Application of a New Paradigm for Cytomegalovirus Disease Prevention in Mayo Clinic's First Face Transplant

Raymund R Razonable, Hatem Amer, Samir Mardini

Research output: Contribution to journalArticle

2 Citations (Scopus)

Abstract

The optimal approach to preventing cytomegalovirus (CMV) disease after face transplant is unknown. We report an individualized hybrid approach, initially using valganciclovir prophylaxis followed by surveillance and preemptive therapy guided by viral and immunologic markers. A 31-year-old man received a near-total face allotransplant for gunshot injury–related severe facial deformities. He was CMV seronegative, and the donor was CMV seropositive (D+/R− mismatch), and he received intravenous ganciclovir followed by oral valganciclovir prophylaxis. Monthly CD8+ T-cell immune competence assay revealed no CMV-specific CD8+ T-cell immunity development during valganciclovir prophylaxis. Because of severe leukopenia, valganciclovir was discontinued at 7 months after transplant when the patient had recovered and sustained normal global CD8+ T-cell function. Weekly CMV polymerase chain reaction testing detected asymptomatic CMV replication (plasma CMV, 549 IU/mL) 3 months later. Short-course preemptive valganciclovir treatment resulted in sustained virologic clearance. The patient had development of CMV-specific CD8+ T cells (12 cells/μL) together with CMV IgM and IgG. No rejection or infection relapse was detected 20 months after transplant. In conclusion, viral and immunologic monitoring allowed for an individualized approach to effective CMV disease prevention after face transplant. This case highlights the importance of understanding the interplay between the host immunity and the pathogen in determining the clinical course and outcome of CMV and other infectious disease syndromes.

Original languageEnglish (US)
Pages (from-to)166-170
Number of pages5
JournalMayo Clinic Proceedings
Volume94
Issue number1
DOIs
StatePublished - Jan 1 2019

Fingerprint

Facial Transplantation
Cytomegalovirus
T-Lymphocytes
Immunity
Biomarkers
Transplants
Immunologic Monitoring
Ganciclovir
Leukopenia
Mental Competency
Communicable Diseases

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Application of a New Paradigm for Cytomegalovirus Disease Prevention in Mayo Clinic's First Face Transplant. / Razonable, Raymund R; Amer, Hatem; Mardini, Samir.

In: Mayo Clinic Proceedings, Vol. 94, No. 1, 01.01.2019, p. 166-170.

Research output: Contribution to journalArticle

@article{e500ba3bd6964aeb8504952369e23b01,
title = "Application of a New Paradigm for Cytomegalovirus Disease Prevention in Mayo Clinic's First Face Transplant",
abstract = "The optimal approach to preventing cytomegalovirus (CMV) disease after face transplant is unknown. We report an individualized hybrid approach, initially using valganciclovir prophylaxis followed by surveillance and preemptive therapy guided by viral and immunologic markers. A 31-year-old man received a near-total face allotransplant for gunshot injury–related severe facial deformities. He was CMV seronegative, and the donor was CMV seropositive (D+/R− mismatch), and he received intravenous ganciclovir followed by oral valganciclovir prophylaxis. Monthly CD8+ T-cell immune competence assay revealed no CMV-specific CD8+ T-cell immunity development during valganciclovir prophylaxis. Because of severe leukopenia, valganciclovir was discontinued at 7 months after transplant when the patient had recovered and sustained normal global CD8+ T-cell function. Weekly CMV polymerase chain reaction testing detected asymptomatic CMV replication (plasma CMV, 549 IU/mL) 3 months later. Short-course preemptive valganciclovir treatment resulted in sustained virologic clearance. The patient had development of CMV-specific CD8+ T cells (12 cells/μL) together with CMV IgM and IgG. No rejection or infection relapse was detected 20 months after transplant. In conclusion, viral and immunologic monitoring allowed for an individualized approach to effective CMV disease prevention after face transplant. This case highlights the importance of understanding the interplay between the host immunity and the pathogen in determining the clinical course and outcome of CMV and other infectious disease syndromes.",
author = "Razonable, {Raymund R} and Hatem Amer and Samir Mardini",
year = "2019",
month = "1",
day = "1",
doi = "10.1016/j.mayocp.2018.09.017",
language = "English (US)",
volume = "94",
pages = "166--170",
journal = "Mayo Clinic Proceedings",
issn = "0025-6196",
publisher = "Elsevier Science",
number = "1",

