Background: Primary cytomegalovirus (CMV) infection is prevalent worldwide and usually results in latency in immunocompetent populations. Reactivation of latent CMV can cause life-threatening complications in immunocompromised hosts. Methods: We used the CMV Brite assay to test CMV antigenemia (pp65) in whole blood samples from 22,192 patients with or without autoimmune diseases in Beijing during 2008–2018. Results: The overall prevalence of CMV antigenemia was 19.5% (9.7%, males; 26.0%, females). The prevalence of CMV antigenemia was 35.1%, 58.6% and 11.4% in whole patients with autoimmune diseases, in patients with systemic lupus erythematosus (SLE) and in patients with non-SLE autoimmune diseases, respectively. All patients with non-autoimmune diseases, patients with HIV/AIDS or transplantation were found to have 5.0%, 27% or 14.8%, respectively. Patients≤20 years with SLE had a significantly higher prevalence of CMV antigenemia than did all SLE patients, on average. Patients>51 years with non-SLE autoimmune diseases had a significantly higher prevalence than did all patients with non-SLE autoimmune diseases, on average. The prevalence of CMV antigenemia in patients admitted to intensive-care units (ICUs) were 9.2%, which was significantly higher than that among all patients with non-autoimmune diseases. Patients with SLE had 23.8% of negative conversion of CMV antigenemia, significantly lower than the percentage of patients with non-SLE autoimmune (64.3%) and non-autoimmune (61.0%) diseases. The mean number of days to negative conversion of CMV antigenemia in patients with SLE was 35.3±35.8 days, which was significantly longer than that in patients with non-SLE autoimmune diseases (15.4±11.9 days) and non-autoimmune diseases (13.6±7.7 days). Conclusions: CMV antigenemia is found more likely in women than in men, more prevalently in patients with SLE than those with HIV/AIDS or transplant recipients, more frequently in patients admitted to ICUs. Patients with SLE had prolonged CMV antigenemia. The role of CMV appears important in SLE.
Keywords: Research Article; Biology and life sciences; Organisms; Viruses; DNA viruses; Herpesviruses; Human cytomegalovirus; Microbiology; Medical microbiology; Microbial pathogens; Viral pathogens; Medicine and health sciences; Pathology and laboratory medicine; Pathogens; Clinical medicine; Clinical immunology; Autoimmune diseases; Immunology; Lupus erythematosus; Systemic lupus erythematosus; Rheumatology; Infectious diseases; Viral diseases; Cytomegalovirus infection; Health care; Health care facilities; Hospitals; Intensive care units; Pharmacology; Drugs; Immunosuppressives; Anatomy; Body fluids; Blood; Physiology
Human cytomegalovirus (CMV) is a member of the subfamily Betatheherpesviridae of the family Herpesviridae. CMV infection in humans has a worldwide distribution, with seroprevalence varying from 45% to 100% in different geographic regions [[
The CMV antigenemia test was first described in 1988 [[
The study was approved by the Ethics Committee (reference no. S-K528) of Peking Union Medical College Hospital (PUMCH). The requirement for informed consent was waived as the blood samples used were collected and tested for routine medical purpose, and we only analyzed the results of the CMV antigenemia assay, which had been reported to the patients and to physicians. Patients' identifying information was removed before the analysis.
A total of 22,192 whole blood samples were collected from patients visiting the PUMCH from May, 2008 to December, 2018; all samples were subsequently tested for CMV antigenemia. All patient categories and demographic information were based on our hospital data. In general, whether patients were in a disease state was uncertain.
The inclusion criteria were blood samples from patients who were Chinese, had complete demographic information, and had laboratory results for the CMV antigenemia test.
Exclusion criteria were blood samples from patients who: were foreigners (as the study was designed for Chinese patients only), from those who had no demographic information, or from those had no laboratory test results for CMV antigenemia. More than one of blood samples collected in fewer than 3 days from one patient were considered repeated samples, and only the first sample was included for analysis; the remaining samples were excluded.
Peripheral whole blood samples were collected using sterile vacuum blood collection tubes contain EDTA.K2 anticoagulant. The CMV Brite assay (IQ products BV, Groningen, the Netherland) was performed to test for CMV antigenemia according to the manufacturer's instructions. Briefly [[
Our laboratory information system (LIS) software was installed on a server. Results of CMV antigenemia assays were stored in the server after testing was completed and the results were reported. To protect patients' identifying information, the LIS was only accessible to staff of the virology division using passwords. The data were exported to Microsoft Excel 2007 (Microsoft Corp., New York, NY, USA), where they were sorted and the results were preliminarily calculated. Statistical analysis was performed using IBM SPSS software version 21.0 (IBM Corp., Armonk, NY, USA). P-values <0.05 were considered statistically significant. The chi-squared test with continuity correction and an independent samples t-test were used to compare the prevalence of CMV antigenemia and the mean number of days until negative conversion of CMV antigenemia.
