CNS Opportunistic Infections:

an update

Paola Cinque

Department of Infectious Diseases

San Raffaele Scientific Institute

Milan, Italy

HANSA Meeting

Goteborg, Sweden, 26-27 May 2011

Frequency of HIV-related CNS-D

at post-mortem examination Milano, 1985-1995

CM

V-E

HIV

-E

To

xo

PC

NS

L

PM

L

HS

V, V

ZV

TB

Cri

pto

NH

L

oth

ers

20%

10%

30%

0

Cinque P and Vago L, AIDS 1997

Incidence of CNS-D in the EuroSIDA cohort

0,01

0,1

1

10

1994 1995 1996 1997 1998 1999 2000 ≥2001

Toxo ADC Crypto

PML PBL FBL

D’Arminio Monforte et al,

Ann Neurol 2004

0,1

1

10

100

Non CNS-D

CNS-D

Positive CSF PCR findings in HIV-infected patientsSan Raffaele Hospital, Milano 1994 - 2001

5

10

15

20

100

75

50

0II/94 I/95 II/95 I/96 II/96 I/97 II/97 I/98

Total patients

EBV+

JCV+

II/98 I/99 II/99

Nu

mb

er

of

po

sit

ive

sa

mp

les

I/00

HAART

CMV

+

II/00 I/01 II/01

Prevalence of HIV-related CNS-D

IRINA cohort, Italy, 2000-2005

0

5

10

15

20

25

30

35

TE HIVE PML Others Crypto EUO PCL TB CMV NHL

P=0.048

P<0.001

P<0.001

P=0.038

naive

experienced

Months from diagnosis

5550454035302520151050

Cu

mu

lativ

e p

rop

ort

ion

su

rviv

ing

1,0

,8

,6

,4

,2

0,0

Log-rank p<0.0001

Survival of HIV-related CNS-DIRINA cohort, 2000-2005

1-year survival prob.

EUO 86%

HIVE 81%

TE 77%

Other 75%

Crypto 73%

TB 65%

PML 48%

PCL 19%

1035 patients

Mortality Hazard Risk

of AIDS-associated events (ADE) during cART

31,620 patients from 15 cohorts

2880 ADE; 377 ADE-related deaths

The Antiretroviral Therapy Cohort Collaboration, CID 2009

Productive JCV infection of the brain: PML

Important progresses in PML

• PML can be (promptly) diagnosed by clinical, neuroimaging and virological assessment

• PML can be monitored by clinical, neuroimaging and virological assessment

0

,2

,4

,6

,8

1

Cu

mu

lative

Su

rviv

al

0 10 20 30 40 50 60

Months

Historical pts

cART

PML can remit following

removal

immunosuppression, i.e.,

by initiating cART

PML: MRI presentation

HIV-related PML with atypical MRI presentation

and fatal fulminant course

March 2007: - Onset of symtpoms

April 2007: - Diagnosis of HIV infection (CD4 122; VL 182,000 c/mL)

- Diagnosis of PML (CSF JCV-DNA 1,520,000 c/mL,

confirmed by brain biopsy)

- Exitus

JCV DNA detection and quantification in CSF

0 25 50 75 100 125 150 175

1

2

3

4

5

6

7

8

9

Diagnostic sensitivity 74%

Diagnostic specificity 99%

Bossolasco et al, Clin Infect Dis 2005

Reduced diagnostic value of JCV-DNA for

PML diagnosis in the cART era

Marzocchetti A. J Clin Microbiol 2005

pre-cART post-cART p

Sensitivity % 17/19 (89.5%) 23/40 (57.5%) 0.014

Specificity % 82/83 (99%) 141/141 (100%) ns

NPV % 98 89 0.05

PPV % 95 100 ns

Diagnostic criteria for PML

In the presence of progressive uni or multifocal neurological

disease and typical MRI lesions:

