EBV-associated Hemophagocytic Syndrome Research Articles

Value of metagenomic next-generation sequencing in children with hemophagocytic syndrome with central nervous system involvement

To study the value of metagenomic next-generation sequencing (mNGS) in detecting intracranial Epstein-Barr virus (EBV) infection in children with hemophagocytic syndrome (HPS) with central nervous system involvement. A retrospective analysis was performed for the cerebrospinal fluid mNGS results of 30 HPS children with central nervous system involvement, which were compared with the results of cerebrospinal fluid EBV-DNA detection and serum EBV antibody profile. The change in serum EBV-DNA copy number after treatment was used to evaluate the efficacy of targeted therapy. The positive rate of EBV in cerebrospinal fluid determined by mNGS was significantly higher than that of EBV-DNA in cerebrospinal fluid (100% vs 10%, P<0.001) and had no significant difference from the positive rate of serum EBV antibody profile (100% vs 93%, P>0.05). The median number of sequences determined by mNGS was 2 400, and serum EBV-DNA copy number before treatment was moderately positively correlated with the number of EBV sequences (rs=0.693, P<0.001). The multiple linear regression analysis showed that the number of sequences determined by mNGS in cerebrospinal fluid increased with the increase in serum EBV-DNA copy number before treatment (P<0.05). EBV-associated HPS often results in EBV-infected viral encephalitis, and mNGS can significantly increase the detection rate of EBV in cerebrospinal fluid, which may help with clinical diagnosis.

A Case of EBV-Associated Hemophagocytic Lymphohistiocytosis in Adult: Lessons from the Treatment Process

Hemophagocytic lymphohistiocytosis (HLH), which was first described in 1939 by paediatricians Scott and Robb-Smith, is a life-threatening disease. HLH is characterized as cytokine release syndrome which is caused by excessive but non-malignant activation of macrophages and/or histiocytes in bone marrow and other reticuloendothelial systems. EBV-HLH is the most common type of infection-associated HLH, has a high mortality rate without prompt and effective treatment. A previous study showed that the one-year mortality rate of EBV-HLH patients is 75%. Here we report a case of EBV-associated hemophagocytic syndrome in adult, and the lessons from the treatment process. Through this case, we think that for EBV-related HLH, EBV-DNA should also be monitored in addition to hemophagocytosis-related indicators during treatment. In addition, DEP regimen may not be suitable for patients who have received at least partial response, because impaired immunological functioning may lead to EBV and hemophagocytic re-activity.

Virus-associated hemophagocytic syndrome in renal transplant recipients: report of 2 cases from a single center.

Virus-associated hemophagocytic syndrome (HPS) is a potentially fatal complication of immunosuppression for transplantation. However, it presents with heterogeneous clinical symptoms (fever, disturbed consciousness, and hepatosplenomegaly) and laboratory findings (pancytopenia, elevated hepatic enzyme levels, abnormal coagulation, and hyperferritinemia), impeding diagnosis. Case 1: A 39-year-old female developed fever 4 years after ABO-incompatible living-related renal transplantation. Laboratory findings revealed thrombocytopenia, elevated hepatic enzymes, Epstein-Barr virus (EBV) DNA seropositivity, and hyperferritinemia. EBV-associated HPS was confirmed by bone marrow aspiration. Steroid pulse therapy and etoposide were ineffective. Disseminated intravascular coagulation resulted in multiple organ failure, and the patient died 32 days after disease onset. Case 2: A 67-year-old male was admitted with rotavirus enteritis a month after living-unrelated renal transplantation. He developed sudden-onset high fever, disturbance of consciousness, and tachypnea 8 days after admission. Laboratory findings revealed elevated hepatic enzyme levels, hyperkalemia, and hyperferritinemia. Emergency continuous hemodiafiltration ameliorated the fever, and steroid pulse therapy improved abnormal laboratory values. Varicella-zoster virus meningitis was confirmed by spinal tap. Acyclovir improved consciousness, and he was discharged 87 days after admission. Fatal virus-associated HPS may develop in organ transplant patients receiving immunosuppressive therapy. Pathognomonic hyperferritinemia is useful for differential diagnosis.

Clinical analysis of Epstein-Barr virus-associated hemophagocytic syndrome in children

