1. Adenovirus and Bone Marrow Transplantation Stephen J. Chanock Immunocompromised Host Section Pediatric Oncology Branch National Cancer Institute

2. Issues for Adenoviral Infection in the Immunocompromised Host The State of the Host Immune Function Exposure to Primary Infection Multiple Serotypes Provides for Recurrent Risk Re-activation Underlying events: “New alterations in Immune function” Co-infection Oncogenic Potential

3. Adenoviral Serology Defined on the basis of standard reference panel of sera Primary epitope: Capsid protein Reflects heterogeneity of Adenovirus genome DNA Homology Groups Specific serotypes are associated with specific clinical manifestations

4. Clinical Features of Infection Vary Among DNA Homology Groups A URI, Tonsillopharyngitis B Hemorrhagic Cystitis, Respiratory Tract C Endemic URI, Tonsillopharyngitis D Keratoconjunctivitis (epidemic) E Conjunctivitis, Pharyngoconjunctival Fever F Gastroenteritis

5. Detection of Adenovirus Culture: Inoculation into cell lines (i.e.A549) Fluorescent antibody staining Tissue detection in situ hybridization Southern blot PCR detection

6. Adenovirus Infection in the Healthy Child >80% between 1 and 5 years have antibody to one or more serotypes Most common site: Upper respiratory tract Mild illness lasts less than 10 days Latency in lymphoid and renal tissue Common serotypes; 1, 2, 3, 5,7 and 41

7. Clinical Syndromes Associated with Adenoviral Infection in the Normal Host In order of decreasing frequency : Ý Pharyngitis Ý Conjunctivitis Ý Gastroenteritis Ý Pneumonia Ý Hemorrhagic Cystitis (young children)

8. Epidemiology of Adenoviral Infection in the Normal Host Infection rate – 40.8/100 person years, below age 1 – 14.4/100 person years, above age 10 Acute Disease – 5% of URI – 8% of childhood pneumonia (3, 4 & 21) – Adult pneumonia (3, 4 & 7) – Subgenus 1, 2 & 5 particularly common during infancy

9. Definitions Infection - Isolation of adenovirus from sterile (excluding gastrointestinal tract) Disease - Positive culture from sterile site, Typical adenoviral nuclear inclusion + Clinical signs and symptoms

10. Clinical Syndromes Associated with Adenoviral Infection in the Immunocompromised Host Ý Disseminated disease (including two or more of each of below) Ý Pneumonia Ý Fulminant hepatits/pancreatitis Ý Colitis/gastroenteritis Ý Hemorrhagic cystitis Ý Encephalitis (rare)

11. Distinct Serotypes Cause Disease in the Immunocompromised Host Serotypes 5, 11, 34 & 35 commonly isolated from immunocompromised adults Series of 46 patients with Adeno 35: – 36 AIDS – 5 BMT – 1 Renal transplant recipient – 1 SCID – 3 Healthy

12. Lessons Learned from Patients with Primary or other Secondary Immunodefciencies  Sporadic neonatal adenoviral pneumonia is severe but localized outbreaks have been reported  SCID population at high risk- even with benign serotypes Severe morbidity and mortality  DiGeoge syndrome-case reports of fatal hepatic necrosis  Solid organ transplant- – Infection of transplanted organ – Source: reactivation and donor  AIDS patients- – Co-infection with other pathogens – Diversity of serotype isolated

13. Adenovirus Infection and BMT Mortality: 18-60% (Hierholzer 1992) Risk factors Age GVHD Conditioning T-cell depletion/HLA

14. Adenoviral Infection in BMTX Risk for Adverse Outcomes: Multiple sites (disseminated) Serotype –11, 34, 35 for hemorrhagic cystitis –2,5,7,9 for pulmonary disease in young patients Co-infection with Opportunistic Infection

