Nine of 56 (20% actuarial) patients receiving a T celldepleted, HLA-identical sibling BMT for hematological malignancy developed hemorrhagic cystitis (HC) 15-368 days post BMT. Hematuria was severe and prolonged (median duration 18 days). In eight patients (89%), a viral etiology was confirmed (four adenovirus, four polyomavirus). HC was associated with significant morbidity, with all patients requiring continuous bladder irrigation and transfusion support for blood loss and thrombocytopenia. HC occurring before day 100 was significantly associated with a reduction in longterm survival: 1/7 (14.3%) patients developing HC before day 100 became long-term survivors vs 21/49 (42.8%) without HC by day 100 (P = 0.034). In univariate analysis, HC was associated with a diagnosis of multiple myeloma (P = 0.02). There was a trend towards a higher incidence of HC in patients reactivating cytomegalovirus (CMV) compared with those remaining CMV negative (18.4 vs 5.5% respectively, P = 0.17). HC was not associated with graft-versus-host disease, or with the transplant dose of CD34 + progenitors or CD3 + cells, patient age or sex. Life-threatening, viral-induced HC and the unusually high incidence of adenovirus-induced HC may have been caused by immune deficiency associated with T cell depletion in this series.

The identification of HLA restricted immune dominant cytotoxic T cell (CTL) epitopes limits immune therapy. Cytomegalovirus (CMV) disease remains a significant cause of morbidity after allogeneic stem cell transplantation. Adoptive immune therapy using CTLs stimulated with immune dominant CMV pp65 peptides may be effective in preventing CMV disease, but immune dominant CMV peptides have been identified for only a few HLA class I molecules. The purpose of this study was to use a novel molecular system to establish a rapid and precise method to identify new HLA-restricted CMV epitopes. Cytomegalovirus pp65 peptides expected to bind to the HLA-24 molecule were identified with a computer algorithm. Five candidate peptides were screened by direct ex vivo stimulation of peripheral blood mononuclear cells (PBMCs) from CMV-seropositive HLA-A*2402 individuals, and quantitative real time PCR (qRT-PCR) was used to evaluate CTL responses by measuring interferon-gamma (IFN-gamma) transcripts. One of the five candidate peptides, pp65341-350 (QYDPVAALFF), induced significant quantities of IFN-gamma mRNA production after 3 hours. PBMCs from CMV-seropositive HLA-A*2402 individuals sensitized in vitro with pp65341-350 also recognized CMV-infected targets. In conclusion, the measurement of IFN-gamma mRNA by qRT-PCR can be used to detect CTL responses 3 hours after peptide stimulation of a small quantity of PBMCs. This method has an advantage over other methods used to identify immune dominant epitopes in that it does not require in vitro expansion of CTLs with cytokines or virally infected targets. As a result, this method measures naturally induced immune reactions.

The authors of a recent study suggested that the duration of deferral for blood donations by smallpox vaccinees should be extended, based on detection of vaccinia virus DNA in 5 blood samples by PCR and the potential for viremia. We found that 4 of 202 blood specimens (from 3 of 27 smallpox vaccinees) were positive for vaccinia virus DNA by PCR; none were positive for virus by culture. Throat swabs were negative by PCR and culture. Thus, while some blood specimens contained vaccinia virus DNA, infectious virus was not detected. Current guidelines for deferral of blood donation in vaccinees seem appropriate.

In October 2001, a letter containing a large number of anthrax spores was sent through the Brentwood post office in Washington, D.C., to a United States Senate office on Capitol Hill, resulting in contamination in both places. Several thousand people who worked at these sites were screened for spore exposure by collecting nasal swab samples. We describe here a screening protocol which we, as a level A laboratory, used on very short notice to process a large number of specimens (3,936 swabs) in order to report preliminary results as quickly as possible. Six isolates from our screening met preliminary criteria for Bacillus anthracis identification and were referred for definitive testing. Although none of the isolates was later confirmed to be B. anthracis, we studied these isolates further to define their biochemical characteristics and 16S rRNA sequences. Four of the six isolates were identified as Bacillus megaterium, one was identified as Bacillus cereus, and one was an unidentifiable Bacillus sp. Our results suggest that large-scale nasal-swab screening for potential exposure to anthrax spores, particularly if not done immediately postexposure, may not be very effective for detecting B. anthracis but may detect a number of Bacillus spp. that are phenotypically very similar to B. anthracis.The threat of biological warfare became a reality in October 2001 when dissemination of spores of Bacillus anthracis, the causative agent of anthrax, occurred through letters sent through the United States postal system, resulting in several cases of anthrax infection. Since dispatch of the contaminated letters followed soon after the terrorist plane crashes in New York City and Washington, D.C., high anxiety prevailed as the nation tried to assess the magnitude of this new bioterrorist attack. The anthrax infections and associated deaths were followed closely by the press and the American public, as the governmental, medical, and scientific communities attempted to deal with real rather than hypothetical anthrax exposures. Although inhalation anthrax had not been reported in the United States since 1978 (2, 15), sporadic cases were reported in other countries, and an outbreak occurred in Sverdlovsk (in the former Soviet Union) in 1979 (12). Guidelines have been established to facilitate prompt and effective response to a bioterrorism event by the public health care system (4, 6, 9). Criteria for laboratory diagnosis of anthrax have also been established (3), and the role of the clinical microbiology laboratory has been addressed (10, 13). Anthrax spores can be aerosolized relatively easily and can resist environmental stresses for a long period. Spores are in the ideal size range (2 to 6 m) for reaching the human lower respiratory tract (7). Consequently, B. anthracis is considered to be one of the organisms that have the highest risk for public health and that could cause mass casualties if used in biowarfare (14).In Washington, D.C., the opening of a highly contaminated letter in a Capitol Hill (CH) office, followed soon ...