Epstein-Barr Virus Reactivation In Patients Research Articles

Could Immune Checkpoint Disorders and EBV Reactivation Be Connected in the Development of Hematological Malignancies in Immunodeficient Patients?

Primary immunodeficiencies (PIDs) and secondary immunodeficiencies (SIDs) are characterized by compromised immune function, rendering individuals susceptible to infections and potentially influencing cancer development. Epstein-Barr virus (EBV), a widespread herpesvirus, has been linked to cancer, particularly in those with weakened immune systems. This study aims to compare selected immune parameters, focusing on immune checkpoint molecules (PD-1/PD-L1, CTLA-4/CD86, CD200R/CD200), and EBV reactivation in patients with chronic lymphocytic leukemia (CLL, a representative of SIDs) and common variable immunodeficiency (CVID, a representative of PIDs). We performed a correlation analysis involving patients diagnosed with CLL, CVID, and a healthy control group. EBV reactivation was assessed using specific antibody serology and viral load quantification. Peripheral blood morphology, biochemistry, and immunophenotyping were performed, with emphasis on T and B lymphocytes expressing immune checkpoints and their serum concentrations. Our findings revealed elevated EBV reactivation markers in both CLL and CVID patients compared with healthy controls, indicating increased viral activity in immunodeficient individuals. Furthermore, immune checkpoint expression analysis demonstrated significantly altered percentages of T and B lymphocytes expressing PD-1/PD-L1, CTLA-4/CD86, and CD200R/CD200 in CLL and CVID patients. This suggests a potential interplay between immune checkpoint dysregulation and EBV reactivation in the context of immunodeficiency. In conclusion, our study underscores the intricate relationship between immune dysfunction, EBV reactivation, and immune checkpoint modulation in the context of immunodeficiency-associated cancers. The altered expression of immune checkpoints, along with heightened EBV reactivation, suggests a potential mechanism for immune evasion and tumor progression. These findings provide insights into the complex interactions that contribute to cancer development in immunocompromised individuals, shedding light on potential therapeutic targets for improved management and treatment outcomes. Further investigations are warranted to elucidate the underlying mechanisms and to explore potential interventions to mitigate cancer risk in these patient populations.

Machine Learning Algorithm As a Prognostic Tool for Epstein-Barr Virus Reactivation after Haploidentical Hematopoietic Stem Cell Transplantation

AbstractBackground: Epstein-Barr virus (EBV) reactivation is one of the most important infections after haploidentical related donor (HID) hematopoietic stem cell transplantation (HSCT). We aimed to establish a comprehensive model with machine learning, which could predict EBV reactivation after HID HSCT with antithymocyte globulin (ATG) for graft-versus-host disease (GVHD) prophylaxis. Method: We enrolled 470 consecutive acute leukemia patients, 60% of them (n=282) were randomly selected as training cohort, and the remains 40% (n=188) were used as validation cohort. Results: The equation was as follows: Probability (EBV reactivation) = , where Y = 0.0250 × (age) - 0.3614 × (gender) + 0.0668 × (underlying disease) - 0.6297 × (disease status before HSCT) - 0.0726 × (DRI) - 0.0118 × (HCT-CI score) + 1.2037 × (HLA disparity) + 0.5347 × (EBV serostatus) + 0.1605 × (conditioning regimen) - 0.2270 × (donor/recipient gender matched) + 0.2304 × (donor/recipient relation) - 0.0170 × (mononuclear cell counts in graft) + 0.0395 × (CD34+ cells count in graft) - 2.4510. The threshold of probability was 0.4623, which separated patients into low- and high-risk groups. The 1-year cumulative incidence of EBV reactivation in the low- and high-risk groups was 11.0% versus 24.5% (P < 0.001), 10.7% versus 19.3% (P = 0.046), and 11.4% versus 31.6% (P = 0.001), respectively, in total, training, and validation cohorts. It also could predict relapse and survival after HID HSCT. Conclusion: We established a comprehensive model which could predict EBV reactivation in HID HSCT recipients using ATG for GVHD prophylaxis. Importance：We established a comprehensive model with machine learning in HID HSCT recipients using ATG for graft-versus-host disease prophylaxis, which separated patients into low- and high-risk groups. It could predict EBV reactivation in total, training, and validation cohort. It could predict EBV reactivation in patient with or without CMV infection, and it could also predict EBV reactivation in patients with or without acute GVHD. It could also predict relapse and survival after HID HSCT. This was the first predicted model for these patients who have a high risk of EBV reactivation and it can be popularized easily. It can also help to conduct risk stratification−directed EBV prophylaxis after HID HSCT. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Novel Risk Factors for Epstein-Barr Virus (EBV) Reactivation and Post-Transplant Lymphoproliferative Disorder (PTLD) after Allogeneic Hematopoietic Stem Cell Transplant

