Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

Infectious Medicine

Monitoring of adenovirus load in stool by real-time PCR permits early detection of impending invasive infection in patients after allogeneic stem cell transplantation

Abstract

Invasive adenovirus (AdV) infections are associated with high morbidity and mortality in allogeneic stem cell transplant recipients. We observed that molecular detection of the virus in stool specimens commonly precedes AdV viremia, suggesting that intestinal infections may represent a common source of virus dissemination. To address this notion, we have investigated 153 consecutive allogeneic transplantations in 138 pediatric patients by quantitative monitoring of AdV in stool specimens and peripheral blood by a pan-adenovirus real-time (RQ)-PCR approach. AdV was detectable in serial stool specimens in all cases of AdV viremia during the post-transplant course (P<0.0001). The incidence of AdV viremia in individuals with peak virus levels in stool specimens above 1 × 10E6 copies per gram (n=22) was 73% vs 0% in patients with AdV levels in stool specimens below this threshold (n=29; P<0.0001). Serial measurement of AdV levels in stool specimens by RQ-PCR permitted early diagnosis of impending invasive infection with a sensitivity and specificity of 100% (95% confidence interval (CI) 96–100%) and 83% (95% CI 67–92%), respectively. The median time span between detection of AdV loads in stool specimens above 1 × 10E6 copies per gram and first observation of viremia was 11 days (range 0–192). Quantitative monitoring of the AdV load in stool specimens therefore provides a rationale for early initiation of antiviral treatment with the aim of preventing progression to life-threatening invasive infection.

This is a preview of subscription content, access via your institution

Access options

Rent or buy this article

Prices vary by article type

from$1.95

to$39.95

Prices may be subject to local taxes which are calculated during checkout

Figure 1
Figure 2

References

  1. Lion T, Baumgartinger R, Watzinger F, Matthes-Martin S, Suda M, Preuner S et al. Molecular monitoring of adenovirus in peripheral blood after allogeneic bone marrow transplantation permits early diagnosis of disseminated disease. Blood 2003; 102: 1114–1120.

    Article  CAS  PubMed  Google Scholar 

  2. Myers GD, Krance RA, Weiss H, Kuehnle I, Demmler G, Heslop HE et al. Adenovirus infection rates in pediatric recipients of alternate donor allogeneic bone marrow transplants receiving either antithymocyte globulin (ATG) or alemtuzumab (Campath). Bone Marrow Transplant 2005; 36: 1001–1008.

    Article  CAS  PubMed  Google Scholar 

  3. Schilham MW, Claas EC, van Zaane W, Heemskerk B, Vossen JM, Lankester AC et al. High levels of adenovirus DNA in serum correlate with fatal outcome of adenovirus infection in children after allogeneic stem-cell transplantation. Clin Infect Dis 2002; 35: 526–532.

    Article  PubMed  Google Scholar 

  4. van Tol MJ, Kroes AC, Schinkel J, Dinkelaar W, Claas EC, Jol-van der Zijde CM et al. Adenovirus infection in paediatric stem cell transplant recipients: increased risk in young children with a delayed immune recovery. Bone Marrow Transplant 2005; 36: 39–50.

    Article  CAS  PubMed  Google Scholar 

  5. Walls T, Hawrami K, Ushiro-Lumb I, Shingadia D, Saha V, Shankar AG . Adenovirus infection after pediatric bone marrow transplantation: is treatment always necessary? Clin Infect Dis 2005; 40: 1244–1249.

    Article  PubMed  Google Scholar 

  6. Runde V, Ross S, Trenschel R, Lagemann E, Basu O, Renzing-Kohler K et al. Adenoviral infection after allogeneic stem cell transplantation (SCT): report on 130 patients from a single SCT unit involved in a prospective multi center surveillance study. Bone Marrow Transplant 2001; 28: 51–57.

    Article  CAS  PubMed  Google Scholar 

  7. Chakrabarti S, Mautner V, Osman H, Collingham KE, Fegan CD, Klapper PE et al. Adenovirus infections following allogeneic stem cell transplantation: incidence and outcome in relation to graft manipulation, immunosuppression, and immune recovery. Blood 2002; 100: 1619–1627.

    Article  CAS  PubMed  Google Scholar 

  8. Benkö M . Family adenovidriae. In: Van Regenmortel M, Fauquet, CM, Bishop, DKL (eds). Virus Taxonomy: Seventh Report of the International Committee on Taxonomy of Viruses. Academic Press: New York, 1999.

    Google Scholar 

  9. De Jong JC, Wermenbol AG, Verweij-Uijterwaal MW, Slaterus KW, Wertheim-Van Dillen P, Van Doornum GJ et al. Adenoviruses from human immunodeficiency virus-infected individuals, including two strains that represent new candidate serotypes Ad50 and Ad51 of species B1 and D, respectively. J Clin Microbiol 1999; 37: 3940–3945.

    CAS  PubMed  PubMed Central  Google Scholar 

  10. Kidd AH, Jonsson M, Garwicz D, Kajon AE, Wermenbol AG, Verweij MW et al. Rapid subgenus identification of human adenovirus isolates by a general PCR. J Clin Microbiol 1996; 34: 622–627.