The primary infection of Epstein-Barr virus (EBV) may results in hemophagocytic syndrome, known as EBV-associated hemophagocytic syndrome (EBV-AHS), but the clinical risk factors complicating this fatal disease in children with infectious mononucleosis (IM) are unknown. The aim of this study was to identify clinical features of EBV-AHS and to evaluate the curative effect of HLH-2004 protocol. The clinical and laboratory data of 644 IM children including 27 children developed into EBV-AHS and 43 HPS children associated with other diseases were retrospectively analyzed and logistic regression was used to identify the clinical risk factors complicating EBV-AHS. The results showed as follows: (1) the prevalence of EBV-AHS in IM children was 4.2% (27/644), and the prevalence in group aged younger than 3 years was higher than in other age groups. The incidence age of EBV-AHS was significantly younger than that of other HPS patients; (2) Liver function damage of group aged older than 7 years was much more severe in HPS patients. (3) Compared with other HPS patients, male patients were more common and liver function damage was severe in EBV-AHS patients, especially in the patients aged at 2 years or younger. (4) The fatality rate in the EBV-AHS patients was 37.0% (10/27). (5)After treatment with HLH-2004 protocol, the fatality rate in patients with EBV-AHS decreased from 50.0% to 18.2%, the overall survival (OS) of 3 years significantly increased (P = 0.032). It is concluded that IM is a benign self-limited disease, of which only about 4.2% patients will develop into EBV-AHS. Clinical risk factors identified in this study may be helpful for early diagnosis of IM children with complicated EBV-ASH, the HLH-2004 protocol can obviously improve prognosis of EBV-HPS.

Atypical Hydroa Vacciniforme-Like Epstein-Barr Virus Associated T/NK-Cell Lymphoproliferative Disorder

Epstein-Barr virus (EBV)-associated T-cell/natural killer (NK)-cell lymphoproliferative disorders (EBV-T/NK-LPDs) accompany severe chronic active EBV infection (CAEBV) or comprise the CAEBV disease entity. The CAEBV disease entity has the common feature of lymphoproliferation of T or NK cells (primarily), and B cells (rarely), with chronic activation of EBV infection. The disease is rare and seems to be more prevalent in East Asian countries. The CAEBV disease entity encompasses heterogenous disorders, including hydroa vacciniforme (HV), hypersensitivity to mosquito bites, EBV-associated hemophagocytic syndrome, NK/T-cell lymphoma, and NK-cell leukemia. Atypical HV-like eruptions are present on sun-exposed and nonexposed areas with facial edema, fever, and hepatosplenomegaly, unlike classic HV. Recently, it has been suggested that classic HV and atypical HV-like eruptions are variants within the same disease spectrum of EBV-T/NK-LPD. We report a Korean boy with an atypical HV-like eruption and various systemic manifestations, including fever, sore throat, abdominal pain, headaches, seizures, and hematologic abnormalities for 2 years. After the initial mild eruption, which resembled a viral exanthem, ulceronecrotic skin lesions gradually developed and were associated with a high-grade fever and constitutional symptoms. He had a CAEBV infection, which showed a predominant proliferation of NK cells with high EBV DNA levels in the peripheral blood. However, in the skin lesions, there were nonneoplastic CD4 T-cell infiltrations predominantly showing a monoclonal T-cell receptor-γ gene rearrangement and positive EBV in situ hybridization.

The Use of Infliximab to Control Recurrent Cytokine Storms in EBV-Associated Angioimmunoblastic Lymphoma and Hemophagocytic Syndrome

Abstract 4887 Introduction:Chronic active Epstein-Barr virus infection (CAEBV) has been implicated in several diseases including hemophagocytic lymphohistiocytosis (EBV-HLH) and lymphomas including Angioimmunoblastic T cell lymphoma. The exact mechanism by which EBV infection causes these complications is currently not well understood. EBV-HLH is a syndrome in which T-cells, NK cells and macrophages are aberrantly activated. Cytokine storms play a major role in cellular damage and organ dysfunction. In the event that the body is unable to clear the EBV viremia, dysregulated T, NK cells and macrophages continue to release cytokines leading to the accumulation of lymphohistiocytic infiltrates into organs and organ damage. Cytokine storms can lead to death from multi-organ failure. During a cytokine storm, levels of several cytokines are elevated including TNF-a, IFN-g, sCD25, IL-12, IL-1, IL-10 and IL-18.1–3 Current lines of therapy of EBV-HLH include steroids, etoposide, cyclosporine, ATG and hematopoietic stem cell transplantation. We report successfully controlling frequent cytokine storms in a patient with EBV induced angioimmunoblastic lymphoma and HLH with weekly infliximab after failure to do so with chemotherapy (CHOP-E; cyclophosphamide, daunorubicin, vincristine, prednisone, etoposide), rituximab and bortezomib. Case:This is a 35 year old African American male with a long history of adenopathy who presented with autoimmune hemolytic anemia, autoimmune thrombocytopenia (ITP), neutropenia with fever and hypotension. Work up revealed persistent EBV viremia and the lymph node biopsy revealed Angioimmunoblastic T cell lymphoma. High dose dexamethasone and Intravenous immunoglobulins (IVIG) failed to control his hemolysis and ITP. Rituximab and bortezomib successfully controlled his autoimmune hemolysis and thrombocytopenia. However, cytokine storm episodes, characterized by high fevers, hypotension and respiratory distress, continued every 1–2 weeks requiring ICU admissions. Chemotherapy (CHOP-E), for his underlying lymphoma, followed by etoposide/steroids (HLH-94 protocol) were also ineffective at controlling his cytokine storms. Considering that he had high levels of TNF-a, infliximab was started in an attempt to control dysregulated macrophages and T-cells, and was able to successfully prevent the cytokine storms. High levels of IL-6, soluble IL-2 receptor and TNF-a were all detected during cytokine storm episodes. The patient is currently getting prepared for an allogeneic stem cell transplant. Discussion:We report successful control of EBV-HLH related cytokine storms, guided by TNF-a levels, with weekly infliximab (Fig 1). Hypercytokinemia is believed to result from dysregulated T cells, NK cells and macrophages as a result of failure to control the EBV viremia. In this case a TNF-a inhibitor (infliximab) was used to control dysregulated macrophages, T and NK cells and block further propagation of inflammatory cytokines. Initially infliximab was initiated on a once every 2 week schedule, however, this failed to prevent cytokine storms with high TNF-a levels. However, weekly dosing of infliximab successfully prevented cytokine storms and controlled his TNF-a levels (Fig 1). Moreover, an attempt to taper off the weekly infliximab and etoposide resulted in relapse of his symptoms and a sharp rise in ferritin levels, a marker for HLH activity (Fig 2). This suggests that infliximab might be an effective therapy in preventing cytokine storms related to EBV-HLH and further studies are warranted. [Display omitted] [Display omitted] Disclosures:Besa:Celgene: Research Funding.