Background: Epstein-Barr virus (EBV) reactivation and EBV-positive post-transplant lymphoproliferative disorder (EBV+PTLD) are often fatal complications following allogeneic hematopoietic stem cell transplant (HSCT). Risk factors for the development of EBV+PTLD after HSCT include human leukocyte antigen (HLA) mismatches, T cell depletion (TCD) and older age, among others. It has been proposed that specific HLA haplotypes are associated with the development of EBV+PTLD after solid organ transplant (SOT) and that pre-emptive use of Rituximab can reduce the risk of EBV+PTLD. We present a retrospective analysis of patients who underwent HSCT in order to determine the impact of donor source, TCD, age, HLA-A1 haplotypes and use of Rituximab prior to HSCT on the development of EBV reactivation and EBV+PTLD after HSCT.Methods: We retrospectively reviewed patients who had undergone allogeneic HSCT at our Institution between January 2012 and December 2016. We analyzed the cumulative incidence of EBV reactivation and EBV+PTLD and the impact of known and novel risk factors.Results: Of 474 patients, 10% developed EBV reactivation and 6% were diagnosed with EBV+PTLD. The cumulative incidence of EBV reactivation and EBV+PTLD was 15% and 11%, respectively, after haplo-cord HSCT, compared to 3% and 2% after MRD HSCT and 8% and 5% after MUD HSCT (p=0.0004 and p=0.02, respectively). EBV reactivation was associated with receipt of ATG compared to Alemtuzumab (p=0.03) and age older than 60 years (p=0.004). The presence of HLA-A1 haplotype in the recipient did not affect the incidence of EBV reactivation and EBV+PTLD (p=0.2 and p=0.9, respectively). The cumulative incidence of EBV reactivation and EBV+PTLD was lower in patients with Rituximab exposure prior to HSCT, although this did not reach statistical significance (p=0.2 and p=0.15, respectively). In a multivariate analysis, donor source (haplo-cord vs HLA-matched) and age older than 60 were found to be independent risk factors for the development of EBV reactivation (HR 1.9; p=0.038 and HR 2.6; p=0.002, respectively) and EBV+PTLD (HR 1.9; p=0.020 and HR 3.5; p=0.004, respectively). PTLD was fatal in 8 of 27 patients (29%) with PTLD and 17% of all patients with EBV reactivation. One patient died of disseminated EBV disease without PTLD.Conclusions: The cumulative incidence of EBV viremia and PTLD after allogeneic HSCT was 10% and 6%, respectively, and led to death in 2% of the patients. Haplo-cord grafts and age older than 60 years were independent risk factors for EBV reactivation and EBV+PTLD. Rituximab use prior to HSCT may confer protection against EBV reactivation and its use in the conditioning regimen of patients undergoing HSCT, at high risk for EBV reactivation, should be studied prospectively. Further studies are needed to determine the impact of HLA haplotypes on the incidence of EBV reactivation in patients after HSCT. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Frequent co-reactivation of Epstein-Barr virus in patients with cytomegalovirus viremia under immunosuppressive therapy and/or chemotherapy.

ObjectiveCo-reactivation of cytomegalovirus (CMV) and Epstein–Barr virus (EBV) occurs in iatrogenically immunosuppressed patients, but the clinical relevance of this is unknown. We aimed to determine the frequency of EBV reactivation in patients with CMV viremia and to explore its clinical significance.MethodsSerum or plasma CMV and EBV DNA was detected by quantitative real-time PCR in 82 patients who received immunosuppressive therapy and/or chemotherapy and underwent CMV antigenemia tests.ResultsCMV DNA was positive in 55 patients, with EBV reactivation being found in 29 of these (52.7%). EBV co-reactivation was significantly associated with aging (>64 years vs. ≤64 years, odds ratio 4.07, 95% confidence interval 1.06–15.6). When older patients were divided into two groups according to age, EBV co-reactivation occurred more frequently in early-old patients (aged 65–74 years) than in late-old patients (aged ≥75 years) (100.0% vs. 53.3%, respectively). Steroid pulse treatment was administered significantly more often in the early-old group than in those aged ≤64 years and ≥75 years (72.7% vs 27.6% vs 14.3%, respectively).ConclusionsCo-reactivation of EBV in patients with CMV viremia highlighted early-old patients and may reflect treatment intensity as well as immunosenescence.

