Viral infection in Immunocompromised patients

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Transplant patients

Particularly at risk of infection with herpes virus

In the first 30 days

• HSV

• HHV 6

 

Between 30 to 90 days of transplant

• CMV

• EBV

• VZV

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Clinical problems

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Pneumonitis

• CMV

• Respiratory viruses (RSV, Parainfluenza)

• HHV 6

• Adenovirus

• Rarely

• Measles

• HSV

• VZV

 

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Hepatitis

• CMV

• HHV 6

• EBV

• Adenovirus

• Hepatitis B, Hepatitis C

 

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Gastroenteritis

• CMV

• HSV 1 and 2

• HHV 6

 

Diarrhoea

• Adenovirus 40/41

 

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Bone marrow suppression

• CMV

• HHV 6

• Adenovirus

• Parvovirus

 

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Encephalitis

• CMV

• HHV 6

• JC virus

 

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Chronic meningitis

• Enterovirus

• HSV

 

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Nephritis

• BK virus

• CMV

 

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Haemorrhagic cystitis

• Adenovirus

• BK virus

 

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Skin rashes

Vesicular

• HSV

• VZV

• Enterovirus

 

Maculopapular rash

• HHV 6

• HHV 7

• Adenovirus

• EBV

 

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Liver transplant patients

Reactivation of Hepatitis B and C is common after transplant.

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HIV infected patients

Similar to transplant patients.

Liver toxicity is common with patients infected with hepatitis B or hepatitis C.

Retinitis

• CMV

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Patients on chemotherapy

Reactivation of Herpes viruses, and hepatitis B or C is common.

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Patients on steroid

Recurrent HSV infection is common.

May reactivate herpes viruses or hepatitis B or C.

 

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Primary infection associated with severe complications

• Chickenpox

• Measles

Prophylaxis immunoglobulin may be given after exposure.

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Investigation

Depending on the clinical problems

• CBC

• LFT

• Chest x-ray

• Endoscopies

• CT scan/ MRI

 

Tests

Respiratory symptoms

• Nasopharyngeal aspirate or swab in viral transport media.

• Bronchioalveolar lavage

Gastroenteritis

• Biopsy and blood in EDTA for PCR

Vesicular rash

• Swab from the vesicle for PCR, IF or virus isolation

Meningitis or encephalitis

• CSF

Hepatitis

• Clotted blood and blood in EDTA for serology and PCR

Nephritis, haemorrhagic cystitis

• Urine and blood in EDTA for PCR

Bone marrow suppression

• Clotted blood, blood in EDTA ( and bone marrow biopsy) for serology and PCR respectively.

 

Management

1. Supportive.

2. Reducing the level of immunosuppressive drugs or starting HAART for HIV patients.

3. Antiviral therapy should be considered to all immunocompromised patients with viral illness if there is any effective antiviral regardless of the cost.

• Intravenous acyclovir for HSV, VZV and EBV.

• Intravenous Gancyclovir or Foscarnet for CMV, HHV 6, EBV.

 Management of CMV infection in Post-transplant patients

 

Investigation and management of CMV infection in transplant patients

 

Aerosolised or iv Ribavirin for RSV, Adenovirus, Parainfluenza and Measles infections.

Cidofovir for Adenovirus, HHV 6, and CMV infections.

 

 

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