From 2008 to 2018, a total of 22,192 whole blood specimens were tested for CMV antigenemia. The general information of patients with autoimmune diseases and non-autoimmune diseases is shown in Table 1. There were 10,749 (48.4%) patients with autoimmune diseases and 11,443 (51.6%) with non-autoimmune diseases. Among the 10,749 patients with autoimmune diseases, 5,379 (50.0%) had SLE and 5,370 (50.0%) had non-SLE autoimmune diseases. The age range of the total 22,192 patients was from 1 day to 97 years old, and the mean age was 41.6±19.4 years old with a median of 41 years. For patients with SLE, the mean age was 31.4±14.8 years with a median of 28 years.
Table 1: General information of patients with autoimmune and non-autoimmune diseases tested for cytomegalovirus antigenemia at Peking Union Medical College Hospital, Beijing (2008 to 2018).
Mean age (y) Malen (%) Femalen (%) Totalsamples. Autoimmune diseases SLE 31.4±14.8 660(12.3) 4,719(87.7) 5,379 Non-SLE Still disease and AOSD 31.5±13.8 45(20.0) 179(80.0) 224 Rheumatoid arthritis 49.8±18.9 69(23.5) 224(76.5) 293 Sjogren syndrome 51.0±13.4 28(8.2) 315(91.8) 343 Polymyositis and dermatomyositis 46.4±15.8 222(35.6) 402(64.4) 624 Vasculitis 47.1±19.3 414(52.0) 382(48.0) 796 Inflammatory bowel disease 39.6±15.2 778(60.0) 520(40.0) 1,298 Other or undefined autoimmunediseases 41.9±19.3 672(37.5) 1,120(62.5) 1,792 Subtotal of autoimmune diseases 37.5±17.5 2,888(26.9) 7,861(73.1) 10,749 Non-autoimmune diseases Cushing syndrome (ACTH-related) 48.3±18.5 15(30.6) 34(69.4) 49 HLH 38.6±19.1 21(37.5) 35(62.5) 56 HIV/AIDS 41.2±10.9 99(89.2) 12(10.8) 111 Post-transplantation# 42.2±14.5 131(60.6) 85(39.4) 216 Elevated serum liver enzymes 38.7±20.9 163(45.2) 198(54.8) 361 Haematologic-/oncologic diseases## 47.0±15.9 552(61.2) 350(38.8) 902 Pneumonia 57.7±19.1 716(54.6) 595(45.4) 1,311 FUO 40.4±19.3 1,412(44.0) 1,794(56.0) 3,206 Other or undefined non-autoimmunediseases 46.5±20.7 2,776(53.1) 2,455(46.9) 5,231 Subtotal of non-autoimmune diseases 45.7±20.2 5,885(51.4) 5,558(48.6) 11,443 Total 41.6±19.4 8,773(39.5) 13,419(60.5) 22,192
- 3 CMV, cytomegalovirus; SLE, systemic lupus erythematosus; AOSD, adult-onset Still disease; ACTH, adenocorticotropic hormone; HLH, hemophagocytic lymphohistiocytosis; FUO, fever of unknown origin
1 # Post-transplantation, includes kidney transplantation (101 cases), liver transplantation (3 cases) and allogeneic stem cell transplantation (112 cases)
- 2 ## Hemato—/oncologic diseases, include myelodysplastic syndrome (49 cases), POEMS syndrome (110 cases), multiple myeloma (91 cases), lymphoma (359 cases) and leukemia (293 cases)
- 4 Note: % values indicate the proportion of men or women in each disease category, this differs from the meaning in Table 2.
As shown in Table 2, the overall prevalence of CMV antigenemia was 19.5% (4,335/22,192); 9.7% (847/8,773) for male patients and 26.0% (3,488/13,419) for female patients, The total sex difference was significant (χ
Table 2: Prevalence of cytomegalovirus antigenemia in male and female patients with autoimmune diseases and non-autoimmune diseases at Peking Union Medical College Hospital, Beijing (2008 to 2018).