}

TY - JOUR

T1 - Application of a New Paradigm for Cytomegalovirus Disease Prevention in Mayo Clinic's First Face Transplant

AU - Razonable, Raymund R

AU - Amer, Hatem

AU - Mardini, Samir

PY - 2019/1/1

Y1 - 2019/1/1

N2 - The optimal approach to preventing cytomegalovirus (CMV) disease after face transplant is unknown. We report an individualized hybrid approach, initially using valganciclovir prophylaxis followed by surveillance and preemptive therapy guided by viral and immunologic markers. A 31-year-old man received a near-total face allotransplant for gunshot injury–related severe facial deformities. He was CMV seronegative, and the donor was CMV seropositive (D+/R− mismatch), and he received intravenous ganciclovir followed by oral valganciclovir prophylaxis. Monthly CD8+ T-cell immune competence assay revealed no CMV-specific CD8+ T-cell immunity development during valganciclovir prophylaxis. Because of severe leukopenia, valganciclovir was discontinued at 7 months after transplant when the patient had recovered and sustained normal global CD8+ T-cell function. Weekly CMV polymerase chain reaction testing detected asymptomatic CMV replication (plasma CMV, 549 IU/mL) 3 months later. Short-course preemptive valganciclovir treatment resulted in sustained virologic clearance. The patient had development of CMV-specific CD8+ T cells (12 cells/μL) together with CMV IgM and IgG. No rejection or infection relapse was detected 20 months after transplant. In conclusion, viral and immunologic monitoring allowed for an individualized approach to effective CMV disease prevention after face transplant. This case highlights the importance of understanding the interplay between the host immunity and the pathogen in determining the clinical course and outcome of CMV and other infectious disease syndromes.

AB - The optimal approach to preventing cytomegalovirus (CMV) disease after face transplant is unknown. We report an individualized hybrid approach, initially using valganciclovir prophylaxis followed by surveillance and preemptive therapy guided by viral and immunologic markers. A 31-year-old man received a near-total face allotransplant for gunshot injury–related severe facial deformities. He was CMV seronegative, and the donor was CMV seropositive (D+/R− mismatch), and he received intravenous ganciclovir followed by oral valganciclovir prophylaxis. Monthly CD8+ T-cell immune competence assay revealed no CMV-specific CD8+ T-cell immunity development during valganciclovir prophylaxis. Because of severe leukopenia, valganciclovir was discontinued at 7 months after transplant when the patient had recovered and sustained normal global CD8+ T-cell function. Weekly CMV polymerase chain reaction testing detected asymptomatic CMV replication (plasma CMV, 549 IU/mL) 3 months later. Short-course preemptive valganciclovir treatment resulted in sustained virologic clearance. The patient had development of CMV-specific CD8+ T cells (12 cells/μL) together with CMV IgM and IgG. No rejection or infection relapse was detected 20 months after transplant. In conclusion, viral and immunologic monitoring allowed for an individualized approach to effective CMV disease prevention after face transplant. This case highlights the importance of understanding the interplay between the host immunity and the pathogen in determining the clinical course and outcome of CMV and other infectious disease syndromes.

UR - http://www.scopus.com/inward/record.url?scp=85059360600&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85059360600&partnerID=8YFLogxK

U2 - 10.1016/j.mayocp.2018.09.017

DO - 10.1016/j.mayocp.2018.09.017

M3 - Article

VL - 94

SP - 166

EP - 170

JO - Mayo Clinic Proceedings

JF - Mayo Clinic Proceedings

SN - 0025-6196

IS - 1

ER -