with Mesna) and total body irradiation (2 Gy twice daily for 3 days). Graft-versus-host disease (GVHD) prophylaxis consisted of intravenous methotrexate ...
Bone Marrow Transplantation, (1997) 20, 997–999 1997 Stockton Press All rights reserved 0268–3369/97 $12.00
Case report Treatment of adenovirus-associated haemorrhagic cystitis with ganciclovir FE Chen1, RHS Liang1, JY Lo2, KY Yuen3, TK Chan1 and M Peiris3 1
Division of Haematology, Oncology and Bone Marrow Transplantation, Department of Medicine, and 3Department of Microbiology, University of Hong Kong, Queen Mary Hospital; and 2Government Virus Unit, Department of Health, Queen Mary Hospital, Hong Kong
Summary: We report a 47-year-old bone marrow transplant recipient with haemorrhagic cystitis caused by adenovirus successfully treated with ganciclovir. This is the first report on the use of ganciclovir for the successful treatment of adenoviral infection. Shell vial culture may be more sensitive than conventional culture in the detection of adenovirus in such patients. Keywords: haemorrhagic cystitis; adenovirus; ganciclovir; BMT
Haemorrhagic cystitis is a relatively common complication following bone marrow transplantation and is often prolonged and distressing for the patient. The condition is attributed to the effects of cyclophosphamide or to the reactivation of polyoma virus (BK)1 due to the immunocompromised status of the patient. It is, however, known that BK virus can also be isolated in many asymptomatic patients suggesting that the virus may not always be pathogenic. As there is no recognised antiviral treatment for BK virus, it is important to ensure that no other treatable aetiological agents are involved. We describe a patient with severe symptoms of haemorrhagic cystitis where both polyoma virus and adenovirus were detected. The symptoms persisted until the patient was treated with ganciclovir. Clinical improvement correlated with the clearance of adenovirus from the urine suggesting that the adenovirus rather than the polyoma virus was the causative agent. The use of ganciclovir was based on studies in vitro2–5 and in animal models6 demonstrating that adenoviruses are sensitive to ganciclovir. This case demonstrates that ganciclovir can also be effective in vivo. Case report LCY was a 47-year-old man who presented with acute myeloid leukaemia in August 1995. He achieved complete Correspondence: Dr FE Chen, Division of Haematology, Oncology and Bone Marrow Transplantation, Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong Received 14 March 1997; accepted 23 July 1997
remission after induction chemotherapy with daunorubicin, cytarabine and etoposide. This was followed by maintenance consolidation with high-dose cytarabine. The leukaemia subsequently relapsed in April 1996 but responded to further salvage chemotherapy with MACE (mitozantrone, etoposide, high-dose cytarabine, dexamethasone) and a second remission was achieved. An allogeneic related donor bone marrow transplant (BMT) was performed in September 1996 using marrow donated by his HLA-identical sister. He was conditioned with busulphan (1.6 mg/kg daily for 4 days), cyclophosphamide (25 mg/kg for 2 days with Mesna) and total body irradiation (2 Gy twice daily for 3 days). Graft-versus-host disease (GVHD) prophylaxis consisted of intravenous methotrexate administered on days 1, 3, 6 and 11 and cyclosporin A from day −1 onwards. The BMT proceeded uneventfully with grade II GVHD of the skin. He engrafted on day +12 and was discharged on day +36 on cyclosporin A and reducing doses of methylprednisolone. Surveillance for CMV by PCR of peripheral blood leucocytes on day +27 showed evidence of asymptomatic infection and he was given pre-emptive therapy consisting of ganciclovir at 5 mg/kg twice daily for 1 week followed by three times weekly doses for a further 2 weeks. On day +52 post-BMT, he was readmitted with gross macroscopic haematuria, severe dysuria and frequency of 20 times a day. He was commenced on hydration and empirical doxycycline to cover possible chlamydial infection but there was no improvement in his condition. Bacterial infection was excluded by repeated sterile cultures of midstream urine samples. Viral investigations were as follows. Fresh specimens of mid-stream urine were used for shell vial culture 7 and electron microscopy. The urine specimen diluted 1:1 in virus transport medium was centrifuged (700 g × 45 min) on to monolayers of human embryonic lung fibroblasts grown on coverslips, incubated for 4 days and stained for adenoviral and cytomegaloviral antigen expression by indirect immunofluorescence using a mouse monoclonal antibody (Chemicon International, Temecula, CA, USA). Selected specimens were also inoculated on Hep 2, Vero and human embryo lung fibroblast cell culture tubes for conventional viral culture, incubated for 21 days and observed for viral cytopathic effects. Electron microscopy was carried out on the ultracentrifuged pellet obtained from 4 ml of urine after negative staining by 3% phosphotungstic acid, pH 6–7.