Repeated Epstein-Barr virus-associated hemophagocytic syndrome in a lupus nephritis patient

A 55-year-old Japanese female was diagnosed with systemic lupus erythematosus (SLE) and developed nephrotic syndrome. She was diagnosed with lupus nephritis by a percutaneous renal biopsy. She was treated with intravenous steroid pulse therapy twice, but it proved to be ineffective. She achieved a complete remission after intravenous cyclophosphamide pulse (CPAIV) therapy. Thereafter, her lupus nephritis was well controlled and demonstrated only a low activity. However, she suffered Epstein- Barr virus (EBV)-associated hemophagocytic syndrome (HPS) twice, and in each case she was treated with anticancer drugs and achieved a complete remission. This was a rare case of lupus nephritis who showed repeated EBV-associated HPS.

EBV‐associated hemophagocytic syndrome

General aspect of the marrow: macrophages with prominent phagocytosis of red cells, platelets, and erythroblasts. The marrow is overall hypocellular (MGG, original magnification ×400). High-power view of two characteristic hemophagocytic macrophages. (A) A macrophage with ingested red cells, platelets, erythroblasts, neutrophil, and assorted debris. (B) A macrophage which has engulfed a large number of erythroblasts (MGG, original magnification ×1,000). Hemophagocytic syndrome or hemophagocytic lymphohistiocytosis (HLH) is a rare syndrome characterized by fever, pancytopenia, organomegaly, multiorgan dysfunction, and hemophagocytosis by a large number of macrophages in bone marrow and other tissues [1]. Central to the pathophysiology is the impaired activity of NK and cytotoxic T lymphocytes resulting in uncontrolled immune activation, hypercytokinemia, and proliferation of macrophages. The diagnosis of HLH relies upon well-established criteria [2]. The syndrome has been described in familial conditions or as a secondary phenomenon to infections, malignancies, and collagen vascular diseases. HLH in the context of infection is best described in association with Epstein-Barr virus (EBV). EBV-associated HLH can occur either in primary infection or as a consequence of viral reactivation. EBV can also be the trigger in both familial and secondary cases. Although uncommon, hemophagocytic syndrome is a serious complication of EBV infection and can be fatal in many cases. Early recognition and prompt initiation of treatment are of great importance to reduce the high morbidity and mortality associated with this condition. The history and representative images from a case of EBV-associated hemophagocytic syndrome are described. The patient's consent has been obtained. A 25-year-old woman was admitted with fever, pancytopenia, and hepatic dysfunction. Five weeks previously, she was diagnosed with infectious mononucleosis on the basis of pharyngitis, fever, and positive EBV antibodies. In the weeks after diagnosis, she continued to complain of intermittent fevers and sweating. Past medical and family history were unremarkable. Physical examination revealed temperature 38°C, icteric sclera, and hepatosplenomegaly. Laboratory values included hemoglobin 8.1 g/dL, leucocytes 2,100 μL−1, neutrophils 720 μL−1, platelets 40,000 μL−1, bilirubin 7.4 mg/dL, ALT 135 U/L, LDH 1,080 U/L, triglycerides 459 mg/dL, and ferritin 6,070 ng/mL. Peripheral blood film morphology was unremarkable. The direct and indirect antiglobulin test and screening for cold autoagglutinins gave negative results. The reticulocyte automated count and absolute value were 1.11% and 31,900 μL−1, respectively, indicating impaired production of red cells. Bone marrow aspiration showed numerous macrophages with striking phagocytosis of blood cells and marrow precursors (Images 1 and 2). EBV serologies indicated primary infection, and the EBV-PCR result was 18,000 copies/mL. Genetic testing for familial HLH was negative. The patient was treated with methylprednisolone and intravenous immunoglobulins and eventually recovered completely.

