after living related liver transplantation and reported the incidence, time course, and clinical features of the virus infection.17 There were 5 recipients with primary HHV-6 infection in the subjects enrolled in the study. Here, we focus on the clinical features of the 5 infants with primary HHV-6 infection after liver transplantation. All 5 recipients had fever without rash at the time of the virus infection, and the symptom disappeared without specific antiviral treatment in 4 of the 5 recipients. CMV Cytomegalovirus HHV-6 Human herpesvirus 6 PCR Polymerase chain reaction
METHODS Sample Preparation EDTA peripheral blood was collected from the donor-recipient pairs at the time of transplantation and fortnightly from the recipients for 2 months after transplantation. Peripheral blood mononuclear cells and plasma were separated by density-gradient centrifugation (Ficoll-Paque; Amersham Pharmacia Biotech). Peripheral blood mononuclear cells were dedicated to virus isolation, and plasma was stored at –20°C for serologic assay and DNA extraction at a later time.
Virologic Examinations of HHV-6 The procedures for isolation and identification of HHV-6 from periph921
YOSHIKAWA ET AL
THE JOURNAL OF PEDIATRICS JUNE 2001
Table. Summary of virologic findings and clinical features of the patients with primary HHV-6 infection and biliary atresia
Donor’s antibody titers
Days after operation
Isolation of HHV-6
HHV-6 PCR
7/M
64
7/F
128
7/F
32
8/F
256
9/F
128
0 14 28 0 14 42 0 14 28 42 0 14 21 28 42 0 14 28 42
— Yes — — — — — — — — — — Yes — — — Yes — —
— P P — — — — P — — — — P — — — P — —
Age (mo)/Sex
HHV-6 Antibody titers
Clinical remarks (days after operation)
IgG
IgM
Fever*
<8 8 64 <8 16 256 <8 8 8 32 <8 64 64 32 32 <8 32 128 128
<8 8 128 <8 <8 <8 <8 <8 8 8 <8 8 8 8 16 <8 <8 16 8
10-13
Treatments
9,10 21-24 5-12
GCV 9-15
16,17
15-18
Pulse therapy 15
Ig, Immunoglobulin; BA; biliary atresia, GCV; gancyclovir, P; positive. *>38.0°C and unknown cause.
eral blood mononuclear cells have been described elsewhere.3 HHV-6 isolation was confirmed by detection of specific immunofluorescence staining with monoclonal antibodies to HHV-6 (kindly provided by Dr T. Okuno, Department of Microbiology, Hyogo Collage of Medicine, Hyogo, Japan) in cultured cells. Antibody titers to HHV6 were measured by an indirect immunofluorescence assay, which has been described.4 A negative result was obtained if the titer was <1:8.
Extraction and Amplification of HHV-6 DNA From Plasma DNA was extracted from 200 µL of plasma with the use of a High Pure Viral Nucleic Acid Kit (Boeringer Mannheim) according to the manufacturer’s instructions. Nested polymerase chain reaction for HHV-6 DNA used 2 primer sets (A/C, HS6AE/HS6AF) as described previously.18 Aliquots of 922
TE buffer were processed as a negative control, and appropriate precautions were taken during sample preparation and performance of the PCR to avoid cross-contamination.
Case Reports and Results Five infants received living related liver transplantations from their mothers at Kyoto University Hospital. Patient characteristics are summarized in the Table. Immunosuppressive therapy was based on tacrolimus (FK506) and lowdose corticosteroid administration as described elsewhere.19 OKT-3 was not used in these recipients. As a prophylaxis for post-transplant infection, each recipient received several antimicrobial agents including antibiotics for 4 days after the operation, myconazole gel for 1 month after the operation, and trimethoprim-sulfamethoxiazole for 12 months after the operation. Acyclovir was also administered orally (10 mg/kg/d) for 6
months after the operation. Screening for the presence of the early antigen of CMV (with the HRP-C7 method) was used for the early detection of CMV antigenemia.20 This method detects the pp65 antigen of CMV in patients’ leukocytes. Gancyclovir treatment was started after positive results in the HRP-C7 test were obtained. The results of virologic examinations, plasma PCR, and clinical features of the recipients are summarized in the Table. All donor mothers were seropositive for HHV-6. All infants had fever, usually 1 to 2 weeks after transplantation; seroconversion to HHV-6 was documented. In addition, 3 children had virus isolated from blood, and 4 had positive PCR assays. One child received gancyclovir therapy because of persistent fever. One child had a rejection episode concurrent with fever. Although all recipients had fever during the time of primary
YOSHIKAWA ET AL
THE JOURNAL OF PEDIATRICS VOLUME 138, NUMBER 6 HHV-6 infection, none had skin rash. During the observation period, no recipient had CMV disease on the basis of antigenemia assay.