    CAS  PubMed  PubMed Central  Google Scholar 

  11. Symeonidis N, Jakubowski A, Pierre-Louis S, Jaffe D, Pamer E, Sepkowitz K et al. Invasive adenoviral infections in T-cell-depleted allogeneic hematopoietic stem cell transplantation: high mortality in the era of cidofovir. Transpl Infect Dis 2007; 9: 108–113.

    Article  CAS  PubMed  Google Scholar 

  12. Xu W, McDonough MC, Erdman DD . Species-specific identification of human adenoviruses by a multiplex PCR assay. J Clin Microbiol 2000; 38: 4114–4120.

    CAS  PubMed  PubMed Central  Google Scholar 

  13. Grondahl B, Puppe W, Hoppe A, Kuhne I, Weigl JA, Schmitt HJ . Rapid identification of nine microorganisms causing acute respiratory tract infections by single-tube multiplex reverse transcription-PCR: feasibility study. J Clin Microbiol 1999; 37: 1–7.

    CAS  PubMed  PubMed Central  Google Scholar 

  14. Oh DY, Gaedicke G, Schreier E . Viral agents of acute gastroenteritis in German children: prevalence and molecular diversity. J Med Virol 2003; 71: 82–93.

    Article  CAS  PubMed  Google Scholar 

  15. Rocholl C, Gerber K, Daly J, Pavia AT, Byington CL . Adenoviral infections in children: the impact of rapid diagnosis. Pediatrics 2004; 113: e51–e56.

    Article  PubMed  Google Scholar 

  16. Avivi I, Chakrabarti S, Milligan DW, Waldmann H, Hale G, Osman H et al. Incidence and outcome of adenovirus disease in transplant recipients after reduced-intensity conditioning with alemtuzumab. Biol Blood Marrow Transplant 2004; 10: 186–194.

    Article  PubMed  Google Scholar 

  17. Hoffman JA, Shah AJ, Ross LA, Kapoor N . Adenoviral infections and a prospective trial of cidofovir in pediatric hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 2001; 7: 388–394.

    Article  CAS  PubMed  Google Scholar 

  18. Lankester AC, Heemskerk B, Claas EC, Schilham MW, Beersma MF, Bredius RG et al. Effect of ribavirin on the plasma viral DNA load in patients with disseminating adenovirus infection. Clin Infect Dis 2004; 38: 1521–1525.

    Article  CAS  PubMed  Google Scholar 

  19. Feuchtinger T, Matthes-Martin S, Richard C, Lion T, Fuhrer M, Hamprecht K et al. Safe adoptive transfer of virus-specific T-cell immunity for the treatment of systemic adenovirus infection after allogeneic stem cell transplantation. Br J Haematol 2006; 134: 64–76.

    Article  PubMed  Google Scholar 

  20. Feuchtinger T, Richard C, Joachim S, Scheible MH, Schumm M, Hamprecht K et al. Clinical grade generation of hexon-specific T cells for adoptive T-cell transfer as a treatment of adenovirus infection after allogeneic stem cell transplantation. J Immunother 2008; 31: 199–206.

    Article  PubMed  Google Scholar 

  21. Ljungman P, Ribaud P, Eyrich M, Matthes-Martin S, Einsele H, Bleakley M et al. Cidofovir for adenovirus infections after allogeneic hematopoietic stem cell transplantation: a survey by the Infectious Diseases Working Party of the European Group for Blood and Marrow Transplantation. Bone Marrow Transplant 2003; 31: 481–486.

    Article  CAS  PubMed  Google Scholar 

  22. Ebner K, Pinsker W, Lion T . Comparative sequence analysis of the hexon gene in the entire spectrum of human adenovirus serotypes: phylogenetic, taxonomic and clinical implications. J Virol 2005; 79: 12635–12642.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Watzinger F, Suda M, Preuner S, Baumgartinger R, Ebner K, Baskova L et al. Real-time quantitative PCR assays for detection and monitoring of pathogenic human viruses in immunosuppressed pediatric patients. J Clin Microbiol 2004; 42: 5189–5198.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Ebner K, Suda M, Watzinger F, Lion T . Molecular detection and quantitative analysis of the entire spectrum of human adenoviruses by a two-reaction real-time PCR assay. J Clin Microbiol 2005; 43: 3049–3053.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Lion T, Gaiger A, Henn T, Horth E, Haas OA, Geissler K et al. Use of quantitative polymerase chain reaction to monitor residual disease in chronic myelogenous leukemia during treatment with interferon. Leukemia 1995; 9: 1353–1360.

    CAS  PubMed  Google Scholar 

  26. Watzinger F, Lion T . Multiplex PCR for quality control of template RNA/cDNA in RT-PCR assays. Leukemia 1998; 12–6: 1984–1993.

    Google Scholar 

  27. Fritsch G, Printz D, Stimpfl M, Dworzak MN, Witt V, Potschger U et al. Quantification of CD34+ cells: comparison of methods. Transfusion 1997; 37: 775–784.