• Histology-confirmed PML: brain biopsy (or post-mortem

examination) showing typical pathologic features with JCV

confirmed either by IHC or ISH

• Laboratory-confirmed PML: demonstration of JCV DNA in

CSF by nucleic acid amplification methods

• Possible PML: absence of both histological confirmation

and JCV demonstration in CSF

Cinque, Koralnik and Clifford, JNV 2002

Portegies, EJN 2004

CDC, NIH, HMA-IDSA guidelines for HIV-OIs, 2009

2

4

6

8

0 50 100 150 200

Days from first CSF sample

Lo

g C

SF

JC

V D

NA

c/m

L

2

3

4

5

6

0 100 200 300

2

3

4

5

6

0 100 200 300

HAART

progressionNo HAART

HAART

stabilization

Bossolasco et al., CID 2005

JCV-DNA level in CSF

as a marker for monitoring PML activity

August 2005 October 2005 August 2006

JCV-DNA 10,792 c/mL

CD4 495 (11%);

VL 262,000 c/mL

JCV-DNA 335 c/mL

CD4 619 (33%)

VL 4198 c/mL

JCV-DNA nd

CD4 1252 (45%)

VL <50 c/mL

ART

JCV-DNA <100 c/mL

CD4 804 (44%)

VL <50 c/mL

March 2006

JCV-DNA level in CSF in a case with favorable outcome

PML onset

JCV-DNA level in CSF in a PML case

progressing over 2.5 years

ART

onset 1.5 yr later

Some important,

unanswered questions

• Why and how a benign infection will progress

into a fatal CNS disease?

• Why will some treated HIV-infected patients

develop PML? Why only half of treated

patients will respond to cART?

• When will we have a specific treatment for

JCV infection and PML?

CNS-OIs and CNS HIV replication

Hagberg L. et al., AIDS Res Ther 2010

JCV replication

in CNS - PML

Immune

competence

Natural history of JCV infection and PML

- Urinary tract

- Bone marrow ?

- CNS ?

Loss of

immune control

JCV

reactivation

Primary

JCV infection

Persistent

JCV infection

CNS seeding ?

50-70% JCV

seroprevalence in

healthy adults

20% JCV DNA

excretion in urine in

healthy adults

• Critical for virus entry in the host cell - interaction with

sialic acid on cell receptor

• Main target for both B-cell and T-cell immune response

JCV capside viral protein-1 (VP-1)

PML-specific JCV VP-1 mutations in CSF

37/40 patients had one of 12 different PML-

specific mutations or deletions in CSF

Gorelik L. et al, JID, in press

L55, K60, S267, S269, S61, P51, H122

S61

S269

K60

S267

H122

L55

Intra-Patient Appearance of PML-Specific

VP1 Mutations

Pt Lab ID SAMPLE mutation mt clone # total clone# type

5067 CSF 122R 25 25 1A

5067 PLASMA 122R 26 26 1A

5067 URINE 0 na 11 1A

5166 CSF 269F 11 11 1Av75R

5166 PLASMA 269F 13 16 1Av75R

5166 URINE 0 na 26 1Av75R

5174 CSF 269F 27 27 1B

5174 PLASMA 269F 37 38 1B

5174 URINE 0 na 13 1B

Gorelik L. et al, JID, in press

PML onset or progression despite

succesful cART: why?

• cART immunereconstitution insufficient

or too slow?

• cART immunereconstitution

exaggerated or too fast?

• Other mechanisms?

Increased frequency of Gd-enhancing MRI PML lesions

paralleles increased ART potency

Sighinolfi et al. 2008

PML survival in the cART periodSan Raffaele Hospital, Milano 1995-2001

(n=108)

Unpublished data

Anti-JCV CD4 T cell proliferative assay

47%

32%

4%

23%

0%

20%

40%

60%

80%

100%

Bas eline W6 M3 M6

% p

ati

en

ts w

ith

po

sit

ive

re

spo

nse

P24 JCV SEB PHA

Gasnault J et al., CROI2007, Poster 379

17%

23%

27%

37%

0%

10%

20%

30%

40%

50%

Bas eline W6 M3 M6

% p

ati

en

ts w

ith

po

sit

ive

re

sp

on

se

Ove r lapping JCV VP1 - peptide s

IFN-gamma CD8 T cell ELISPOT

JCV-specific T-cell responses

in cART-treated patients with PML

Longitudinal assessment of T-cell responses

against JCV VP1-p261 in patients with active PML

cART Plex Stop IS

cART cART ongoing

Days from 1st sampling

Remission

Progression

PML onset or progression despite

succesful cART: why?

