Influence of highly active antiretroviral therapy on the development of CMV disease in HIV positive patients at high risk for CMV disease

5 Pages·0.112 MB·English

by  Verbraak F., Boom R. et al.

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1186 BrJOphthalmol1999;83:1186–1189
Influence of highly active antiretroviral therapy on
the development of CMV disease in HIV positive
patients at high risk for CMV disease
FrankDVerbraak,RenéBoom,PaulineMEWertheim-vanDillen,
GerardusJvandenHorn,AizeKijlstra,MarcDdeSmet
Abstract Conclusion—In HIV positive patients at
Background/aims—In the pre-HAART high risk of CMV retinitis, either with a
era,HIV positive patients with CD4+ cell positive CMV PCR assay in blood and/or
countsbelow50cells·10 6/l,andthosewith withCD4+cellcountsbelow50cell·10 6/l,
detectable cytomegalovirus (CMV) DNA HAARTcausesadramaticdecreaseinthe
intheirperipheralblood,wereconsidered occurrenceofCMVdisease.Thisdecrease
to be at high risk for the development of is paralleled by an increase in CD4+ cell
CMV disease. With the start of highly count, and a decrease in the amount of
active antiretroviral therapy (HAART), a CMV DNA in the blood,which was below
restoration of immune function occurred detection levels in all patients with CD4+
in these patients, and as a consequence cellcountsabove100cells·10 6/l.
patients became less vulnerable to CMV (BrJOphthalmol1999;83:1186–1189)
disease.Sinceitisnotexactlyknownhow
HAART influences CMV viral load in
peripheral blood and the incidence of The presence of cytomegalovirus (CMV)
CMV disease in high risk HIV positive DNAeitherinwholebloodorincellfreesam-
patients a group of patients was followed ples has been recognised as an important risk
beforeandafterinitiationofHAART. factor,inadditiontolowCD4+cellcounts,for
Methods—29 HIV positive patients, seen thedevelopmentofclinicalmanifestCMVdis-
in the first 3 months of 1996 at the AIDS easeinHIVpositivepatients.Studiesonserum
Departmentof clinicoftheAcademicMedicalCentre,at or plasma samples reported useful statistical
Ophthalmology, highriskfordevelopmentofCMVdisease variables for CMV DNA polymerase chain
AcademicMedical
Centre,Universityof (positiveCMVDNAassayinbloodand/or reaction(PCR)assaysinpredictingCMVdis-
Amsterdam, CD4+cellcountbelow50cells·10 6/l),not ease (sensitivity between 75% and 90%;
Amsterdam, receivinganti-CMVmaintenancetherapy, specificity between 60% and 85%; positive
Netherlands were included in a prospective cohort predictivevaluebetween60and70%;negative
FDVerbraak study. HAART was started in the second predictive value between 80 and 98%).1–6 The
GJvandenHorn
AKijlstra trimesterof1996.Patientswereevaluated overall incidence of CMV retinitis in these
MDdeSmet for the occurrence of CMV retinitis, or studiesduringafollowupperiodof12months
CMV disease elsewhere, comparing the was between 25% and 35%. Spector et al
Laboratoryof incidenceofCMVeventsbeforeandafter reporteda12monthKaplan–MeierCMVdis-
Microbiology, the start of HAART. Following the intro- easeeventrateof14%inPCRCMVnegative
Departmentof
ductionofHAART,CD4+cellcountsand patients and of 43% in the PCR positive
Virology,Academic
MedicalCentre, quantitative polymerase chain reaction patients,correspondingtoa3.4-foldincreased