DISCUSSION According to epidemiologic analyses, primary HHV-6 infection occurs between 6 months and 2 years of age in most children.4,5 The 5 recipients described in this report were infants between 7 and 9 months of age. Seroconversion to HHV-6 after transplantation was observed in these recipients. Moreover, 3 of the 5 recipients had HHV-6 viremia, and in 4 of the 5 recipients active virus replication was indicated by the detection of the virus genome in plasma21 approximately 2 to 3 weeks after transplantation. These results indicate that primary HHV-6 infection occurred in these 5 recipients. It is thought that cell-mediated immunity plays an important role in controlling virus replication in the host. It is also well known that primary varicella zoster virus infection in immunocompromized children is severe and sometimes fatal. Ward et al22 described the first adult case of primary HHV-6 infection after liver transplantation, in which the patient had pyrexia, convulsion, and hepatitis. Moreover, Lau et al16 reported an infant with primary HHV-6 infection after bone marrow transplantation caused by bone marrow transfusion from a patient with exanthem subitum. The patient had fever, skin rash, hepatitis, and bone marrow suppression and was treated with gancyclovir because of severe marrow suppression. Although only case 3 in this report received gancyclovir to manage persistent fever, clinical symptoms disappeared without specific antiviral treatment in the other 4 cases. Moreover, we previously reported15 that an infant with acute lymphoblastic leukemia had pyrexia for 9 days as a result of primary HHV-6 infection, and that the symptoms were
tolerable and disappeared without specific antiviral treatment. These results suggest that primary HHV-6 infection in immunocompromised patients including organ transplant recipients is not always severe. However, the severity of clinical manifestations in such patients may vary depending on impairment of the host immunity. There are no reports of randomized clinical studies comparing antiviral agents; accumulating reports in vitro and in organ transplant recipients suggest efficacy of gancyclovir or foscarnet.23-28 The pathogenesis of skin eruption in exanthem subitum, a clinical feature of primary HHV-6 infection in immunocompetent infants, has not been elucidated. The frequency of the typical exanthem subitum in the patients with primary HHV-6 infection is >70% in Japan.14 It is almost comparable with that reported from Sweden29 but higher than that found in United States.30 Although the reason for this discrepancy is unknown, most Japanese children with primary HHV-6 infection have skin rash after subsidence of fever. All 5 infants in this report had pyrexia at the time of HHV-6 infection, without skin rash after the subsidence of fever. The infant with primary HHV-6 infection during an induction therapy for acute lymphoblastic leukemia also had fever without rash.15 These findings suggest that host immunity against HHV-6 may play an important role in the pathogenesis of skin eruption in exanthem subitum. In contrast to our cases, the infant reported by Lau et al16 had fever and skin rash 18 days after bone marrow transplantation. Moreover, the virus antigen was detected in a cell infiltrating into a skin biopsy specimen. It has been suggested that HHV-6 infection causes fever and skin rash, which is similar to acute graft versus host disease, approximately 2 to 4 weeks after bone marrow transplantation.31,32 Therefore the pathogenesis of skin eruption after bone marrow transplantation, which occurs at the time of HHV-6 infection,
may be different from that of skin eruptions observed in patients with exanthem subitum. HHV-6 infection can cause several complications after liver transplantation such as unexplained fever,17,33,34 encephalitis,23 bone marrow suppression,23 skin rash,23 hepatic dysfunction,35 and rejection.35,36 In addition to unexplained fever, case 5 had rejection confirmed by pathologic examination at the time of HHV-6 infection. Several reports have suggested that HHV-6 infection after liver transplantation is associated with graft rejection,35,36 and so the virus infection might be involved in the rejection in this case. Further studies including in vitro analysis are required to explore an association between HHV-6 infection and graft rejection. HHV-6 infection occurred at 2 to 3 weeks after transplantation in the 5 cases we have presented and in the patient reported by Ward et al.22 The incubation period of primary HHV-6 infection is approximately 2 weeks.37 All donors in this report had evidence of past infection with HHV-6. Taken together with these observations, it is likely that HHV-6 is transmitted by donor graft. It has been suggested that residual mononuclear cells latently infected with HHV-6 in donor liver graft may play an important role as a source of infection.38 Another possible route of the virus transmission is blood transfusion. Molecular epidemiologic analysis of the viruses obtained from donors and recipients will clarify epidemiology. Takeda Chemical Industries, Ltd, Osaka, Japan, kindly supplied recombinant human interleukin-2.