    Article  CAS  PubMed  Google Scholar 

  28. Flomenberg P, Babbitt J, Drobyski WR, Ash RC, Carrigan DR, Sedmak GV et al. Increasing incidence of adenovirus disease in bone marrow transplant recipients. J Infect Dis 1994; 169: 775–781.

    Article  CAS  PubMed  Google Scholar 

  29. Suparno C, Milligan DW, Moss PA, Mautner V . Adenovirus infections in stem cell transplant recipients: recent developments in understanding of pathogenesis, diagnosis and management. Leuk Lymphoma 2004; 45: 873–885.

    Article  PubMed  Google Scholar 

  30. Robin M, Marque-Juillet S, Scieux C, Peffault de Latour R, Ferry C, Rocha V et al. Disseminated adenovirus infections after allogeneic hematopoietic stem cell transplantation: incidence, risk factors and outcome. Haematologica 2007; 92: 1254–1257.

    Article  PubMed  Google Scholar 

  31. Sivaprakasam P, Carr TF, Coussons M, Khalid T, Bailey AS, Guiver M et al. Improved outcome from invasive adenovirus infection in pediatric patients after hemopoietic stem cell transplantation using intensive clinical surveillance and early intervention. J Pediatr Hematol Oncol 2007; 29: 81–85.

    Article  PubMed  Google Scholar 

  32. van Tol MJ, Claas EC, Heemskerk B, Veltrop-Duits LA, de Brouwer CS, van Vreeswijk T et al. Adenovirus infection in children after allogeneic stem cell transplantation: diagnosis, treatment and immunity. Bone Marrow Transplant 2005; 35 (Suppl 1): S73–S76.

    Article  PubMed  Google Scholar 

  33. Kampmann B, Cubitt D, Walls T, Naik P, Depala M, Samarasinghe S et al. Improved outcome for children with disseminated adenoviral infection following allogeneic stem cell transplantation. Br J Haematol 2005; 130: 595–603.

    Article  CAS  PubMed  Google Scholar 

  34. Muller WJ, Levin MJ, Shin YK, Robinson C, Quinones R, Malcolm J et al. Clinical and in vitro evaluation of cidofovir for treatment of adenovirus infection in pediatric hematopoietic stem cell transplant recipients. Clin Infect Dis 2005; 41: 1812–1816.

    Article  CAS  PubMed  Google Scholar 

  35. Neofytos D, Ojha A, Mookerjee B, Wagner J, Filicko J, Ferber A et al. Treatment of adenovirus disease in stem cell transplant recipients with cidofovir. Biol Blood Marrow Transplant 2007; 13: 74–81.

    Article  CAS  PubMed  Google Scholar 

  36. Yusuf U, Hale GA, Carr J, Gu Z, Benaim E, Woodard P et al. Cidofovir for the treatment of adenoviral infection in pediatric hematopoietic stem cell transplant patients. Transplantation 2006; 81: 1398–1404.

    Article  CAS  PubMed  Google Scholar 

  37. Garnett CT, Erdman D, Xu W, Gooding LR . Prevalence and quantitation of species C adenovirus DNA in human mucosal lymphocytes. J Virol 2002; 76: 10608–10616.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  38. Guarner J, de Leon-Bojorge B, Lopez-Corella E, Ferebee-Harris T, Gooding L, Garnett CT et al. Intestinal intussusception associated with adenovirus infection in Mexican children. Am J Clin Pathol 2003; 120: 845–850.

    Article  PubMed  Google Scholar 

  39. Leung AY, Chan M, Cheng VC, Yuen KY, Kwong YL . Quantification of adenovirus in the lower respiratory tract of patients without clinical adenovirus-related respiratory disease. Clin Infect Dis 2005; 40: 1541–1544.

    Article  PubMed  Google Scholar 

  40. Neumann R, Genersch E, Eggers HJ . Detection of adenovirus nucleic acid sequences in human tonsils in the absence of infectious virus. Virus Res 1987; 7: 93–97.

    Article  CAS  PubMed  Google Scholar 

  41. Baldwin A, Kingman H, Darville M, Foot AB, Grier D, Cornish JM et al. Outcome and clinical course of 100 patients with adenovirus infection following bone marrow transplantation. Bone Marrow Transplant 2000; 26: 1333–1338.

    Article  CAS  PubMed  Google Scholar 

  42. Anderson EJ, Guzman-Cottrill JA, Kletzel M, Thormann K, Sullivan C, Zheng X et al. High-risk adenovirus-infected pediatric allogeneic hematopoietic progenitor cell transplant recipients and preemptive cidofovir therapy. Pediatr Transplant 2008; 12: 219–227.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to T Lion.

Ethics declarations

Competing interests

The authors declare no conflict of interest.

Additional information

Supplementary Information accompanies the paper on the Leukemia website

Supplementary information

Rights and permissions

Reprints and permissions

About this article

Cite this article

Lion, T., Kosulin, K., Landlinger, C. et al. Monitoring of adenovirus load in stool by real-time PCR permits early detection of impending invasive infection in patients after allogeneic stem cell transplantation. Leukemia 24, 706–714 (2010). https://doi.org/10.1038/leu.2010.4

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/leu.2010.4

Keywords

This article is cited by

Search

Quick links