Patients' Peripheral Blood as a Possible Source of Donor-Derived NK Cells for Ex Vivo Expansion and Genetic Modification for Post-Transplant Cellular Immunotherapy In Cord Blood Recipients

AbstractAbstract 2094Haploidentical natural killer (NK) cells can induce and consolidate remission in patients with high-risk acute myeloid leukemia (AML) (Rubnitz et al. J Clin Onc 24: 371, 2010). Recently, significantly reduced relapse rates were observed in AML patients who received killer immunoglobulin-like receptor ligand-mismatched cord blood, suggesting effective alloreactivity of cord blood-derived NK cells (Willemze et al. Leukemia 23: 492, 2009). Cord blood transplantation (CBT) is an effective alternative source for allogeneic hematopoietic cell transplantation in both children and adults. However, its therapeutic efficacy for malignant diseases is limited by the lack of available donor effector cells, such as cytotoxic T lymphocytes, lymphokine-activated killer cells, NK-like T cells and NK cells, for treatment of hematological relapse and posttransplant lymphoproliferative disorder and/or for scheduled posttransplant cellular immunotherapy against refractory diseases. We previously reported a method that induces NK cells to proliferate and reliably allows their genetic modification in healthy individuals and leukemia patients in remission receiving maintenance chemotherapy (Imai et al. Blood 106: 376, 2005). To explore the possibility of using patients' peripheral blood as a source for posttransplant NK cell therapy, we used our method to expand donor-derived NK cells from peripheral blood of CBT recipients early after engraftment. We also examined whether NK cells can be rendered cytotoxic against original leukemia blasts by transferring an antigen-specific artificial immunoreceptor gene. This study was approved by an institutional ethical committee. Patients received CBT for consolidation of hematological malignancy (n=7), neuroblastoma (n=1) or resolution of refractory EBV-associated hemophagocytic syndrome (n=1) with myeloablative (n=7) or reduced intensity conditioning (RIC) regimens (n=2). The patients were enrolled in the study after engraftment and peripheral blood was obtained after appropriate written consent was obtained. A chimerism study using short tandem repeat assays showed complete donor chimerism in all patients except one who received RIC-CBT. The peripheral blood was obtained at a median of 92 days post-CBT (range: 46–303 days) and subjected to ex vivo activation and expansion using a previously described protocol with slight modifications. Briefly, peripheral blood was coincubated with modified K562 cells expressing membrane-bound IL-15 and 4-1BB ligand (K562-mb15-41BBL) in the presence of low-dose IL-2 (10 U/mL). Most patients were on maintenance immunosuppressive therapy with calcineurin inhibitors with (n=3) or without (n=6) systemic corticosteroids. After 7 days of culture, a median 11.0-fold expansion (range: 5.3–28.9-fold) was observed in all but one patient who had been administered chemotherapy with Mylotarg for relapsed AML a few days before the blood sampling. The expansion rate in the first week was less efficient in CBT recipients than in healthy individuals (>20-fold), probably because of the immunosuppressants administered. However, an additional 2-week culture in the presence of high-dose IL-2 (1000 U/mL) yielded a median 206-fold expansion (range: 101–1381-fold in 21 days). The expanded NK cells exhibited upregulation of activating receptors including NKG2D, NCRp30 and NCRp44, and vigorous cytotoxicity against K562 cells (86.8–97.7% at an E/T ratio of 1:1). The NK cells were susceptible to retroviral genetic modification with the MSCV-IRES-GFP vector (median GFP-positive cells, 52.7%, n=10). Finally, peripheral NK cells from patients with acute lymphoblastic leukemia were expanded and transduced with the chimeric immunoreceptor gene anti-CD19-BB-ζ. The donor-derived NK cells expressed large amounts of anti-CD19 chimeric receptors on their surface and killed original leukemia blasts that were highly resistant to NK cell lysis (e.g. anti-CD19 vs. non-signaling receptor: 69% vs. 0% at an E/T ratio of 1:1). These results suggest that, in CBT recipients, ex vivo expansion and genetic modification of donor-derived NK cells from the patients' peripheral blood is feasible. Because peripheral blood can be easily and repeatedly obtained, the method described here will allow multiple scheduled infusions. This preliminary study may lead to a novel strategy for posttransplant donor-NK cell therapy in CBT recipients. Disclosures:No relevant conflicts of interest to declare.