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Urine collected on day +54 showed evidence of adenovirus by shell vial culture and by direct electron microscopy (Table 1). In addition, electron microscopy revealed BK virus in the same urine specimen. Cytomegalovirus was not detected by shell vial culture. Spin cytology of the urine at this stage also revealed cells with basophilic brick-like intranuclear inclusions in keeping with adenovirus infection. These results were available by day +67, at which time the patient was recommenced on full dose ganciclovir (5 mg/kg twice daily). The urine was still positive for adenovirus by shell vial culture 3 days after starting ganciclovir but negative after 10 days of therapy, remaining negative thereafter. The patient’s symptoms improved rapidly within 3 days of starting therapy and completely resolved after 2 weeks of treatment (day +79). The adenovirus could not be isolated by conventional virus culture even from urine specimens found positive by shell vial culture. Discussion Haemorrhagic cystitis is a common complication following bone marrow transplantation and chemotherapy. Some of these cases are due to the effects of cytotoxic drugs (eg cyclophosphamide8) while others have been attributed to the polyoma virus BK, adenoviruses and occasionally to CMV. Because these viruses are sometimes found in the urine of immunocompromised patients without cystitis, establishing a causal link between virus detection and pathogenicity can be difficult. In our patient we believe that adenovirus was the main cause of the cystitis because the clearing of the virus by antiviral therapy was associated with prompt resolution of symptoms. Detection of BK virus, on the other hand, did not correlate with the clinical course and continued to be present long after resolution of the symptoms. It is known that the adenovirus serotypes with tropism for the urinary tract are usually types 11, 21, 34, 35, 37 and other as yet unidentified types.9–11 Recombinant viruses, eg between type 35 and serotype 7, 3 or 11 have also been described. The adenovirus serotypes associated with this patient’s cystitis could not be determined because the virus failed to grow in conventional cell culture although it was readily detectable by shell vial culture and electron microscopy. This may reflect the increased sensitivity of the shell vial culture method. This may be due to the additional centrifugation step used in this method. Alternatively, the fact that shell vial culture only requires viral
Table 1
Urine results
Days post-BMT
Shell vial CMV
Shell vial adenovirus
+54 +70 +77 +97 +108
negative NA NA negative NA
positive positive negative negative NA
NA = not available.
Electron microscopy adenovirus + polyoma negative polyoma NA polyoma
antigen expression in the cells (it does not rely on complete productive virus replication) may also contribute to increased sensitivity as well as resulting in quicker result (4–5 days). It is possible that adenoviral haemorrhagic cystitis may be under-recognised by relying on conventional culture methods and shell vial culture may be a more appropriate diagnostic approach. The use of alternative cell lines such as A 549 may further improve sensitivity. There are previous case reports describing the successful treatment of adenoviral haemorrhagic cystitis with ribavirin10,11 and vidarabine.12 Ganciclovir is often used for treatment of CMV disease in bone marrow transplant recipients. It has also been shown to have activity against a number of adenovirus serotypes in vitro2,5 although its activity against adenovirus may be lower than that against CMV. Sensitivity to ganciclovir of all patient isolates could not be determined because it was not isolated in culture. There is only one other published report documenting the successful use of ganciclovir in adenoviral disease.13 This was in a renal transplant recipient with haemorrhagic cystitis, where improvement was concurrent with a reduction in azathioprine dosage as well as ganciclovir treatment. In other communications its use has been proposed, but not actually tried.3 Ganciclovir is excreted unchanged via the urine and drug levels in the kidney are higher than those found in the blood14 whereas only 32–53% of intravenous or oral ribavirin is recoverable from the urine.15 Thus, ganciclovir may have a pharmacokinetic advantage over oral ribavirin in the treatment of haemorrhagic cystitis which may not necessarily apply to adenoviral disease in other organs. Ganciclovir has not previously been successfully used for adenoviral haemorrhagic cystitis in bone marrow transplant recipients, where presumably due to the more intense immunosuppression, this condition is usually more intractable.
Acknowledgements We acknowledge help from Dr KH Chan and staff at the Department of Microbiology, Queen Mary Hospital for technical help.
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