Immunosuppressant indulges EBV reactivation and related lymphoproliferative disease by inhibiting Vδ2+ T cells activities after hematopoietic transplantation for blood malignancies

BackgroundFollowing the extensive use of immunosuppressive drugs in the clinic, immunosuppression-associated side effects have received increasing attention. Epstein-Barr virus (EBV) reactivation and related lymphoproliferative diseases (LPD) are the lethal complications...

PS1543 RELIEVING IMMUNOSUPPRESSION IMPROVES VΔ2+ T CELLS RECOVERY AND DECREASES EBV REACTIVATION AFTER HEMATOPOIETIC TRANSPLANTATION

Background:Immunosuppressive drugs have been widely used for transplantation over the last decade. Mycophenolate mofetil (MMF) and cyclosporine A (CsA) are usually used to prevent and treat graft‐versus‐host disease (GVHD) in the context of hematopoietic stem cell transplantation (HSCT). With the numerous studies reported the clinical efficacy of immunosuppressants, attentions for their side effects, such as opportunistic infections, are increasing. Epstein–Barr virus (EBV) reactivation and its related diseases are the common threats with high mortality after haploidentical HSCT (haploHSCT). Although the immunosuppression was associated with EBV infection after solid organ transplantation, this correlation has been less reported in the scenario of hematopoietic transplantation. We previously showed that recovery of Vδ2+ T cells inversely correlated to EBV reactivation after haploHSCT and Vδ2+ T cells isolated from haploHSCT recipients were not expanded by aminobisphosphonates stimulation. The influence of immunosuppressants on the Vδ2+ T cells recovery and anti‐EBV cytotoxicity post‐HSCT are unknown.Aims:To investigate the impacts of immunosuppressive drugs on the Vδ2+ T cells expansion and function, and whether relieving the immunosuppression can improve Vδ2+ T cells recovery and decrease EBV reactivation in the setting of allogeneic HSCT.Methods:Mycophenolic acid (MPA) is an active form of MMF and usually used in the in‐vitro functional experiments. Pamidronate was used to trigger the expansion of Vδ2+ T cells in peripheral blood mononuclear cells isolated from healthy donors, with or without immunosuppressants (MPA and CsA). The activation, proliferation, functional receptor expression, cytokines production, and EBV‐specific cytotoxicity of Vδ2+ T cellswere detected by flow cytometry. This study also included a cohort of 165 patients undergoing haploHSCT. These patients were divided into 2 groups based on the different courses of MMF administration for GVHD prophylaxis. The recoveries of T‐cell subsets and incidences of EBV reactivation were statistically compared.Results:Peripheral Vδ2+ T cells from healthy donors were dramatically expanded by pamidronate stimulation for 10 days, with the percentage of Vδ2+ T cells in total MNCs was increased from 2.8% to 89%. In contrast, MPA and CsA treatment profoundly attenuated this expansion given that Vδ2 cells levels were even lower than baseline under the same condition. The activation (expression of CD25) and IFN‐γ production of Vδ2 cells were inhibited while NKG2D expression was moderately decreased by both drugs. Consistently, EBV‐specific cytotoxicity of Vδ2 cells were also impaired after treatment with MPA and CsA. The recoveries of T‐cell subsets were monitored in patients with different courses of MMF following haploHSCT. Recoveries of other detected T‐cell subpopulations at day 30 were significantly faster in the shorter MMF group than the longer MMF group. The level of Vδ2 cells was continuously increased from 30 to 90 days post‐haploHSCT after reducing the course of MMF, accompanied with a decreased incidence of EBV reactivation. Day‐30 Vδ2 levels remained an independent factor for EBV reactivation in patients with different MMF durations.Summary/Conclusion:Reliving the suppression of MMF and CsA is favorable to anti‐EBV immunity probably through recovering Vδ2 cells expansion and function. These findings will help improve the outcome of hematopoietic transplant.

Elevated Levels of Interferon-γ Are Associated with High Levels of Epstein-Barr Virus Reactivation in Patients with the Intestinal Type of Gastric Cancer.