Measurement of Epstein-Barr virus DNA load using a novel quantification standard containing two EBV DNA targets and SYBR Green I dye

BackgroundReactivation of Epstein-Barr virus (EBV) infection may cause serious, life-threatening complications in immunocompromised individuals. EBV DNA is often detected in EBV-associated disease states, with viral load believed to be a reflection of virus activity. Two separate real-time quantitative polymerase chain reaction (QPCR) assays using SYBR Green I dye and a single quantification standard containing two EBV genes, Epstein-Barr nuclear antigen-1 (EBNA-1) and BamHI fragment H rightward open reading frame-1 (BHRF-1), were developed to detect and measure absolute EBV DNA load in patients with various EBV-associated diseases. EBV DNA loads and viral capsid antigen (VCA) IgG antibody titres were also quantified on a population sample.ResultsEBV DNA was measurable in ethylenediaminetetraacetic acid (EDTA) whole blood, peripheral blood mononuclear cells (PBMCs), plasma and cerebrospinal fluid (CSF) samples. EBV DNA loads were detectable from 8.0 × 102 to 1.3 × 108 copies/ml in post-transplant lymphoproliferative disease (n = 5), 1.5 × 103 to 2.0 × 105 copies/ml in infectious mononucleosis (n = 7), 7.5 × 104 to 1.1 × 105 copies/ml in EBV-associated haemophagocytic syndrome (n = 1), 2.0 × 102 to 5.6 × 103 copies/ml in HIV-infected patients (n = 12), and 2.0 × 102 to 9.1 × 104 copies/ml in the population sample (n = 218). EBNA-1 and BHRF-1 DNA were detected in 11.0% and 21.6% of the population sample respectively. There was a modest correlation between VCA IgG antibody titre and BHRF-1 DNA load (rho = 0.13, p = 0.05) but not EBNA-1 DNA load (rho = 0.11, p = 0.11).ConclusionTwo sensitive and specific real-time PCR assays using SYBR Green I dye and a single quantification standard containing two EBV DNA targets, were developed for the detection and measurement of EBV DNA load in a variety of clinical samples. These assays have application in the investigation of EBV-related illnesses in immunocompromised individuals.

Clinical features and changes of peripheral blood lymphocyte subsets in children with EBV-associated hemophagocytic syndrome

Objective To summarize clinical features and changes of peripheral blood lymphocyte subsets in children with EBV-associated hemophagocytic syndrome. Methods Twenty children diagnosed with EBV-AHS were characterized by hemophagocytic syndrome and had the evidence of EBV infection.Clinical characteristics were analyzed and proportions of lymphocyte subsets of CD4+ ,CD8+, CD19+,CD16+CD56+ and CD4+/CD8+ in peripheral venous blood were determined by flow cytometry. Twenty healthy children matched in age and gender with these patients were selected as control. Results In all the diagnostic items of EBV-AHS, fever, decline of cells over two lineages in blood routine, enhanced lactate dehydrogenase ( ＞1 000 U/L) and ferritin ( ＞ 1 500 g/L),decreased high-density lipoprotein occurred in all the patients with an incidence of 100%. The percentages of CD8 + T and CD19 + B in children with EBV-AHS were higher than those in control group(53.70% ± 10.6% vs 27.05% ±8.22%,24.95% ±5.34% vs 11.85 % ± 4. 53 %, respectively), while levels of CD4 + T and CD16 + CD56 + NK cell were lower compared with control group (23.60% ±6. 42% vs 45.20% ±5.74% ,5.55% ±2. 87% vs 14. 70% ±4. 16% ,respectively ,P ＜ 0.01 ). Conclusion Disorder of cellular and humoral immunity happens in patients with EBV-AHS, which could be implicated in the pathogenesis and progression of EBV-AHS. Key words: EBV-associated hemophagocytic syndrome; Immune function; Lymphocyte subsets; Flow cytometry

Progress in diagnosis and treatment of Epstein-Barr virus-associated hemophagocytic syndrome

Hemophagocytic syndrome (HS) is a syndrome characterized with complicated etiology and mechanism,the pathological hallmark of this syndrome is unregulated proliferation and activation of histio-cytes and phagocytosis. HS comprises the primary forms and secondary forms,the primary forms are related to the familial genetic defects,and the secondary forms are caused by acquired infections,especially the Epstein-Barr virus ( EBV) infection. EBV-associated HS is a rapidly progressive disease with a high rate of mortality. In this paper,we aim to review the recent progress in diagnosis and treatment of EBV-associated HS. Key words: Epstein-Barr virus; Hemophagocytic lymphohistiocytosis; Diagnosis; Treatment

Meet the expert: microbiology case presentation severe EBV infection in a 22-year-old male

