Cytomegalovirus Pneumonia after Bone Marrow Transplantation Successfully Treated with the Combination of Ganciclovir and High-Dose Intravenous Immune Globulin

  1. David Emanuel, MD;
  2. Isabel Cunningham, MD;
  3. Kethy Jules-Elysee, MD;
  4. Joel A. Brochstein, MD;
  5. Nancy A. Kernan, MD;
  6. Joseph Laver, MD;
  7. Diane Stover, MD;
  8. Dorothy A. White, MD;
  9. Anna Fels, MD;
  10. Bruce Polsky, MD;
  11. Hugo Castro-Malaspina, MD;
  12. Joanne R. Peppard, MT;
  13. Patricia Bartus, BS;
  14. Ulrich Hammerling, PhD; and
  15. Richard J. O'Reilly, MD

    Abstract

    Study Objective: To assess the efficacy of the combination of the antiviral agent ganciclovir (9-1,3 dihydroxy-2-propoxymethylguanine) and high-dose intravenous immune globulin for treating cytomegalovirus interstitial pneumonitis after allogeneic bone marrow transplantation.

    Design: Nonrandomized prospective trial of combined treatment with two drugs; findings in these patients were compared with those in control patients treated with either of the two drugs alone.

    Setting: Medical, pediatric, and intensive care units of a tertiary-care cancer treatment center.

    Patients: Consecutive cases of 10 patients in the study group and of 11 patients in a historical control group with evidence of cytomegalovirus pneumonia after bone marrow transplantation for treatment of leukemia or congenital immune deficiency.

    Interventions: Study Group (10 patients): ganciclovir, 2. 5 mg/kg body weight, three times daily for 20 days, plus intravenous immune globulin, 500 mg/kg every other day for ten doses. Patients were then given ganciclovir, 5 mg/kg · d three to five times a week for 20 more doses, and intravenous immune globulin, 500 mg/kg twice a week for 8 more doses. Control Group (11 patients): ganciclovir alone (2 patients), 5 mg/kg twice a day for 14 to 21 days; cytomegalovirus hyperimmune globulin (5 patients), 400 mg/kg · d for 10 days; and intravenous immune globulin (4 patients), 400 mg/kg · d for 10 days.

    Measurements and Main Results: Responses were observed in all patients treated with combination therapy; 7 of 10 patients were alive and well, and had no recurrence of disease at a median of 10 months after therapy. No therapeutic benefit was observed, and none of the 11 patients treated with either ganciclovir or intravenous immune globulin alone survived (P = 0.001 by Fisher exact test).

    Conclusions: Ganciclovir, when combined with high-dose intravenous immune globulin, appears to have significantly altered the outcome of patients with cytomegalovirus pneumonia after allogeneic bone marrow transplantation.

    Article and Author Information

    • From the Memorial Sloan-Kettering Cancer Center and the Sloan-Kettering Institute, New York, New York. For current author addresses, see end of text.

    • Grant Support: Partial support by grants CA 23766 and K08-CA00984 from the National Cancer Institute, the National Institutes of Health. Dr. Emanuel is the recipient of Clinical Investigator Award K08-CA00984-03.

    • Requests for Reprints: David Emanuel, MD, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021.

    • Current Author Addresses: Drs. Emanuel, Cunningham, Brochstein, Kernan, Laver, Castro-Malaspina and O'Reilly: Bone Marrow Transplantation Service; Drs. Stover, White, Fels and Jules-Elysee: Cardiopulmonary Service; and Dr. Polsky: Division of Infectious Diseases, Memorial Hospital, 1275 York Avenue, New York, NY 10021. Dr. Hammerling and Ms. Bartus and Peppard: Sloan-Kettering Institute, 1275 York Avenue, New York, NY 10021.

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    1. Ann Intern Med November 15, 1988 vol. 109 no. 10 777-782
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