Background The inflammatory response directed against Helicobacter pylori (HP) is believed to be one of the main triggers of the appearance of gastric lesions and their progression to gastric cancer (GC). Epstein-Barr virus (EBV) has been found responsible for about 10% of all GCs, but the inflammatory response has not been studied in GC patients with evidence of high levels of EBV reactivation. Objective To determine the relationship between inflammation and antibodies against EBV reactivation antigens, HP, and the bacterium virulence factor CagA in patients with GC. Methods 127 GC patients, 46 gastritis patients, and 197 healthy subjects were studied. IL-1β, IL-6, IL-8, IL-10, TNF-α, TGF-β, MCP-1, and IFN-γ levels were measured in serum or plasma and compared against the antibody titers of VCA-IgG, HP, and the HP virulence factor CagA. Statistical associations were estimated. Results Significant ORs and positive trends were found between VCA-IgG and IFN-γ, specifically for patients with GC of intestinal type (OR: 6.4, 95% C.I. 1.2–35.4) (p < 0.044). Conclusions We confirmed a positive association between a marker of EBV reactivation and intestinal gastric cancer and present evidence of a correlation with elevated serum levels of IFN-γ, but not with the other cytokines.

Cytomegalovirus and Epstein-Barr virus reactivation in the intensive care unit.

The purpose of this work was to evaluate the reactivation of cytomegalovirus (CMV) and Epstein-Barr virus (EBV) in immunocompetent patients in the intensive care unit (ICU) and to identify risk factors associated with reactivation. In this observational prospective study, 60adult immunocompetent patients who stayed at least 7days in an ICU were evaluated. During hospitalization, the viral load was monitored at admission and on day 7 with polymerase chain reaction to detect viral reactivation and weekly thereafter on days 14, 21, and 28 if hospitalization continued. The mean age of patients was 63.3years (±23.4years) and 34 (56.7 %) of them were male. Mean APACHE II scores for patients was 25at admission. Of these patients, 28 were hospitalized in the internal ICU and 32 were hospitalized in the anesthesiology ICU. CMV/EBV reactivation was found in 17individuals (12 for EBV, 3 for CMV, and 2 for both). The median high-sensitive C-reactive protein value in patients with CMV reactivation was significantly higher than in those patients without CMV reactivation (p= 0.037). EBV reactivation was statistically higher in patients with mechanical ventilation compared to patients without mechanical ventilation (p= 0.023). EBV reactivation in patients with fever was found to be statistically higher than in the patients without fever (p= 0.035). There is aneed for extended studies with alarger number of patients from specific groups to better understand the reactivation frequency and identify risk factors. EBV and CMV reactivation should be taken into consideration in critically ill patients with fever, without specific symptoms and unresponsive to the treatment.

Epstein–Barr virus reactivation in extranodal natural killer/T-cell lymphoma patients: a previously unrecognized serious adverse event in a pilot study with romidepsin

Romidepsin, a histone deacetylase (HDAC) inhibitor, has been approved for the treatment of relapsed and refractory peripheral T-cell lymphoma. However, the efficacy and safety of romidepsin has never been studied in patients with relapsed or refractory extranodal natural killer (NK)/T-cell lymphoma (ENKTL). We conducted an open-label, prospective pilot study to evaluate the efficacy and feasibility of romidepsin in the treatment of patients with ENKTL. The treatment was intravenous infusion of romidepsin (14 mg/m(2)) for 4 h on days 1, 8, and 15 of a 28-day cycle, and was repeated until disease progression or the occurrence of unacceptable toxicity. A total of five patients enrolled on to this pilot study. However, three patients developed fever and elevated liver enzyme and bilirubin levels immediately after their first administration of romidepsin. We suspected that these events were associated with Epstein-Barr virus (EBV) reactivation because of the rapidly elevated EBV DNA titers in blood from these patients. An in vitro study with the ENKTL cell line SNK-6 cells also showed that HDAC inhibitors including romidepsin increased the copy number of EBV DNA in a dose-dependent manner. These findings suggested that romidepsin-induced histone acetylation reversed the repressed state of the genes required for EBV reactivation and that romidepsin treatment may have caused EBV reactivation in EBV-infected tumor cells in ENKTL patients. Therefore, we discontinued the enrollment of patients into this pilot study. Our study suggests that the use of romidepsin may cause severe EBV reactivation in patients with ENKTL.