Universityof (PCR)forCMVDNAinbloodweremoni- risk of developing CMV disease.In over 90%
Amsterdam, tored in all patients who remained alive of cases CMV disease manifested itself as
Amsterdam, andwerenotreceivinganti-CMVmainte- retinitis.2
Netherlands
nancetherapy(n=22).Followupwasper- The use of antiretroviral combination
RBoom
PMEWertheim-van formeduntilAugust1998;themeanfollow therapy—for example, triple threrapy consist-
Dillen up after the start of HAART was 14.9 ing of two reverse transcriptase inhibitors and
months(range8–22months). one protease inhibitor, often called highly
Departmentof Results—In the pre-HAART period four active antiretroviral therapy (HAART), has
Ophthalmo-Immunology,patientsdevelopedCMVdisease,andfour resultedinadramaticchangeinthemorbidity
theNetherlands
died (without clinically manifest CMV associated with HIV. A significant decline in
OphthalmicResearch
Institute,Amsterdam, disease). After the start of HAART no the incidence of CMV disease has been
Netherlands patient developed CMV disease or died. reportedinpatientsreceivingthiscombination
AKijlstra WithHAART,themeanCD4+cellcounts antiretroviral therapy.78 Van den Horn et al
increased from 34 cells ·10 6/l to 194 cells reported that patients with CMV retinitis
CFroarnrkesDpoVnedrebnrcaeakto,:University ·10 6/l at the end of follow up. CMV DNA treated with HAART showed no recurrences
ofAmsterdam,Academic could be detected in the blood of 11 duringafollowupperiodof42–52weekspro-
MedicalCentre,Department patients.Quantification showed a decline vided the CD4+ cell counts remained above
oGf2O–2p4h5th,aPlOmoBloogxy2,2R7o0o0m, in the amount of detectable DNA during 100 cells ·10 6/l.9 HAART induces a rapid
1100DEAmsterdam, followup.Atthelastexaminationonlyone redistribution and eventually a restoration of
Netherlands. patientshowedapositivePCRassay.This the immune system, and as a result, patients,
was the only patient with a CD4+ cell normallyexpectedtobeathighriskfordevel-
Acceptedforpublication
24May1999 countremainingbelow100cells·10 6/l. oping CMV retinitis or recurrences of already
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InfluenceofHAARTonthedevelopmentofCMVdiseaseinHIVpositivepatients 1187
Table1 EVectofHAARTonoccurrenceofCMVeventsandsurvivalinHIVpositivepatientsathighriskfordeveloping
CMVdisease
BeforeHAART(n=29) AfterHAART(n=22)
PCR+ PCR− Timetoeventor PCR+ PCR−
(n=16) (n=13) death(months)* (n=10) (n=12)
CMVevents(n) 4 — 0.5,2,2,3 — —
Death(n) 3 1 1,2,2,4 — —
Living,withoutanti-CMVmaintenancetherapy(n) 10 12 — 7 11
Meanfollowup(months) 5.0† 14.9‡
HAART=highlyactiveantiretroviraltherapy;PCR=polymerasechainreaction;+=positiveresult,−=negativeresult;*time
betweenstartofstudyandoccurrenceofevent/death;†meanfollowupbetweenstartofstudyandstartofHAART;‡meanfollow
upfollowingstartofHAART.
present CMV retinitis, are again able to neuropathy. Additionally at each visit, the
suppressactiveCMVinfection. treating physician from the department of
Since it is not known exactly how HAART internalmedicinereceivedaquestionnaireand
influencesCMVviralloadinperipheralblood wasexplicitlyaskedforanysignsofextraocular
or the incidence of CMV disease in high risk CMV disease. CD4+ cell counts were per-
HIV positive patients, we assessed a group of formedeverythirdmonth.
patientsbeforeandafterthestartofHAART.