REFERENCES 1. Salahuddin SZ, Ablashi DV, Markham PD, Josephs SF, Sturzenegger S, Kaplan M, et al. Isolation of a new virus, HBLV, in patients with lymphoproliferative disorders. Science 1986;234:596-601. 923
YOSHIKAWA ET AL
2. Yamanishi K, Okuno T, Shiraki K, Takahashi M, Kondo T, Asano Y, et al. Identification of human herpesvirus-6 as a causal agent for exanthem subitum. Lancet 1988;1:1065-7. 3. Asano Y, Yoshikawa T, Suga S, Yazaki T, Hata T, Nagai T, et al. Viremia and neutralizing antibody response in infants with exanthem subitum. J Pediatr 1989;114:535-9. 4. Yoshikawa T, Suga S, Asano Y, Yazaki T, Kodama H, Ozaki T. Distribution of antibodies to a causative agent of exanthem subitum (human herpesvirus-6) in healthy individuals. Pediatrics 1989; 84:675-7. 5. Okuno T, Takahashi K, Balachandra K, Shiraki K, Yamanishi K, Takahashi M, et al. Seroepidemiology of human herpesvirus 6 infection in normal children and adults. J Clin Microbiol 1989;27:651-3. 6. Yoshikawa T, Nakashima T, Suga S, Asano Y, Yazaki T, Kimura H, et al. Human herpesvirus-6 DNA in cerebrospinal fluid of a child with exanthem subitum and meningoencephalitis. Pediatrics 1992;89:888-90. 7. Suga S, Yoshikawa T, Asano Y, Kozawa T, Nakashima T, Kobayashi I, et al. Clinical and virological analyses of 21 infants with exanthem subitum (roseola infantum) and central nervous system complications. Ann Neurol 1993;33:597-603. 8. Asano Y, Yoshikawa T, Suga S, Hata T, Yamazaki T, Yazaki T. Simultaneous occurrence of human herpesvirus 6 infection and intussusception in three infants. Pediatr Infect Dis J 1991;10: 335-7. 9. Yoshikawa T, Asano Y, Kobayashi I, Nakashima T, Yazaki T. Exacerbation of idiopathic thrombocytopenic purpura by primary human herpesvirus 6 infection. Pediatr Infect Dis J 1993;12: 409-10. 10. Asano Y, Yoshikawa T, Suga S, Yazaki T, Kondo K, Yamanishi K. Fatal fulminant hepatitis in an infant with human herpesvirus-6 infection. Lancet 1990; 355:862-3. 11. Huang LM, Lee CY, Lin KH, Chuu WM, Lee PL, Chen RL, et al. Human herpesvirus-6 associated with fatal haemophagocytic syndrome. Lancet 1990;336:60-1. 12. Prezioso PJ, Cangiarella J, Lee M, Nuovo GJ, Borkowsky W, Orlow SJ, et al. Fatal disseminated infection with human herpesvirus-6. J Pediatr 1992; 120:921-3. 13. Asano Y, Yoshikawa T, Kajita Y, 924
THE JOURNAL OF PEDIATRICS JUNE 2001
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
Ogura R, Suga S, Yazaki T, et al. Fatal encephalitis/encephalopathy in primary human herpesvirus-6 infection. Arch Dis Child 1992;120:921-3. Asano Y, Yoshikawa T, Suga S, Kobayashi I, Nakashima T, Yazaki T, et al. Clinical features of infants with primary human herpesvirus 6 infection (exanthem subitum, roseola infantum). Pediatrics 1994;93:104-8. Yoshikawa T, Kobayashi I, Asano Y, Nakashima T, Yazaki T, Kojima S, et al. Clinical features of primary human herpesvirus-6 infection in an infant with acute lymphoblastic leukemia. Am J Pediatr Hematol Oncol 1993; 15:424-6. Lau YL, Peiris M, Chan GCF, Chan ACL, Chiu D, Ha SY. Primary human herpesvirus 6 infection transmitted from donor to recipient through bone marrow infusion. Bone Marrow Transplant 1998;21:1063-6. Yoshikawa T, Ihira M, Suzuki K, Suga S, Iida K, Saito Y, et al. Human herpesvirus 6 infection after living related liver transplantation. J Med Virol 2000;62:52-9. Suga S, Yoshikawa T, Kajita Y, Ozaki T, Asano Y. Prospective study of persistence and