A 22-year-old male with a history of Type 1 diabetes was admitted to a local hospital in March of this year with generalised malaise and headache. He was noted to have a mild transaminitis, and variant lymphocytes in his blood film. A Monospot test performed at the time was negative. A lumbar puncture was also entirely normal, and he was diagnosed with an unspecified viral illness, and discharged. He re-presented to hospital in early August with a history of headache, fever, dyspnoea and abdominal pain. He was found to have diffuse lymphadenopathy, and massive hepatosplenomegaly. He had variant lymphocytes, thrombocytopenia and severe hepatitis. A mononucleosis screen was positive, and his Epstein-Barr virus (EBV) serology was consistent with primary infection. He had multi-organ failure requiring ventilatory support, vasopressors, continuous haemofiltration, and had marked cholestatic liver function tests. Initial plasma EBV DNA PCR demonstrated 710 000 copies/mL. Testing for cytomegalovirus (CMV) and human herpes virus-6 (HHV-6) was negative. After correction of his coagulopathy and thrombocytopenia, a lymph node biopsy was performed; this showed reactive changes consistent with infectious mononucleosis lymphadenitis, and some evidence of haemophagocytosis. After discussion, it was decided that there were no features of lymphoma on the biopsy. Initial genetic testing for X-linked immunodeficiency was negative. A working diagnosis of EBV-associated haemophagocytic syndrome was made, and he was commenced on cyclosporine, etoposide and hydro-cortisone. Over the next fortnight, his EBV levels reduced slightly, he was able to maintain his own ventilation, and his hepatic function improved, although he remained in anuric renal failure, and was still profoundly pancytopenic. He was discharged to the ward, but developed a severe nosocomial pneumonia with a marked deterioration in his hepatic function. His bilirubin level was elevated at over 400 μmol/L, and he developed intractable seizures secondary to encephalopathy. Six weeks into his hospital admission he died. A post-mortem revealed haemophagocytosis in multiple organs, with high EBV levels throughout the body. Further results of testing for additional primary immunodeficiency disorders are pending. This case raised several issues for us: • spectrum of EBV infections and review of previous cases of fulminant EBV infection at our institution; • histological similarities between EBV lymphadenitis and lymphoma; • pathophysiology and treatment of haemophagocytic syndrome; • association of haemophagocytic syndrome with certain infections.

Epstein-Barr virus persistence in the absence of conventional memory B cells: IgM+IgD+CD27+ B cells harbor the virus in X-linked lymphoproliferative disease patients

AbstractEpstein-Barr virus (EBV) persists in healthy virus carriers within the immunoglobulin (Ig)D−CD27+ (class-switched) memory B-cell compartment that normally arises through antigen stimulation and germinal center transit. Patients with X-linked lymphoproliferative disease (XLP) lack such class-switched memory B cells but are highly susceptible to EBV infection, often developing fatal symptoms resembling those seen in EBV-associated hemophagocytic syndrome (EBV-AHS), a disease caused by aberrant virus entry into the NK- or T-cell system. Here we show that XLP patients who survive primary EBV exposure carry relatively high virus loads in the B-cell, but not the NK- or T-cell, compartment. Interestingly, in the absence of conventional class-switched memory B cells, the circulating EBV load was concentrated within a small population of IgM+IgD+CD27+ (nonswitched) memory cells rather than within the numerically dominant naive (IgM+IgD+CD27−) or transitional (CD10+CD27−) subsets. In 2 prospectively studied patients, the circulating EBV load was stable and markers of virus polymorphism detected the same resident strain over time. These results provide the first definitive evidence that EBV can establish persistence in the B-cell system in the absence of fully functional germinal center activity and of a class-switched memory B-cell compartment.

Successful treatment of refractory Langerhans cell histiocytosis by allogeneic peripheral blood stem cell transplantation

We describe a six-yr-old boy who exhibited typical signs and symptoms of LCH with EBV-associated hemophagocytic syndrome from the age of 15 months. Multiple courses of conventional chemotherapy achieved only marginal improvement over the ensuring five yr. During this period, this boy experienced recurrent episodes of hemophagocytic syndrome associated with CMV infection. Five yr after the first diagnosis of LCH, the patient was treated with allogeneic PBSCT from his HLA-identical eight-yr-old brother. PBSCT was performed using a TBI-incorporating conditioning regimen comprising TBI, busulfan, and cyclophosphamide. Diabetes insipidus, typically a permanent consequence of LCH, was well controlled by DDAVP therapy. At the time of writing, this boy is alive and well, and had been disease-free for more than two yr after the PBSCT.

Epidermal cell necrosis with direct epidermal infiltration of Epstein–Barr virus (EBV)-encoded small nuclear RNA-positive T lymphocytes in a patient with EBV-associated haemophagocytic syndrome