MaleCMV antigenemian (%) FemaleCMVantigenemian (%) TotalCMVantigenemian (%) χ2 P-value Autoimmune diseases SLE 381(57.7) 2,773(58.8) 3,154(58.6) 0.215 0.643### Non-SLE Still disease and AOSD 3(6.7) 13(7.3) 16(7.1) Rheumatoid arthritis 14(20.3) 44(19.6) 58(19.8) Sjogren syndrome 4(14.3) 67(21.3) 71(20.7) Polymyositis and dermatomyositis 36(16.2) 56(13.9) 92(14.7) 0.427 0.514 Vasculitis 30(7.2) 39(10.2) 69(8.7) 1.845 0.174 Inflammatory bowel disease 58(7.5) 37(7.1) 95(7.3) Subtotal of six autoimmunediseases above 145(9.3) 256(12.7) 401(11.2) 9.54 0.002 Other or undefinedautoimmune diseases 59(8.8) 154(13.8) 213(11.9) 9.438 0.002 Subtotal of autoimmunediseases 585(20.3) 3,183(40.5) 3,768(35.1) 378.96 0.000 Non-autoimmune diseases Cushing syndrome (ACTH-related) 0(0) 2(5.9) 2(4.1) HLH 6(28.6) 12(34.3) 18(32.1) HIV/AIDS 26(26.3) 4(33.3) 30(27.0) Post-transplantation# 23(17.6) 9(10.6) 32(14.8) 1.47 0.225 Elevated serum liver enzymes 7(4.3) 9(4.5) 16(4.4) Haematologic-/oncologic diseases## 30(5.4) 16(4.6) 46(5.1) Pneumonia 62(8.7) 62(10.4) 124(9.6) FUO 24(1.7) 71(4.0) 95(3.0) 12.04 0.001 Other or undefined non-autoimmune diseases 84(3.0) 120(4.9) 204(3.9) 11.56 0.001 Subtotal of non-autoimmunediseases 262(4.5) 305(5.5) 567(5.0) 6.29 0.012 Total 847(9.7) 3,488(26.0) 4,335(19.5) 899.9 0.000
- 7 CMV, cytomegalovirus; SLE, systemic lupus erythematosus; AOSD, adult-onset Still disease; ACTH, adenocorticotropic hormone; HLH, hemophagocytic lymphohistiocytosis; FUO, fever of unknown origin
- 5 # Post-transplantation, includes kidney transplantation (101 cases), liver transplantation (3 cases), allogeneic stem cell transplantation (112 cases)
- 6 ## Hematologic-/oncologic diseases, include myelodysplastic syndrome (49 cases), POEMS syndrome (110 cases), multiple myeloma (91 cases), lymphoma (359 cases) and leukemia (293 cases)
- 8 ### Comparison of prevalence of cytomegalovirus antigenemia between male and female patients with SLE. Same patterns were used for other comparisons in patients with other diseases or symptoms in Table 2.
- 9 Note: % values indicate positive rate of CMV antigenemia in men or women, or in both men and women, in each disease category, this differs from the meaning in Table 1.
Details of age-related prevalence of CMV antigenemia in patients with autoimmune diseases and non-autoimmune diseases are shown in Table 3. For patients with SLE <20 years old, the prevalence of CMV antigenmia was between 63% (<10yrs) and 67% (11–20yrs); both significantly higher than the 58.6% (3,154/5,379) in all SLE patients on average. In contrast, for patients with non-SLE autoimmune diseases >51 years old, the prevalence of CMV antigenemia was between 14% (≥61yrs) to 15% (51–60yrs); both significantly higher than 11.4% (614/5,370) in all patients with non-SLE autoimmune diseases on average.
Table 3: Age-related prevalence of cytomegalovirus antigenemia in patients with SLE, non-SLE autoimmune diseases and non-autoimmune diseases at Peking Union Medical College Hospital, Beijing (2008 to 2018).
SLECMV antigenemiaPositive, n (%) Non-SLE autoimmuneCMV antigenemiaPositive, n (%) Non-autoimmuneCMV antigenemiaPositive, n (%) χ2 P-value Male Female Total 0–10y 9(39.1) 144(70.2) 153(67.1) 15(9.0) 12(3.3) 48.93 0.000# 11–20y 112(67.9) 628(62.6) 740(63.4) 31(6.1) 31(3.4) 8.68 0.003## 21–30y 99(57.2) 807(57.8) 906(57.7) 67(8.2) 94(5.0) 31–40y 70(53.8) 463(56.3) 533(56.0) 72(9.2) 62(3.8) 41–50y 55(58.5) 411(57.3) 466(57.5) 116(11.3) 85(5.1) 51–60y 5(20.8) 220(54.9) 225(53.0) 167(15.5) 99(5.1) 13.51 0.000### 61y– 31(60.8) 100(57.5) 131(58.2) 146(14.6) 184(6.0) 7.88 0.005#### Total 381(57.7) 2,773(58.8) 3,154(58.6) 614(11.4) 567(5.0)
- 10 Autoimmune, autoimmune diseases
- 11 # Comparison of the prevalence of cytomegalovirus antigenemia between SLE patients ≤10 years old (63.4%, 740/1,168) and total SLE patients, on average (58.6%, 3,154/5,379).