PCRANALYSIS
Patientsandmethods CMV DNA was purified from 50 µl EDTA
PATIENTSELECTION bloodspecimenstogetherwith70moleculesof
Patients were selected from a group of 100 internal control (IC) DNA as described previ-
consecutive HIV positive patients seen in ously, using 20 µl of size fractionated silica
MarchandApril1996attheAIDSclinicofthe particles.10DNAwaselutedin100µlTEbuVer
AcademicMedicalCenteroftheUniversityof (10 mM TRIS,1 mM EDTA,pH 8.0).CMV
Amsterdam. Eligible patients either tested DNA levels in blood were determined as
positiveforCMVPCRinblood(n=18),orhad describedpreviously(BoomR,SolC,WeelJ,et
a CD4+ count below 50 cells ·10 6/l (n=15). al. A highly sensitive assay for detection and
WithtwoexceptionsallPCRpositivepatients quantificationofhumancytomegalovirusDNA
hadaCD4+countbelow50cells·10 6/l.Four in serum and plasma by PCR and electro-
patients refused to participate. All other chemiluminescence,submitted).Inshort,puri-
patients (n=29) underwent a full ophthalmo- fied DNA (25 µl) was subjected to a 35 cycle
logical examination, including funduscopy in PCRwithasingleprimerpairwhichamplifiesa
mydriasisatbaseline. 578bpDNAfragmentfromexon4ofthemajor
ACMVeventcouldbeeitheraCMVretini- immediateearlygeneofCMVandafragmentof
tis,definedasanecrotisingretinitiswithchar- identical size and GC content from IC DNA.
acteristic “cheese-like” appearance with or The amounts of CMV and IC PCR products
without haemorrhages, as observed by an were subsequently determined by electro-
experienced ophthalmologist, or extraocular chemiluminescence (ECL) in the QPCR Sys-
CMVdisease,forwhichdiagnosisimmunohis- tem 5000 (Perkin Elmer) after hybridisation
tologicalproofhadtobepresent. with (TRIS (2,2'-bipyridine) ruthenium (II)
BeforethestartofHAARTfourpatientsdied chelate) (TBR) labelled probes specific for
without clinically manifest CMV disease, after either CMV or IC amplimers. The viral load
4,7,9,and15weeksrespectively.Themeanfol- (expressedascopiesCMV/mlblood)wascalcu-
low up period for the other patients from the latedfromtheratio(R)ofCMVoverICECL
startofthestudytothestartofHAARTwas5 signals (after background correction) by the
months (range 4–6 months). All patients were algorithm“copiesCMV/mlblood=R· 1400”.
givenHAARTinthesecondtrimesterof1996.
HAART consisted of triple therapy, using a STATISTICALANALYSIS
combinationoftworeversetranscriptaseinhibi- ForstatisticalanalysiswecomparedtheCMV
torsandoneproteaseinhibitor. eventrate,duringfollowupbeforethestartof
ThreepatientsdevelopedCMVretinitisand HAART, with CMV event rate following the
received anti-CMV maintenance therapy. start of HAART, using the Kaplan–Meier
Thesepatientswereexcludedfromfurtherfol- methodandthelogranktest.11
low up. Mean follow up after the start of
HAART for those patients not receiving Results
anti-CMV maintenance therapy (n= 22), was Fourpatients,allbelongingtotheCMVPCR
14.9months(range8–22months). positive patient group, developed a clinically
BetweenNovember1996andJuly1998the manifest CMV disease in the pre-HAART
22 patients without anti-CMV maintenance period, after 1, 7, 9, and 12 weeks. Three
therapy underwent a full ophthalmological patients were diagnosed with a CMV retinitis
examination,includingfunduscopyinmydria- andallwereputonmaintenancetherapyafter
sis,everymonthduringthefirst6months,and successful induction therapy. One patient
every other month during the remaining part developedaCMVcolitisandonlyreceiveda3
of follow up.At the same time blood samples week induction therapy. Additionally, four
were taken for quantitative PCR analysis. At patientsdiedbeforethestartofHAART,with-
each visit patients were asked for complaints outclinicallymanifestCMVdisease,after4,7,
related to oesophagitis, colitis, pneumonia, or 8,and17weeksrespectively(Table1).
