Human T-Cell Lymphotropic Viruses Follow-up: Deterrence/Prevention, Complications, Prognosis

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Follow-up

Deterrence/Prevention

Strategies for human T-cell lymphotropic virus (HTLV) infection prevention should include education regarding transmission on a global and individual basis. Both HTLV-1 and HTLV-2 can be transmitted through breastfeeding, sexual contact, and direct blood-to-blood contact.

Women diagnosed with HTLV infection should not breast feed. In Japan, HTLV screening is a standard procedure in pregnant women, and seropositive women are discouraged from breastfeeding. One caveat is that infant malnutrition result from breastfeeding avoidance in endemic developing nations.

The routine use of latex condoms should be recommended, as well as limiting the number of sexual partners.

Parenteral transmission of HTLV is prevented through abstaining from needle sharing and through blood-donor screening.

Complications

Complications of HTLV infection are due mostly to end-stage diseases rather than to the infection itself, as the vast majority of individuals with this infection are asymptomatic. However, the following should be kept in consideration:

HTLV-1 is a risk factor for the development of severe strongyloidiasis; close follow-up of patients following treatment for strongyloidiasis is recommended.^[49]

Patients with adult T-cell leukemia (ATL) are immunocompromised, potentially leading to opportunistic infections including the following:

Pneumocystis jiroveci pneumonia: Prophylaxis with sulfamethoxazole-trimethoprim should be initiated.
Cryptococcal meningitis
Fungal infections
Viral infections (eg, cytomegalovirus, herpes zoster, herpes simplex)
S stercoralis infection: Prophylaxis with ivermectin or albendazole should be considered in patients with a history of past or present exposure or positive serology results. ^[49]

Co-infection of either HTLV-1 or HTLV-2 with HIV remains a controversial topic.

Conclusive and reproducible data of such coinfections are not yet available, as most of the data are limited by the testing methodology.

Theoretically, HTLV-1 and HIV affect the same cell type, and the additive result might be detrimental to the immune system, leading to faster progression to AIDS. Future research might lead to recommendations concerning coinfections (eg, starting HAART or prophylaxis for opportunistic infections); however, no specific guidelines exist at this time. A recent retrospective cohort study of Peruvian men with HIV/HTLV-1 coinfection did not show that coinfection increased the risk of death.^[50]This area remains controversial, as some studies show an unfavorable outcome for HIV/HTLV-1 coinfection, while others do not.

No evidence has shown that HIV/HTLV-2 coinfection leads to faster progression to AIDS; in fact, coinfection might have some protective effects based on in vitro studies.^[51]

Prognosis

Infection with HTLV-1 or HTLV-2 is lifelong, and most (95%) infected individuals remain asymptomatic throughout life, without progression to any end-point diseases.

The latency period for ATL is about 20-40 years. Patients with smoldering and chronic type ATL live an average of 2 years, and those with acute and lymphoma-type ATL live an average of 6 months. Chemotherapy or interferon plus antiretroviral drugs can produce complete remission, but the median survival remains under 2 years.

HTLV-1–associated myelopathy/tropical spastic paraparesis (HAM/TSP) carries a poor prognosis. The latency period ranges from a few months to 30 years postinfection. Within 10 years of onset, despite therapy, most patients are unable to walk unassisted and are wheelchair-bound within 21 years.^[41]

Patient Education

Patients determined to have infection with any subtype of HTLV should share this information with their physicians and undergo regular follow-up.

Education should focus on preventing transmission to others through unprotected sexual activity. Sexual partners of patients with HTLV-1 infection who are in a mutually monogamous sexual relationship should consider being tested. If the partner is positive then no further recommendation is warranted. If the partner is negative, then the use of latex condoms is advised. Specific testing guidelines for partners of HTLV-2 infected individuals have not been established.

Patients should be instructed to avoid sharing needles.

Women with HTLV-1 or HTLV-2 infection should not breast feed their infants. If this is unfeasible (ie, women in undeveloped countries), breastfeeding should be limited to the first 6 months.

Patients should be counseled against donating blood, body organs, or tissues.

Patients with HTLV-1 infection should be informed about the 1%-6% lifetime chance of developing ATL or HAM/TSP.^[43]

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Author

Ewa Maria Szczypinska, MD Fellow, Department of Infectious Diseases, Orlando Health

Ewa Maria Szczypinska, MD is a member of the following medical societies: Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Coauthor(s)

Mark R Wallace, MD, FACP, FIDSA Clinical Professor of Medicine, Florida State University College of Medicine; Clinical Professor of Medicine, University of Central Florida College of Medicine

Mark R Wallace, MD, FACP, FIDSA is a member of the following medical societies: American College of Physicians, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, International AIDS Society, Florida Infectious Diseases Society

Disclosure: Nothing to disclose.

Booth Wainscoat, DO Assistant Director, Division of Infectious Disease, Hartford Hospital; Assistant Professor of Clinical Medicine, University of Connecticut School of Medicine

Booth Wainscoat, DO is a member of the following medical societies: Infectious Diseases Society of America

Disclosure: Received consulting fee from Gilead for consulting.

Christopher Mark Salas, MD Fellow, Department of Infectious Diseases, Lifespan, The Warren Alpert Medical School of Brown University

Disclosure: Nothing to disclose.

Josiah D Rich, MD, MPH Professor of Medicine and Epidemiology, Brown University Medical School

Josiah D Rich, MD, MPH is a member of the following medical societies: American College of Physicians, American Federation for Medical Research, American Medical Association, American Public Health Association, Infectious Diseases Society of America, Massachusetts Medical Society, Rhode Island Medical Society

Disclosure: Received ownership interest from alkermes stockholder for none; Received ownership interest from isis stockholder for none; Received ownership interest from repligen for none.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Joseph F John, Jr, MD, FACP, FIDSA, FSHEA Clinical Professor of Medicine, Molecular Genetics and Microbiology, Medical University of South Carolina College of Medicine; Associate Chief of Staff for Education, Ralph H Johnson Veterans Affairs Medical Center

Joseph F John, Jr, MD, FACP, FIDSA, FSHEA is a member of the following medical societies: Charleston County Medical Association, Infectious Diseases Society of America, South Carolina Infectious Diseases Society

Disclosure: Nothing to disclose.

Chief Editor

Pranatharthi Haran Chandrasekar, MBBS, MD Professor, Chief of Infectious Disease, Department of Internal Medicine, Wayne State University School of Medicine

Pranatharthi Haran Chandrasekar, MBBS, MD is a member of the following medical societies: American College of Physicians, American Society for Microbiology, International Immunocompromised Host Society, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

Joseph R Masci, MD, FACP, FCCP Professor of Medicine, Professor of Preventive Medicine, Icahn School of Medicine at Mount Sinai; Director of Medicine, Elmhurst Hospital Center

Joseph R Masci, MD, FACP, FCCP is a member of the following medical societies: American Association for the Advancement of Science, American College of Chest Physicians, American College of Physicians, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, International AIDS Society, International Society for Infectious Diseases, New York Academy of Medicine, New York Academy of Sciences, Physicians for Social Responsibility, Royal Society of Medicine, Association of Program Directors in Internal Medicine, Physicians for Human Rights, Association of Professors of Medicine, HIV Medicine Association, American Academy of HIV Medicine, Association of Specialty Professors, International Association of Providers of AIDS Care, Federation of American Scientists, American Society of Tropical Medicine and Hygiene

Disclosure: Nothing to disclose.

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