excretion of human herpesvirus 6 in patients with exanthem subitum and their parents. Pediatrics 1998;102:900-4. The US multicenter FK506 liver study group. A comparison of tacrolimus (FK506) and cyclosporin for immunosuppression in liver transplantation. N Engl J Med 1994;331:1110-5. Eizuru Y, Minematsu T, Minamishima Y, Ebihara K, Takahashi K, Tamura K, et al. Rapid diagnosis of cytomegalovirus infection by direct immunoperoxidase staining with human monoclonal antibody against an immediate early antigen. Microbiol Immunol 1991;35:1015-22. Secchiero P, Carrigan DR, Asano Y, Benedetti L, Crowley RW, Komaroff AL, et al. Detection of human herpesvirus 6 in plasma of children with primary infection and immunosuppressed patients by polymerase chain reaction. J Infect Dis 1995;171:27380. Ward KN, Gray JJ, Efstathiou S. Brief report: primary human herpesvirus 6 infection in a patient following liver transplantation from a seropositive donor. J Med Virol 1989; 28:69-72. Singh N, Carrigan DR, Gayowski T, Singh J, Marino IR. Variant B human
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
herpesvirus 6 associated febrile dermatosis with thrombocytopenia and encephalopathy in a liver transplant recipient. Transplantation 1995;60: 1355-7. Rosenfeld CS, Rybka WB, Weinbaum D, Carrigan DR, Knox KK, Andrews DF, et al. Late graft failure due to dual bone marrow infection with variant A and B of human herpesvirus-6. Exp Hematol 1995;23:626-9. Mookerjee BP, Vogelsang G. Human herpesvirus-6 encephalitis after bone marrow transplantation: successful treatment with ganciclovir. Bone Marrow Transplant 1997;20:905-6. Cole PD, Stiles J, Boulad F, Small TN, O’Reilly RJ, George D, et al. Successful treatment of human herpesvirus 6 encephalitis in a bone marrow transplant recipient. Clin Infect Dis 1998;27:653-4. Rieux C, Gautheret-Dejean A, Challine-Lehmann D, Kirch C, Agut H, Vernant JP. Human herpesvirus-6 meningoencephalitis in a recipient of an unrelated allogeneic bone marrow transplantation. Transplantation 1998; 65:1408-11. Burns WH, Sanford GR. Susceptibility of human herpesvirus 6 to antivirals in vitro. J Infect Dis 1990;162:634-7. Linnavouri K, Peltola H, Hovi T. Serology versus clinical signs or symptoms and main laboratory findings in the diagnosis of exanthem subitum (roseola infantum). Pediatrics 1992;89: 103-6. Pruksananonda P, Hall CB, Insel RA, McIntyre K, Pellet PE, Long CE, et al. Primary human herpesvirus 6 infection in young children. N Engl J Med 1992;326:1445-50. Asano Y, Yoshikawa T, Suga S, Nakashima T, Yazaki T, Fukuda M, et al. Reactivation of herpesvirus type 6 in children receiving bone marrow transplants for leukemia. N Engl J Med 1991;324:634-5. Yoshikawa T, Suga S, Asano Y, Nakashima T, Yazaki T, Sobue R, et al. Human herpesvirus-6 infection in bone marrow transplantation. Blood 1991;78:1381-4. Yoshikawa T, Ihira M, Furukawa H, Suga S, Asonuma K, Tanaka K, et al. Four cases of human herpesvirus 6 variant B infection after pediatric liver transplantation. Transplantation 1998; 65:1266-9. Chang FY, Singh N, Gayowski T, Wagener MM, Marino IR. Fever in liver
YOSHIKAWA ET AL
THE JOURNAL OF PEDIATRICS VOLUME 138, NUMBER 6 transplant recipients: changing spectrum of etiologic agents. Clin Infect Dis 1998;26:59-32. 35. Lautenschlager I, Hockerstedt K, Linnavouri K, Taskinen E. Human herpesvirus infection after liver transplantation. Clin Infect Dis 1998;26:702-7.