- 12 ## Comparison of the prevalence of cytomegalovirus antigenemia between SLE patients aged 11–20 years (67.1%, 153/228) and total SLE patients, on average (58.6%, 3,154/5,379).
- 13 ### Comparison of prevalence of cytomegalovirus antigenemia between patients with non-SLE autoimmune diseases aged 51–60 years (67.1%, 153/228) and all patients with non-SLE autoimmune diseases (11.4, 614/5,370).
- 14 #### Comparison of prevalence of cytomegalovirus antigenemia between patients with non-SLE autoimmune diseases >60 years old (14.6%, 146/998) and all patients with non-SLE autoimmune diseases (11.4, 614/5,370).
Table 4 shows the prevalence of CMV antigenemia among patients with non-autoimmune diseases in various hospital departments. The prevalence of CMV antigenemia in patients admitted to ICUs (including internal medicine ICU, surgical ICU and coronary care unit) was 9.2% (122/1328), this was significantly higher than the prevalence of 5.0% (567/11,443) among all patients with non-autoimmune diseases on average (χ
Table 4: Prevalence of cytomegalovirus antigenemia in patients with non-autoimmune diseases in various departments of Peking Union Medical College Hospital, Beijing (2008 to 2018).
Department Totalsamples CMV antigenemiapositive(n) % χ2 P-value Pediatrics 486 12 2.5 Internal Medicine 4,060 172 4.2 Immunology 657 49 7.5 7.548 0.006## Infectious Diseases 2,073 65 3.1 Emergency 1,313 78 5.9 ICUs# 1328 122 9.2 40.9 0.000 Other 1,526 69 4.5 Total 11,443 567 5.0
- 15 # ICUs (intensive care units) include internal medicine ICU (1024 cases), surgical ICU (258 cases) and coronary care unit (46 cases)
- 16 ## Comparison of the incidence of cytomegalovirus antigenemia among patients admitted to the department of immunology (7.5%, 49/657) and patients admitted to all departments, on average (5.0%, 567/11,443). The same patterns were used for other comparisons among patients in Table 4.
A total of 2,481 (56.5%, 2,481/4,335) blood samples with CMV antigenemia previously were recollected and retested after 3 to 2,884 days (up to 7.9 years) from the time of the previous assay. The 2,481 patients with positive CMV antigenemia who were being followed up by analyzing subsequent blood sample results were from the same patients. Patients with SLE had the lowest proportion (23.8%, 461/1,936) of negative conversion of CMV antigenemia, as compared with patients with non-SLE autoimmune diseases (64.3%, 202/314, χ
Table 5: Proportions of negative conversion of cytomegalovirus antigenemia among male and female patients with autoimmune diseases and non-autoimmune diseases at Peking Union Medical College Hospital, Beijing (2008 to 2018).
MaleCMV antigenemiaNeg conv, n (%) FemaleCMV antigenemiaNeg conv, n (%) TotalCMV antigenemiaNeg conv, n (%) χ2 P-value SLE 58(24.5) 403(23.7) 461(23.8) 0.03 0.862# Non-SLE 88(75.9) 114(57.6) 202(64.3) 8.12 0.004## Non-autoimmune diseases 68(64.2) 73(58.4) 141(61.0) Total 214(46.6) 590(29.2) 804(32.4) 51.2 0.000###
- 17 Neg conv, negative conversion
- 18 # Comparison of proportions of negative conversion of cytomegalovirus antigenemia between male and female patients with SLE.
- 19 ## Comparison of proportions of negative conversion of cytomegalovirus antigenemia between male and female patients with non-SLE and non-autoimmune diseases.
- 20 ###Comparison of proportions of negative conversion of cytomegalovirus antigenemia between all male and all female patients.
