3. Open in a separate window Fig. no skin lesion that suggested a varicella zoster virus infection, and the PCR analysis of the CSF for herpes simplex virus (type 1 & 2) and human herpes virus 6 were all negative. However, the PCR analysis of the CSF was positive for CMV (Fig. 2). Based on the typical radiologic findings, the positive PCR for CMV from the CSF, and recurrent CMV DNAemia in the peripheral blood in spite of long-term antiviral therapy, a CMV ventriculoencephalitis had been diagnosed in the case. Eventually the patient died of progressive deterioration of CNS function on day 190. The clinical course and laboratory data of the patient are summarized in Fig. 3. Open in a separate window Fig. 1 Brain magnetic resonance images. The T1-weighted image (A) showed periventricular enhancement of subependymal regions (), which indicated the ventriculoencephalitis. The FLAIR image (B) showed hyperintense lesions (*) in the hippocampus bilaterally, which can be seen in diffuse encephalitis. Open in a separate window Fig. 2 Gel electrophoresis of DNA fragments amplified by multiplex PCR. DNA was extracted using a QIAamp DNA Mini Kit (QIAGEN, Germany). Then, the PCR for CMV and HHV-6, described previously by Park et al. (18), was performed as positive control. Template DNAs for the different viruses were isolated Folic acid from each CMV AD169 (ATCC VR-538) and HHV6-B (HST strain, provided by K Tanaka-Taya, Osaka University Graduate School of Medicine, Osaka, Japan). Lanes: M, 100 bp DNA ladder; 1, negative control; 2, CMV; 3, HHV-6; 4, CSF Folic acid of the patient. Open in a separate window Fig. 3 The clinical course and RQ-PCR data. *Cut-off value for pre-emptive therapy of CMV DNAemia in cord blood transplantation recipients as part of high-risk group at our center. DISCUSSION Recently, posttransplant immune reconstitution after SCT varies because of availability of alternate donor and variety of preparative regimens and graft manipulations. The unrelated wire blood SCT and haploidentical transplantation themselves may be correlated with a high incidence of CMV reactivation, when compared to matched sibling or unrelated SCT (5, 6), as well as the use of antithymocyte globulin, fludarabine, and alemtuzumab (humanized monoclonal CD52 antibody) as part of the preparative routine (7-13). In particular, the combination of fludarabine and alemtuzumab might cause a higher risk of CMV illness and earlier CMV illness following allogeneic SCT compared to additional preparations (8). Chakrabarti et al. (7) suggested that the individuals receiving alemtuzumab, a total dose of 100 mg, experienced a higher incidence of CMV illness; a lower dose of alemtuzumab might be related with a reduced risk of CMV illness. Our individual received a much lower dose of alemtuzumab, a total dose of 20 mg. However, he had a recurrent CMV reactivation and finally developed CMV retinitis and ventriculoencephalitis. A combination of intravenous foscarnet and ganciclovir has been advocated for treatment of solitary drug-resistant CMV disease (14, 15). We tried the combination regimen of foscarnet and ganciclovir, expected to have synergistic effects, for the treatment of CMV retinitis because of two reasons; 1) we used the combination of fludarabine and alemtuzumab for CBT preparation, which might possess made the patient highly susceptible to CMV reactivation; 2) CMV retinitis formulated after treatment with CMV DNAemia despite the recent continuous treatment with foscarnet. Clinically, the treatment failure of CMV disease with antiviral medicines may be associated with antiviral resistance and/or inadequate penetration of the drug into the infected cells (1, 3, 16, 17). The recurrent CMV DNAemia and progressive CMV disease unresponsive to antiviral Folic acid providers and anti-CMV immunoglobulin for about 150 days, suggest antiviral resistant-mutant CMV in the case. However, it is the limitation of the current study that we could not KIAA1819 perform drug susceptibility analysis, CMV genotyping or phenotyping for drug resistance-associated mutations, or measurement of the drug levels in the plasma and CSF. In summary, more aggressive prophylaxis as well as preemptive therapy for CMV.