Diagnose und Therapie von Virusinfektionen bei Kindern und Jugendlichen mit neoplastischen Erkrankungen

Zusammenfassung

Virusinfektionen, die bei Immunkompetenten zumeist harmlos verlaufen, können bei Kindern und Jugendlichen mit hämatologischen Neoplasien oder nach Stammzelltransplantation schwere Krankheitsbilder mit zum Teil lebensbedrohlichen Komplikationen auslösen. Diese Patienten leiden, aufgrund der Grunderkrankung und ihrer Therapie, unter einer fehlenden bzw. eingeschränkten Lymphozytenfunktion und sind daher für schwere Virusinfektionen besonders gefährdet. Da in Zukunft ein Anstieg an stärker immunsuppressiven Chemotherapien und an mismatched bzw. T-Zell-depletierten Transplantationen zu erwarten ist, muss deshalb mit einer Zunahme viraler Infektionen in diesen Patientengruppen gerechnet werden. Im Bereich der Diagnostik viraler Infektionen sind die PCR-Methoden hervorzuheben, mit denen die quantitative Bestimmung der Viruslast sowohl im Screening als auch zur Therapiekontrolle durchgeführt werden können. Besonders bei Immunsupprimierten wird oftmals nur ein unzureichendes Ansprechen der viralen Erkrankungen auf die virostatische Therapie gesehen. Gleichzeitig besitzen diese Medikamente z. T. schwerwiegende Nebenwirkungen, so dass bei ihrem Einsatz auf zusätzliche Toxizitäten geachtet werden muss. Die Entwicklung alternativer Therapieformen ist daher notwendig. Hierbei scheint die Gabe von Virus-spezifischen T-Zellen eine Therapieoption für die Zukunft darzustellen. Die vorliegende Arbeit enthält Empfehlungen der „Arbeitsgruppe Infektionen” der deutschen Gesellschaft für Pädiatrische Onkologie und Hämatologie (GPOH) und der Deutschen Gesellschaft für Pädiatrische Infektiologie (DGPI) zur Diagnose und Behandlung von Virusinfektionen bei Kindern mit einer onkologischen Grunderkrankung. Sie basieren auf dem Zulassungsstatus bei pädiatrischen Patienten sowie klinischen Studien, Fallserien und Expertenmeinungen analog den Evidenz-Kriterien der Infectious Diseases Society of America (IDSA).

Abstract

Children with cancer or stem cell transplantation (SCT) are at considerable risk to develop life threatening viral infections. Due to both underlying disease and immunsuppressive therapy lymphocyte number and function are low and the cellular immunity against viral infections is restricted or missing. As immunosuppressive treatment regimens and mismatched or T-cell-depleted stem cell products are being used increasingly, viral infections will become an even greater problem in the future. PCR-based methods have become an indispensable tool for early recognition, preemptive therapy, and monitoring therapeutic responses by qualitative and quantitative approaches. Assays are now available that allow for parallel screening of the 16 most common viral agents. Responses to antiviral therapy are often limited in immunocompromised patients and mainly depend on the time of their initiation. Most antiviral agents have a toxicity profile that may become clinically relevant and curtail antiviral therapy. New options for treatment are therefore warranted. For the next future, these may include the transfer of specific T-cells and other immunotherapeutic approaches. This article provides the recommendations of the Infectious Diseases Working Party of the German Society for Pediatric Hematology/Oncology (GPOH) and the German Society for Pediatric Infectious Diseases (DGPI) for diagnosis and treatment of viral infections in children with cancer or post HSCT. They are based on the results of clinical trials, case series and expert opinions using the evidence criteria set forth by the Infectious Diseases Society of America (IDSA).

Schlüsselwörter

Krebs - Stammzelltransplantation - Kinder - Infektionen - Viren - Diagnose - Therapie - Aciclovir - Brivudin - Cidofovir - Foscarnet - Ganciclovir - Oseltamivir - Ribavirin - Vidarabin - Zanamivir

Key words

cancer - stem cell transplantation - children - virus - diagnosis - treatment - acyclovir - brivudin - cidofovir - foscarnet - ganciclovir - oseltamivir - ribavirin - vidarabine - zanamivir

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