British Journal of DermatologyVolume 157, Issue 5 p. 1053-1056 Epidermal cell necrosis with direct epidermal infiltration of Epstein–Barr virus (EBV)-encoded small nuclear RNA-positive T lymphocytes in a patient with EBV-associated haemophagocytic syndrome Y. Kawachi, Y. Kawachi Department of Dermatology, Institute of Clinical Medicine, University of Tsukuba, 1-1-1 Ten-nodai, Tsukuba, Ibaraki 305-8575, JapanE-mail: kyasuhir@md.tsukuba.ac.jpSearch for more papers by this authorM. Itoh, M. Itoh Department of Dermatology, Institute of Clinical Medicine, University of Tsukuba, 1-1-1 Ten-nodai, Tsukuba, Ibaraki 305-8575, JapanE-mail: kyasuhir@md.tsukuba.ac.jpSearch for more papers by this authorY. Fujisawa, Y. Fujisawa Department of Dermatology, Institute of Clinical Medicine, University of Tsukuba, 1-1-1 Ten-nodai, Tsukuba, Ibaraki 305-8575, JapanE-mail: kyasuhir@md.tsukuba.ac.jpSearch for more papers by this authorJ. Furuta, J. Furuta Department of Dermatology, Institute of Clinical Medicine, University of Tsukuba, 1-1-1 Ten-nodai, Tsukuba, Ibaraki 305-8575, JapanE-mail: kyasuhir@md.tsukuba.ac.jpSearch for more papers by this authorY. Nakamura, Y. Nakamura Department of Dermatology, Institute of Clinical Medicine, University of Tsukuba, 1-1-1 Ten-nodai, Tsukuba, Ibaraki 305-8575, JapanE-mail: kyasuhir@md.tsukuba.ac.jpSearch for more papers by this authorT. Banno, T. Banno Department of Dermatology, Institute of Clinical Medicine, University of Tsukuba, 1-1-1 Ten-nodai, Tsukuba, Ibaraki 305-8575, JapanE-mail: kyasuhir@md.tsukuba.ac.jpSearch for more papers by this authorT. Takahashi, T. Takahashi Department of Dermatology, Institute of Clinical Medicine, University of Tsukuba, 1-1-1 Ten-nodai, Tsukuba, Ibaraki 305-8575, JapanE-mail: kyasuhir@md.tsukuba.ac.jpSearch for more papers by this authorF. Otsuka, F. Otsuka Department of Dermatology, Institute of Clinical Medicine, University of Tsukuba, 1-1-1 Ten-nodai, Tsukuba, Ibaraki 305-8575, JapanE-mail: kyasuhir@md.tsukuba.ac.jpSearch for more papers by this author Y. Kawachi, Y. Kawachi Department of Dermatology, Institute of Clinical Medicine, University of Tsukuba, 1-1-1 Ten-nodai, Tsukuba, Ibaraki 305-8575, JapanE-mail: kyasuhir@md.tsukuba.ac.jpSearch for more papers by this authorM. Itoh, M. Itoh Department of Dermatology, Institute of Clinical Medicine, University of Tsukuba, 1-1-1 Ten-nodai, Tsukuba, Ibaraki 305-8575, JapanE-mail: kyasuhir@md.tsukuba.ac.jpSearch for more papers by this authorY. Fujisawa, Y. Fujisawa Department of Dermatology, Institute of Clinical Medicine, University of Tsukuba, 1-1-1 Ten-nodai, Tsukuba, Ibaraki 305-8575, JapanE-mail: kyasuhir@md.tsukuba.ac.jpSearch for more papers by this authorJ. Furuta, J. Furuta Department of Dermatology, Institute of Clinical Medicine, University of Tsukuba, 1-1-1 Ten-nodai, Tsukuba, Ibaraki 305-8575, JapanE-mail: kyasuhir@md.tsukuba.ac.jpSearch for more papers by this authorY. Nakamura, Y. Nakamura Department of Dermatology, Institute of Clinical Medicine, University of Tsukuba, 1-1-1 Ten-nodai, Tsukuba, Ibaraki 305-8575, JapanE-mail: kyasuhir@md.tsukuba.ac.jpSearch for more papers by this authorT. Banno, T. Banno Department of Dermatology, Institute of Clinical Medicine, University of Tsukuba, 1-1-1 Ten-nodai, Tsukuba, Ibaraki 305-8575, JapanE-mail: kyasuhir@md.tsukuba.ac.jpSearch for more papers by this authorT. Takahashi, T. Takahashi Department of Dermatology, Institute of Clinical Medicine, University of Tsukuba, 1-1-1 Ten-nodai, Tsukuba, Ibaraki 305-8575, JapanE-mail: kyasuhir@md.tsukuba.ac.jpSearch for more papers by this authorF. Otsuka, F. Otsuka Department of Dermatology, Institute of Clinical Medicine, University of Tsukuba, 1-1-1 Ten-nodai, Tsukuba, Ibaraki 305-8575, JapanE-mail: kyasuhir@md.tsukuba.ac.jpSearch for more papers by this author First published: 24 August 2007 https://doi.org/10.1111/j.1365-2133.2007.08142.xCitations: 9 Conflicts of interest: none declared. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume157, Issue5November 2007Pages 1053-1056 RelatedInformation

Epstein-Barr Virus (EBV) Latent Membrane Protein-1 Down-Regulates Tumor Necrosis Factor-α (TNF-α) Receptor-1 and Confers Resistance to TNF-α-Induced Apoptosis in T Cells: Implication for the Progression to T-Cell Lymphoma in EBV-Associated Hemophagocytic Syndrome