36. Lautenschlager I, Hockerstedt K, Linnavouri K, Taskinen E. Human herpesvirus 6 infection increase adhesion molecule expression in liver allografts. Transplant Proc 1998;31:479-80. 37. Kemp CH, Shaw EB, Jackson JR, Silver HK. Studies on etiology of ex-
anthem subitum (roseola infantum). J Pediatr 1950;37:561-8. 38. Yoshikawa T, Suzuki K, Ihira M, Furukawa H, Suga S, Iwasaki T, et al. Human herpesvirus 6 latently infects mononuclear cells but not liver tissue. J Clin Pathol 1999;52:65-7.
50 Years Ago in The Journal of Pediatrics THE EFFECT OF ALLERGY MANAGEMENT ON GROWTH AND DEVELOPMENT OF ALLERGIC CHILDREN Welsh JB. J Pediatr 1951;38:571-5 In this article, written 5 decades ago, Welsh made an important observation that continues to be of great interest to those of us who treat children with allergies today. He demonstrated that children with allergic disease tend to have poor growth, which improves with treatment of their allergies. His study was based on an initial report by Cohen and Abrams,1 who demonstrated that growth delay in allergic children was 2.5 times higher than expected. In that report from Cleveland, two case histories were presented, which indicated improvement in growth when the patient’s allergic symptoms were treated. Welsh examined 34 children with a variety of allergic disorders, including seasonal and perennial allergic rhinitis and allergic asthma. They were followed up to determine whether initiation of treatment would improve their growth parameters. Patients were counseled on allergen avoidance or given specific immune desensitization after screening with a panel of skin tests with 240 antigens. Growth progress was determined in the children after initiation of therapy, based on weight and height compared with age and developmental level (Wetzel grids). The key finding of Welsh’s study was that appropriate management of the allergic diseases in many of these children normalized their growth, eliminating the expected growth failure increase described by Cohen and Abrams.1 It is interesting that the allergy testing techniques described by Welsh vary little from what is done in allergy clinics today and have changed little since they were described by Blackley in 1865 and Schloss in 1912. Also, although current pharmacologic options for the treatment of allergies are diverse, allergen avoidance and specific immune desensitization remain two of the pillars of allergy control 50 years after the publication of this work. Today, we continue to struggle with issues of growth in children with allergic disorders. Authors of recent published reports have reviewed growth in children treated with corticosteroids for allergic symptoms; these reports demonstrate our ongoing need to understand how allergic disease, and its treatment, affect the growth of the patients for whom we provide care. Dr Welsh closes with an insightful comment on the state of asthma management that is as true now as when written: “Although present-day allergy management is not without limitations, most authorities agree that the increasing progress of allergic manifestations can be arrested and severe asthma definitely minimized or eliminated in 75 to 85 percent of cases. In this way, certain predisposing factors to chronic respiratory infection or malformation may be minimized in susceptible individuals.” Michael O. Daines, MD Gurjit K. Khurana Hershey, MD, PhD Children’s Hospital Medical Center Division of Pulmonary Medicine, Allergy, and Clinical Immunology Cincinnati, OH 45229-3039 9/37/115892 doi:10.1067/mpd.2001.115892
REFERENCE 1. Cohen MB, Abrams JE. Growth patterns of allergic children. J Allergy 1948;19:165.
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