15. Adenoviral Infections in BMT Patients  Adenoviral infection 20.9%, adenoviral disease 6.5% in 201 BMT patients (Flomenberg 1994)  Risk Factors for Disease – Isolation of virus from multiple sites – Moderate to severe aGVHD – Infection more common in children (31.3% vs. 13.6%)  Time of onset of post transplant – Pediatric, mean <30 days – Adults, mean > 90 days  ??Significance of primary infection

16. Adenoviral Infections in BMT Patients  1300 adult patients (Mirza 1995) – Allogeneic 6% vs. 1% in autologous – GVHD not a risk factor – 40% fatal, 50% self-limited, 10% asymptomatic  Incidence 4.9% in 1051 (Shields 1985) – 9.8% death rate due to adenovirus – GVHD only risk factor for occurrence  Incidence 13.5% among 74 T-cell-depleted allogenic BMT patients (Blanke 1995) – 50% adenovirus-related mortality – GVHD and co-infection non-contributory

17. Adenoviral Infections in BMT Pediatric Patients I  96 children reported by Wasserman (1988) – Adenovirus in 18%, more common than adults – 20% with GVHD and 17% without GVHD – Ad12, uncommon in normal host, recovered from 4 patients – Major risk factor: preconditioning regimen

18. Adenoviral Infections in BMT Pediatric Patients II Hale (1999): Retrospective study of 206 children 6% Adenovirus infection Restricted to Hematologic Malignancies Detection: Median of 54 d (-4 to +333) Type of graft: Mismatch/MUD 11.6% HLA-match sib 7.7% Autograft 1.1%

19. Adenoviral Infections in BMT Pediatric Patients III Hale et al. (cont.) Most Common: Hemorrhagic Cystitis 7/13 died (only 1 clearly due to adenovirus) Sites involved: 1.77 (range 1-4) Risk factors: TBI: OR=14.11 (by univariate and multiple logistic regression analysis) Type of graft OR=9.92 (univariate only)

20. Hemorrhagic Cystitis and Adenovirus Infection in BMT Major complication in BMT Compounded by Cyclophosphamide Serotypes 11 and 35 (propensity for urinary tract) Ad35 infects neonates and establishes latency until immunosuppression Screening- Unproven

21. Primary Disease vs. Reactivation Reactivation has been implicated in the majority of disease Incidence of primary infection may be higher in children Case reports of primary infection and fatal adenoviral disease in infants Might expect an increased incidence of primary infection as more infants undergo BMT

22. Source of Adenovirus in BMT Patients Primary Infection – Case reports document fatal primary infection – Will primary infections increase as more infants receive BMT? Re-infection – Nosocomial transmission documented – Altered susceptibility to re-infection? Reactivation – Incidence of viral gastroenteritis as high as 15 to 20%

23. Treatment of Adenovirus Infection in BMT Treatment options are limited because no effective therapy is available Antivirals:Poor record, occ. anecdotal case Ribavirin (intravenous) Ganciclovir Intravenous IgG Donor pool may not have sufficient serotype specific antibodies (i.e., 11, 35)

24. Adenoviruses in HIV Infection 1. Not a major source of morbidity and mortality Chronic diarrhea 2. Increased excretion in urine (esp serotype 35) 12% overall- mainly Group B ( Question of recombination 7 and 34 (closely related serotypes) 3. New serotypes identified

25. Issues for Adenoviral Infection in the Immunocompromised Host The State of the Host Immune Function Exposure to Primary Infection Multiple Serotypes Provides for Recurrent Risk Re-activation Underlying events: “New alterations in Immune function” Co-infection Oncogenic Potential

26. Future Issues Development of new antiviral therapies Use of cytotoxic lymphocytes (e.g., EBV, CMV) Early detection Adenovirus PCR/Antigen detection Host susceptibility factors Genetic Therapy-induced

27. Adenovirus Infection in Gene Transfer Protocols Response and Site of Inoculation High Risk Sites: Pulmonary Hepatic State of the Host Immune Function Undergoing Change Iatrogenic vs Disease-Related Recombination events between closely related serotypes