The infection of T cells by Epstein-Barr virus (EBV) may result in hemophagocytic syndrome (HPS) through enhanced cytokine secretion, particularly tumor necrosis factor-alpha (TNF-alpha), by EBV latent membrane protein-1 (LMP-1). One bewildering observation of HPS patients is relapsing disease or progression to T-cell lymphoma. This finding raises the question whether EBV LMP-1-expressing T cells may survive and proliferate in the cytokine milieu of HPS. To explore this possibility, we tested the sensitivity of LMP-1-expressing T cells to apoptosis in the presence of TNF-alpha. LMP-1 up-regulated TNF-alpha through TRAF2,5 and nuclear factor-kappaB pathway in T cells. The LMP-1-expressing T cells then became resistant to TNF-alpha-induced apoptosis. Interestingly, the expression of TNFR1 was remarkably down-regulated by LMP-1 in T cells. Furthermore, the TNF-alpha/TNFR1 downstream death signal TNFR1-associated death domain protein was constitutively recruited by LMP-1, and the activities of apoptotic caspases 3, 8, and 9 were suppressed. Reconstitution of TNFR1 successfully reversed the TNF-alpha-induced apoptotic cascades. Therefore, EBV LMP-1 not only activates T cells to proliferate but also confers resistance to TNF-alpha-mediated apoptosis via down-regulation of TNFR1 in the cytokine milieu of HPS. This finding provides a potential mechanism to explain the disease persistence or progression to T-cell lymphoma in HPS patients.

Emergence of Anti-Red Blood Cell Antibodies Triggers Red Cell Phagocytosis by Activated Macrophages in a Rabbit Model of Epstein-Barr Virus-Associated Hemophagocytic Syndrome

Hemophagocytic syndrome (HPS) is a fatal complication frequently associated with viral infections. In childhood HPS, Epstein-Barr virus (EBV) is the major causative agent, and red blood cells (RBCs) are predominantly phagocytosed by macrophages. To investigate the mechanism of RBC phagocytosis triggered by EBV infection, we adopted a rabbit model of EBV-associated HPS previously established by using Herpesvirus papio (HVP). The kinetics of virus-host interaction was studied. Using flow cytometry, we detected the emergence of antibody-coated RBCs, as well as anti-platelet antibodies, at peak virus load period at weeks 3 to 4 after HVP injection, and the titers increased thereafter. The presence of anti-RBCs preceded RBC phagocytosis in tissues and predicted the full-blown development of HPS. The anti-RBC antibodies showed cross-reactivity with Paul-Bunnell heterophile antibodies. Preabsorption of the HVP-infected serum with control RBCs removed the majority of anti-RBC activities and remarkably reduced RBC phagocytosis. The RBC phagocytosis was specifically mediated via an Fc fragment of antibodies in the presence of macrophage activation. Therefore, the emergence of anti-RBC antibodies and the presence of macrophage activation are both essential in the development of HPS. Our observations in this animal model provide a potential mechanism for hemophagocytosis in EBV infection.

Late-Onset Fatal Epstein-Barr Virus-Associated Hemophagocytic Syndrome following Cord Blood Cell Transplantation for Adult Acute Lymphoblastic Leukemia

A 43-year-old Japanese woman underwent unrelated cord blood transplantation (CBT) during remission for acute lymphoblastic leukemia with t(4; 11)(q21;q23). Tacrolimus was given for prophylaxis of graft-versus-host disease. The posttransplantation clinical course was mostly uneventful, and the leukemia remained in remission. Fourteen months after CBT, the patient developed pancytopenia and hepatic dysfunction with persistent high-grade fever. The bone marrow was hypocellular with increased numbers of macrophages and hemophagocytes. The numbers of Epstein-Barr virus (EBV) copies in peripheral blood samples were remarkably high. Although the patient showed complete donor-type hematopoiesis, the titer of viral capsid antigen immunoglobulin G was low, and the results of a test for EBV nuclear antigen were negative. There was no clinical response to the reduction of immunosuppressive therapy or to the administration of high-dose methylprednisolone, human immunoglobulin, or acyclovir. The patient died 466 days after CBT of massive gastrointestinal hemorrhage due to bone marrow and hepatic failures. This case demonstrates that fatal EBV-associated hemophagocytic syndrome (HPS) can occur more than 1 year after CBT. This report is the first of a case of late-onset EBV-associated HPS following CBT.

MR Findings of Fulminent Leukoencephalopathy in EBV-Associated Hemophagocytic Syndrome

Various manifestations of brain involvement for patients with virus-associated hemophagocytic syndrome have been reported. Here, we report on the sequential magnetic resonance (MR) findings of acute demyelination of the entire brain with subsequent brain atrophy in a follow-up study of a 25-month-old boy who was admitted with fever and then diagnosed with infectious mononucleosis and EBV-associated hemophagocytic syndrome. We also review other conditions that should be included in the differential diagnosis of this disease.