• cART immunereconstitution insufficient

or too slow?

• cART immunereconstitution

exaggerated or too fast?

• Other mechanisms?

PML, cART and

immunoreconstitution

No evidenceof PML

cART‘Unmasking’

PML-IRIS

PML diagnosedand treated

cART‘Paradoxical’

PML-IRIS

Paradoxical worsening of PML following cART

Courtesy of

Pilar Miralles, Madrid, Spain

After 12 weeks

of cARTPML onset

5-Oct-07 31-Jan-0825-Oct-07 15-Nov-07

JCV DNA n.d.

CD4 31 (3.8%);

VL <50 c/mL

JCV-DNA <100 c/mL

CD4 37

VL <50 c/mL

JCV-DNA 455 c/mL

CD4 79

VL <50 c/mL

JCV-DNA 2320 c/mL

CD4 9

VL 2930 c/mL

June ‘07

ART

HD IV

steroids

Paradoxical worsening of PML following cART and

response to corticosteroids

PML onset or progression despite

succesful cART: why?

• cART immunereconstitution insufficient

or too slow?

• cART immunereconstitution

exaggerated or too fast?

• Other mechanisms?

PML-specific treatments

• Non-recommended* – Cytarabine (AII)

– Cidofovir (AII)

– IFN (BIII)

– Topotecan (BIII)

• Use not justified in routine* – 5HT2a Inhibitors (BIII)

• Clinical trial on Mefloquine: terminated

• CMX-001 ??? (Patel A, JAC 2010)

• Immune-based interventions – Adoptive JCV-specific T-cell transfer ??? (Balduzzi A, BMT 2010)

– IL-7 ??? (Patel A, JAC 2010)

CDC, NIH, HMA-IDSA

guidelines for HIV-OIs, 2009

High CSF HIV RNA level in CNS-OIs

Hagberg L. et al., AIDS Res Ther 2010

2

3

4

5

6

Lo

g10

HIV

-1 R

NA

co

pie

s/m

l

2

3

4

5

6

2

3

4

5

6

Toxoplasmosis Cryptococcosis CMV encephalitis

Onset Onset OnsetPost-tx Post-tx Post-tx

Changes of CSF HIV RNA level

in patients with CNS-Ois

No cART, CNS OI treatment only

CNS-OIs and CNS HIV replication

• May CNS-OIs favor HIV replication?

– High CSF level due to brain barriers

dysruption?

– Other mechanisms?

• May HIV replication favor onset or

progression of CNS-OI?

Origin of high CSF HIV RNA level in CNS-Ois

(peripheral vs. intrathecal)

• CSF HIV infection seems to be compartmentalized in

a significant number of CNS-OI cases

% diversity between CSF and plasma RT sequences

Lower rate of death in treated patients

with CPE score >1.5

9932 pts with first neurological AIDS-defining event

FHDH-ANRS CO4

Lenoy et al, Neurology 2011

But loss of association if model adjusted for plasma VL

Non significantly higher incidence of CNS-D in

patients with higher CPE score

251/22356 patients who started ART (1996-2008)

UK CollaborativeHIV Cohort (CHIC) Study

Lenoy et al, Neurology 2011

CNS-OIs and HIV replication

• High CSF HIV RNA levels in CNS-OIs

• Possible synergistic effect of HIV and

opportunistic agents on the CNS

• Whether treatment of HIV CNS infection

is beneficial for care or prevention of

CNS OIs is unknown

Acknowledgements

Neurovirology Unit, ID Dept. San Raffaele Sci. Inst., Milan

• Arabella Bestetti

• Simona Bossolasco

• Manuela Testa

• Francesca Ferretti

• Annamaria Pazzi

• Ester Tuveri

• Adriano Lazzarin and colleagues from the ID Dept.

• Simonetta Gerevini (Neuroradiology)

• Manuela Nebuloni and Luca Vago, University of Milan

• Magnus Gisslen and Lars Hagberg, University of Goteborg, Sweden

• Dick Price, University of San Francisco California

• Andrea Antinori and colleagues, L. Spallanzani ID Institute, Rome, Italy

• Leonid Gorelik and staff at Biogen Idec, Cambridge, MS