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1188 Verbraak,Boom,Wertheim-vanDillen,etal
Table2 EVectofHAARTonCD4+cellcountsandCMVviralloadin22HIVpositivepatients,withoutanti-CMVmaintenancetherapy,athighrisk
fordevelopingCMVdisease
BeforeHAART AfterHAART Lastexam
Exam0 Exam1 Exam2 Exam3 Exam4 Exam5 Exam6 Exam7
Patient Aftern
No CD4+ PCR CD4+ PCR PCR PCR CD4+ PCR PCR PCR CD4+ PCR months PCR CD4+
1 10 1469 70 — — — 110 — — — 230 — 18 — 130
2 150 914 150 — — — 140 — — — 180 — 18 — 150
3 20 1136 210 — — — 250 — — — 250 — 12 — 170
4 20 562 90 — — — 220 — — — ND — 9 — 460
5 40 1529 160 — — — 130 — — 171 140 — 18 — 170
6 40 382 30 2071 1474 ND ND ND ND ND 100 — 12 — 100
7 40 2355 100 — — 376 150 584 — — 170 — 16# — 180
8 90 1259 170 384 — — 200 — — — 190 — 22 — 200
9* 30 1423 90 — — 947 100 — ND ND ND ND 13 — 100
10* 20 604 140 133 — — 200 — — — 200 — 16 — 200
11 30 — 10 — — 237 ND ND — — ND ND 12 — 180
12 20 — 60 6488 1464 — 130 534 602 — 140 — 13 — 120
13 20 — 30 — 186 875 40 — 346 — 20 — 16 727 60
14 10 — 110 — — — 260 — — — 170 — 16* — 340
15 20 — 60 — — — 90 — — — 80 — 17 — 250
16 50 — 190 — ND ND 130 — ND ND ND ND 9 — 130
17 30 — 70 — — — 150 — — — 170 — 16 — 110
18 10 — 230 — — — 60 — — — 170 — 18 — 250
19 10 — 80 — — ND 100 — — — 130 — 13 — 190
20 30 — 140 — — ND ND ND ND ND ND 8 — 140
21 30 — 50 — — — 80 — — — ND — 14 — 130
22* 30 — 120 — — — 190 — 148 — 400 — 22 — 500
CD4+=CD4+cellcount(cells· 106/l);HAART=highlyactiveantiretroviraltherapy;PCR=quantitativepolymerasechainreaction,incopiesCMV·10 6/ml;−=
negativeresult;ND=notdone;exam0=firstexamination,atintake,beforethestartofHAART;exam1–7=examinations,monthly,afterthestartofHAART.After
the7thexamination,followupscheduledeveryothermonth,resultsnotshown.*Patient9,10,and22previousdiagnosisofextraocularCMVdisease.;†patient7one
positivetest12monthsafterstartHAART(280copies/ml);‡patient14onepositivetest14monthsafterstartHAART(98copies/ml);lastexamafternmonths=
lastexaminationofthepatientatnmonthsafterthestartofHAART.
Following the start of HAART none of the Discussion
22 patients not receiving anti-CMV mainte- In this study we present data showing that in
nance treatment developed clinically manifest 22 patients, previously considered to be at
CMVdiseaseduringameanfollowupof14.9 extremely high risk for developing CMV
months (range 8–22 months), and none of disease, not one new case of CMV disease
thesepatientsdied. manifested itself during a mean follow up of
Statistical analysis comparing the incidence 14.9months(range8–22months).
ofCMVdiseaseinpatientsbeforeandafterthe HAARTresultedinagradualriseinCD4+
start of HAART using the Kaplan–Meier lymphocyte counts and a gradual drop in
method and the log rank test resulted in a p CMVviralloadintheperipheralblood.Atthe
valueof0.05. lastexaminationCMVDNAbecameundetec-
MostpatientsrespondedtoHAARTwitha table,withtheexceptionofonepatientwhose
steady increase in their CD4+ cell counts CD4+cellcountremainedlessthan100cells
(Table 2). The mean CD4 positive count ·10 6/l.Nopatientdiedduringfollowup.
