Plasma Polymerase Chain Reaction for Cytomegalovirus Dna After Allogeneic Marrow Transplantation

Abstract

In a prospective longitudinal study, detection of cytomegalovirus (CMV) DNA in plasma (plasma polymerase chain reaction [PCR]) was compared with PCR of CMV DNA in peripheral blood leukocytes (PBL PCR), the CMV pp65 antigenemia assay, and viral cultures from blood, urine, and throat of 29 patients, 14 of whom received pp65 antigenemia-guided early ganciclovir treatment and 15 of whom received ganciclovir at engraftment. Among 328 blood samples tested by all methods, PBL PCR was the most sensitive test, followed by the pp65 antigenemia assay, plasma PCR, and viremia. In the 14 patients who received pp65 antigenemia-guided early treatment, the incidence of PBL PCR, pp65 antigenemia, plasma PCR, and viremia before day 100 was 79%, 79%, 71%, and 27%, respectively, with a median day of onset of day 32, 42, 45, and 51, respectively. Nine patients (64%) became positive by PBL PCR, pp65 antigenemia, and plasma PCR. Of 15 patients who were treated with ganciclovir at engraftment, 12 (80%) became positive by PBL PCR, plasma PCR, and/or pp65 antigenemia while receiving ganciclovir; 3 (20%) had breakthrough infection with all three methods, including 2 with high-grade antigenemia (more than three positive cells in duplicate staining); none of these patients subsequently developed positive CMV cultures or disease. In 49 specimens, PBL PCR and/or pp65 antigenemia assay could not be performed because of insufficient neutrophil counts. In conclusion, the sensitivity of plasma PCR is significantly lower than that of PBL PCR but similar to that of the pp65 antigenemia assay. Plasma PCR may be particularly useful in clinical situations in which a less sensitive and possibly more specific assay is warranted or in which leukocyte counts are inadequate to perform cell-based assays.

Qualitative Plasma PCR Assay (AMPLICOR CMV Test) versus pp65 Antigenemia Assay for Monitoring Cytomegalovirus Viremia and Guiding Preemptive Ganciclovir Therapy in Allogeneic Stem Cell Transplantation

“…Of these, the last two approaches are the most commonly used since the indiscriminate use of ganciclovir causes myelosuppression, resulting in an increased incidence of fungal and bacterial infections (12,13,27); delays immune reconstitution; and predisposes the patient to the development of late CMV end-stage organ disease (17). A variety of CMV diagnostic tests have been used for the surveillance of CMV infection in allogeneic bone marrow transplant recipients and as triggers for the initiation of preemptive therapy, including the leukocyte shell vial culture assay (4,13,15,21), the pp65 antigenemia assay (AG) (2, 3-6, 10, 15, 16, 19-22), and more recently, several qualitative and quantitative PCR and hybridization procedures that detect CMV DNA in either blood leukocytes or plasma (1, 4, 6, 8, 9, 14-16, 18-20, 22). No consensus as to which assay is optimal for such purposes has been reached, however.…”

“…A limited number of studies have nevertheless directly compared the diagnostic utilities of qualitative plasma CMV DNA PCR assays and AG for the detection of CMV viremia and their suitability for guiding preemptive therapy in allogeneic stem cell or bone marrow transplant recipients (4,6,15,16,19,20,22). Furthermore, most of these studies (4,15,19,20,22) have used in-house PCR assays, which complicates direct comparison of data and, thus, assessment of the true clinical value of the methods. Here we report on the experience of our group with a commercially available plasma CMV DNA PCR assay (the AMPLICOR CMV test; Roche Diagnostics, Branchburg, N.J.) and AG for the surveillance of CMV viremia in allogeneic stem cell transplant recipients, assessing their suitabilities for use in triggering the initiation of preemptive ganciclovir therapy.…”

“…No consensus as to which assay is optimal for such purposes has been reached, however. A limited number of studies have nevertheless directly compared the diagnostic utilities of qualitative plasma CMV DNA PCR assays and AG for the detection of CMV viremia and their suitability for guiding preemptive therapy in allogeneic stem cell or bone marrow transplant recipients (4,6,15,16,19,20,22). Furthermore, most of these studies (4,15,19,20,22) have used in-house PCR assays, which complicates direct comparison of data and, thus, assessment of the true clinical value of the methods.…”

CMV monitoring using blood cells and plasma: a comparison of apples with oranges?

“…6,15 Also, during blast crisis of leukemia (one patient) active CMV infection could not be identified in blood cells. WBC aplasia after myeloablative radiochemotherapy generally occurs during the first weeks after hemopoietic stem cell transplantation.…”

Incidence of cytomegalovirus (CMV) infection in allogeneic hematopoietic stem cell recipients at low risk of CMV infection

“…PCR of whole blood or leukocytes has been shown to be more sensitive than that of plasma to detect CMV reactivation. 5,6 However, we think that the use of plasma for PCR allows the detection of only free virions indicating active viral replication, which may be more clinically relevant. In addition, the semiquantitative PCR of plasma has been previously shown to correlate with the risk of CMV diseases.…”