The number of days from positive to negative conversion of CMV antigenemia in patients with SLE ranged from 3 to 2,884 days, and the mean ± standard deviation (SD) was 133.9±419.9 days with a median of 21 days. Clearly, 2,884 days (7.9 years) is meaningless for calculating the time to negative conversion of CMV antigenemia as there might be many rounds of disease activities during such a long period. Hence, we established the definition that data of 10% of patients with the longest periods to negative conversion would not be used in the calculation and this definition was also applied to calculations for patients with non-SLE autoimmune diseases and non-autoimmune diseases. The number of days was calculated according to above definition and the results are shown in Table 6. The mean number of days to negative conversion of CMV antigenemia in patients with SLE were 35.3±35.8 days, which was significantly more than the 15.4±11.9 days in patients with non-SLE autoimmune diseases (t = 7.32, P<0.001) and the 13.6±7.7 days in patients with non-autoimmune diseases (t = 6.76, P<0.001). The mean number of days until negative conversion of CMV antigenemia was significantly different between male and female patients with non-SLE autoimmune diseases and non-autoimmune diseases (t = 2.80, P = 0.005) but not between male and female patients with SLE (t = 0.287, P = 0.774).
Table 6: Comparison of the number days until negative conversion of cytomegalovirus antigenemia in male and female patients with autoimmune diseases and non-autoimmune diseases at Peking Union Medical College Hospital, Beijing (2008 to 2018).
MaleNumber of days(mean±SD) FemaleNumber of days(mean±SD) TotalNumber of days(mean±SD) t P- value SLE 36.7±37.2 35.1±35.8 35.3±35.8 0.287 0.774# Non-SLE 13.6±8.2 17.1±15.3 15.4±11.9 2.80 0.005## Non-autoimmune diseases 12.1±6.5 15.6±10.2 13.6±7.7 Total 17.0±13.9 28.7±29.8 25.4±26.2 4.00 0.000###
- 21 # Comparison for number of days from positive to negative conversion of CMV antigenemia between male and female patients with SLE.
- 22 ## Comparison for number of days from positive to negative conversion of CMV antigenemia between male and female patients with non-SLE and non-autoimmune diseases.
- 23 ### Comparison for number of days from positive to negative conversion of CMV antigenemia between all male and all female patients.
As shown in Table 2, the average prevalence (35.1%) of CMV antigenemia in patients with autoimmune diseases has exceeded the prevalence in traditionally immunocompromised patients, such as 27.0% in patients with HIV/AIDS and 14.8% in patients post-transplantation. Among our patients with autoimmune diseases, the prevalence of CMV antigenemia in those with SLE (58.6%) was much higher than in patients with non-SLE autoimmune diseases: for example, 20.7% in patients with Sjogren syndrome, 19.8% in patients with rheumatoid arthritis and 14.7% in patients with polymyositis and dermatomyositis. There were many studies supporting the hypothesis that CMV infection plays a role in inducing or triggering autoimmune diseases such as SLE [[
For non-autoimmune diseases, active CMV infection is also common in patients with immunocompromised conditions or those taking immunosuppressive medications containing corticosteroids, such as patients with HIV/AIDS or hemophagocytic lymphohistiocytosis [[
As shown in Table 2, whole female patients with non-SLE autoimmune diseases had significantly higher prevalence of CMV antigenemia than the male patients although sex differences were not found in any particular disease, such as polymyositis and dermatomyositis, or vasculitis due to the limit of sample size. Similarly, females with non-autoimmune diseases were also observed to have higher prevalence of CMV antigenemia than males, confirming that women with non-SLE autoimmune or non-autoimmune diseases are more vulnerable to CMV reactivation than men.
Adolescent patients with SLE equal or less than 20 years old were more likely to have CMV antigenemia than adult or elderly patients with SLE, as shown in Table 3. The reason could be that immunosuppressive treatment is more frequently prescribed among teenagers with SLE [[
To compare the prevalence of CMV antigenemia among various departments (Table 4), we only analyzed data of patients with non-autoimmune diseases because the department of immunology in our hospital is responsible for most diagnosis and treatment of patients with autoimmune diseases. The prevalence of CMV antigenemia in patients admitted to the ICUs was 9.2%, the highest among all patients with non-autoimmune diseases in our study. Active CMV infection is increased among immunocompetent patients admitted to the ICU [[
Zhang, et al [[
S1 File. Excel database of CMVpp65 antigenemia between 2008 and 2018. (XLSX)
We thank Jun Wang and Wenhang Yang at our institution for providing excellent technical assistance. We would like to thank Editage (
By Jingtao Cui, Writing – review & editing; Wenjuan Yan, Writing – original draft; Hongjie Xie, Methodology; Shaoxia Xu, Writing – review & editing; Qiaofeng Wang, Methodology; Weihong Zhang, Methodology and Anping Ni, Writing – review & editing