increased from 32 cells ·10 6/l (range 10–150) ComparingtheincidenceofCMVdiseasein
at the start of follow up, through 144 cells the patients before and after the start of
·10 6/l (range 40 to 260) halfway, to 194 cells HAART,usingtheKaplan–Meiermethodwith
·10 6/l (range 60–500) at the last examination. the log rank test, we found a statistically
With the exception of one patient (patient significant, albeit weak, diVerence between
number 13), all CD4+ cell counts were over bothobservationperiods(p=0.05).Aplacebo
100cells·10 6/latthelastexamination. controlledtrial(withholdingHAARTtothese
In eight patients a positive CMV PCR test patients)wasconsideredtobeunethical.
wasobtainedduringfollowupafterthestartof Patients with a history of extraocular CMV
HAART(Table2).QuantificationofthePCR disease have been reported to be especially
testshowedadecreaseoftheamountofCMV pronetothesubsequentdevelopmentofCMV
DNA detectable in the peripheral blood of all retinitis.Over85%ofthesepatientsdeveloped
these patients. At the seventh examination, a CMV retinitis after a mean follow up of 6.4
longest follow up 10 months after the start of months.12Notoneofthethreepatients(patient
HAART, none of the tested patients had nos 9,10,and 22,Table 2) in this study with
detectable CMV DNA in their blood. How- gastrointestinalCMVdiseasedevelopedCMV
ever,inpatient7,12monthsfollowingstartof retinitis during follow up after the start of
HAART, 280 CMV copies/ml could be HAART.
measured, and in patient 14, 14 months The fact that no clinically manifest CMV
following the start of HAART, 98 CMV diseaseoccurredinourgroupofHIVpositive
copies/ml could be detected (not shown in patientscanonlybeexplainedbythesuccessof
Table2).Atthelastexamination,afteramean the HAART treatment. Others have also
follow up of 14.9 months, only one patient reportedthedecreasedincidenceofCMVdis-
(number13)testedpositive,withaCMVviral ease in HIV positive patients with favourable
load of 727 copies/ml.This was also the only responses to HAART treatment.7–9 The de-
patient with a CD4+ cell count less than 100 crease of CMV viral load found in this study
cells·10 6/l. confirmstherestorationoftheimmunesystem,
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InfluenceofHAARTonthedevelopmentofCMVdiseaseinHIVpositivepatients 1189
enabling the patients to successfully suppress This decrease is paralleled by an increase in
reactivationfromtheirlatentCMVinfection. CD4+lymphocytecount,andadecreaseinthe
All four patients with clinically manifest amount of CMV DNA in the blood, which
CMV disease in the pre-HAART period becomes undetectable in all patients with
belongedtothegroupofpatientswithaCMV CD4+cellcountsabove100cells·10 6/l.
PCRpositivebloodtest.Thisobservationcon-
firms the predictive value of the PCR assay,
even though the patient number is small,and 1 RasmussenL,ZipetoD,WolitzRA,etal.Riskforretinitisin
patientswithAIDScanbeassessedbyquantificationof
pre-HAARTfollowupshort(sensitivity100%, thresholdlevelsofcytomegalovirusDNAburdeninblood.
specificity55%,positivepredictivevalue23%, JInfectDis1997;176:1146–55.
2 SpectorSA,WongR,HsiaK,etal.Plasmacytomegalovirus
negative predictive value 100%). The test (CMV)DNAloadpredictsdiseaseandsurvivalinAIDS
resultscomparefavourablywiththosereported patients.JClinInvest1998;101:497–502.
3 DodtKK,JacobsonPH,HofmannB,etal.Developmentof
in the literature, suggesting at least an equal cytomegalovirus(CMV)diseasemaybepredictedinHIV-
sensitivity.1–6 infectedpatientsbyCMVpolymerasechainreactionand
theantigenemiatest.AIDS1997;11:F21–8.