The Influence of Epstein-Barr Virus Reactivation in Patients with Graves' Disease

In Graves' disease, the IgG class autoantibody against thyrotropin receptor (TRAb) is produced excessively and induces hyperthyroidism. Epstein-Barr virus (EBV) is one of the human herpesviruses that persists for life, mainly in B lymphocytes, and is occasionally reactivated. Therefore, EBV may affect the antibody production of B lymphocytes that would normally produce TRAb. The purpose of the present study was to evaluate the association of EBV reactivation with the etiology of Graves' disease. Serum levels of EBV antibodies and IgE were determined by ELISA. TRAb levels were determined by radioreceptor assay. We performed in-situ hybridization (ISH) of EBV-encoded small RNA (EBER)1 on the thyroid tissue of one of our patients. In Graves' disease patients with TRAb levels ≥ 10%, EA antibody levels, which indicate EBV reactivation, were moderately but significantly correlated with the levels of TRAb, and weakly but significantly correlated with IgE. EBER1-ISH revealed that one of our patients had EBV-infected lymphocytes infiltrating the thyroid gland. EBV reactivation may stimulate antibody-producing B lymphocytes predisposed to make TRAb, and this may contribute to or exacerbate the disease.

High incidence of cytomegalovirus, human herpesvirus-6, and Epstein-Barr virus reactivation in patients receiving cytotoxic chemotherapy for Adult T cell leukemia

The etiology of cytomegalovirus (CMV), human herpesvirus-6 (HHV-6), and Epstein-Barr virus (EBV) reactivation and the potential for complications following cytotoxic chemotherapy in the absence of allogeneic transplantation are not clearly understood. Patients with adult T cell leukemia (ATL) are susceptible to opportunistic infections. In this study, the incidence, kinetics and clinical significance of reactivation of CMV, HHV-6, and EBV in ATL patients were investigated. Viral DNA in a total of 468 plasma samples from 34 patients was quantified using real-time PCR. The probability of CMV, HHV-6, and EBV reactivation by 100 days after the start of chemotherapy was 50.6%, 52.3%, and 21.6%, respectively. Although most CMV reactivations were self-limited, plasma CMV DNA tended to persist or increase if the CMV DNA levels in plasma reached ≥ 10(4) copies/ml. CMV reactivation was negatively associated with survival, but the P-value for this association was near the borderline of statistical significance (P=0.052). One patient developed fatal interstitial pneumonia concomitant with peak CMV DNA accumulation (1.6 × 10(6)  copies/ml plasma). Most HHV-6 and EBV reactivations were self-limited, and no disease resulting from HHV-6 or EBV was confirmed. HHV-6 and EBV reactivation were not associated with reduced survival (P=0.35 and 0.11, respectively). These findings demonstrated that subclinical reactivation of CMV, HHV-6, and EBV were common in ATL patients receiving chemotherapy. There were differences in the viral reactivation patterns among the three viruses. A CMV load ≥ 10(4) copies/ml plasma was indicative of subsequent exacerbation of CMV reactivation and developing serious clinical course.

Incidence and Dynamics of Epstein-Barr Virus Reactivation After Alemtuzumab-Based Conditioning for Allogeneic Hematopoietic Stem-Cell Transplantation

Reactivation of Epstein-Barr virus (EBV) infection and posttransplant lymphoproliferative disorder (PTLD) pose a significant risk after T-cell-depleted (TCD) allogeneic hematopoietic stem-cell transplantation (HSCT). The pattern of EBV reactivation in patients receiving allogeneic HSCT, incorporating in vivo or in vitro alemtuzumab as the method of TCD, is not known. Monitoring for EBV DNA was performed by quantitative polymerase chain reaction on whole blood in 111 consecutive adults undergoing HSCT using alemtuzumab-based TCD. Patients with more than 40,000 copies/mL were screened for PTLD, followed by the withdrawal of immunosuppression and a single infusion of rituximab. The 2-year cumulative incidence of EBV DNAemia was 40.3%. In vivo alemtuzumab was associated with earlier EBV reactivation than in vitro alemtuzumab (100-day incidence 22.7% vs. 2.8%, P=0.006). Eighteen patients (16%) had EBV DNAemia of more than 40,000 copies/mL. In evaluable patients, the initial rate of increase in EBV DNA levels was significantly faster in those who went on to treatment with rituximab than in patients who were left untreated (mean doubling time 3.5 days vs. 4.2 days, P=0.003). Rituximab treatment induced rapid declines in EBV DNA with an average half-life of 1.2+/-0.7 days. Only one patient (0.9%) had histologic confirmation of PTLD and subsequently attained a complete remission with rituximab that persists at 18 months. Alemtuzumab-based TCD is associated with a high frequency of EBV reactivation but a low (<1%) risk of PTLD using a strategy of preemptive rituximab therapy.