Although HAART is considered very eVec- 4 ShinkayM,BozetteSA,PowderlyW,etal.Utilityofurine
andleukocyteculturesandplasmaDNApolymerasechain
tiveintreatingHIVinfection,withasometimes
reaction for identification of AIDS patients at risk for
dramaticimprovementintheclinicalmanifes- developing human cytomegalovirus disease. J Infect Dis
tations of opportunistic infections, CMV dis- 1997;175:302–8.
5 LaueT,MertenskotterT,GrewingT,etal.Clinicalsignifi-
easehasbeenreportedinHIVpositivepatients cance of qualitative human Cytomegalovirus (HCMV)
detection in cell-free serum samples in HIV-infected
after the start of HAART, even after a rise of
patientsatriskforHCMVdisease.AIDS1997;11:1195–6.
CD4+ lymphocyte count above 100 cells 6 Bowen EF, Sabin CA, Wilson P, et al. Cytomegalovirus
·10 6/l.1314 Diagnosis was made very shortly (CMV) viraemia detected by polymerase chain reaction
identifiesagroupofHIV-positivepatientsathighriskof
after the initiation of HAART, within a 4–8 CMVdisease.AIDS1997;11:889–93.
weekperiod.Duringtherestoffollowupafter 7 Ash S. Combination HIV therapy and opportunistic
infectionsoftheeyeinpeoplewithAIDS.BrJOphthalmol
thesefirst2months,notonenewcaseofCMV 1998;82:981–3.
diseaseoccurredinthesestudies. 8 WalshJC,JonesCD,BarnesEA,etal.Increasingsurvivalin
AIDSpatientswithcytomegalovirusretinitistreatedwith
After the start of HAART,uveitis or vitritis combination antiretroviral therapy including protease
hasbeendescribedinsomepatientswithCMV inhibitors.AIDS1998;12:613–8.
9 VandenHornGJ,MeenkenC,DannerSA,etal.EVectsof
retinitis.13Thiswasbelievedtobeduetoresto- proteaseinhibitorsonthecourseofCMVretinitisinrela-
ration of the previously deficient immune tiontoCD4+lymphocyteresponsesinHIV+patients.BrJ
Ophthalmol1998;82:988–90.
response in these patients, leading to an 10 BoomR,SolCJ,SalimansMM,etal.Rapidandsimple
intraocular inflammatory response against the methodforpurificationofnucleicacids.JClinMicrobiol
1990;28:495–503.
virus.InourstudynonewcaseofCMVretini- 11 AltmanDG.Comparinggroups—categoricaldata.Practical
tisdevelopedafterthestartofHAART,nordid statisticsformedicalresearch.1sted.London:Chapman&
Hall,1991:229–72.
anypatientshowedsignsofuveitis. 12 VerbraakFD,vandenHornGJ,vanderMeerJTM,etal.
WeconcludethatinHIVpositivepatientsat Risk of developing CMV retinitis following non-ocular
CMVdiseaseinAIDSpatients.BrJOphthalmol1998;82:
high risk for development of CMV disease, 748–50.
eitherwithapositiveCMVPCRassayinblood 13 JacobsonMA,ZegansM,PavanPR,etal.Cytomegalovirus
retinitis after initiation of highly active antiretroviral
and/or with CD4+ lymphocyte counts below therapy.Lancet1997;349:1443–5.
50 cells ·10 6/l, HAART causes a dramatic 14 MallolasJ,ArrizabalagaJ,LoncaM,etal.Cytomegalovirus
disease in HIV-1-infected patients treated with protease
decrease in the occurrence of CMV disease. inhibitors.AIDS1997;11:1785–7.
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Influence of highly active antiretroviral therapy
on the development of CMV disease in HIV
positive patients at high risk for CMV disease
Frank D Verbraak, René Boom, Pauline M E Wertheim-van Dillen, Gerardus
J van den Horn, Aize Kijlstra and Marc D de Smet
Br J Ophthalmol 1999 83: 1186-1189
doi: 10.1136/bjo.83.10.1186
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