Epstein-Barr Virus Viremia Research Articles

CD8 encephalitis with CSF EBV viraemia and HIV drug resistance, a case series

IntroductionCD8 encephalitis is a relatively recently described condition in the setting of HIV infection. It is becoming increasingly recognised in recent years though is still likely underdiagnosed. MethodsWe present three cases of encephalitis in HIV-positive black African females initially presenting with neurological pathology. Two cases concern recent presentations of patients attending HIV services at a large tertiary referral hospital and the third case involves a retrospective analysis of an archived case. Results and discussionMRI brain demonstrated periventricular white matter changes in 2 cases and a cerebellar lesion in the third case. CSF examination revealed lymphocytosis and elevated protein levels. CSF HIV viral load analysis showed viral escape along with new antiretroviral drug resistance mutations. CSF flow cytometry studies demonstrated a reversed CD4:CD8 ratio with a high CD8+ cells percentage. All patients had EBV DNA detected in their CSF. Brain biopsy in two patients confirmed CD8 encephalitis and also revealed isolated cells demonstrating EBV positivity by in-situ hybridization using EBER (Epstein–Barr virus-encoded small RNAs). Treatment with steroids and ART optimisation led to significant clinical and radiological improvements in all cases. DiscussionCD8 encephalitis should be considered as a cause of neurological symptoms and confusion in the HIV-positive patient, particularly if poor ART adherence or viral resistance are suspected. Brain biopsy should be considered in HIV-positive patients with encephalopathy of uncertain cause. Early treatment with high-dose corticosteroids when suspecting this diagnosis is essential for a favourable outcome. The prognosis is variable but can be favourable even following severe encephalopathy. The presence of new INSTI mutations in the CSF but absent peripherally in two INSTI-era patients is a novel finding for this case series in the context of CD8 encephalitis. The role played by EBV in this disease remains unclear and warrants further investigation.

Primary Epstein-Barr Virus Infection With Marked Cholestasis, Warm Autoimmune Hemolytic Anemia, and Pancytopenia

Abstract Primary Epstein-Barr virus (EBV) infection may rarely present with cholestatic hepatitis or hemolytic anemia. We share a case of EBV-associated infectious mononucleosis presenting with a unique triad of findings comprising cholestatic hepatitis with marked hyperbilirubinemia, warm autoimmune hemolytic anemia, and pancytopenia. Early diagnostic challenges included negative Monospot heterophile testing. Additional testing revealed EBV serologies consistent with acute primary infection, EBV viremia and bone marrow biopsy showing EBV-encoded RNA–positive cells. A tapered prednisone course was administered for warm autoimmune hemolytic anemia. Improvement in symptoms and laboratory findings occurred over 3 weeks.

Association Between Cytomegalovirus and Epstein-Barr Virus Viremia And Human Immunodeficiency Virus DNA Levels in the Reservoir of Kenyan Infants Receiving Antiretroviral Therapy.

Identifying determinants of human immunodeficiency virus (HIV) reservoir levels may inform novel viral eradication strategies. Cytomegalovirus (CMV) and Epstein-Barr virus (EBV) coinfections were assessed as predictors of HIV proviral DNA level in 26 HIV RNA-suppressed Kenyan children starting antiretroviral therapy before 7 months of age. Earlier acquisition of CMV and EBV and higher cumulative burden of systemic EBV DNA viremia were each associated with higher HIV DNA level in the reservoir after 24 months of antiretroviral therapy, independent of HIV RNA levels over time. These data suggest that delaying or containing CMV and EBV viremia may be novel strategies to limit HIV reservoir formation.

Disease Course and Treatment Response of Eosinophilic Gastrointestinal Diseases in Children With Liver Transplantation: Long-Term Follow-Up.

To describe the clinical and laboratory profile, natural course, treatment outcome, and risk factors of posttransplant esophageal and nonesophageal eosinophilic gastrointestinal disorders (EGIDs). All children (aged <18 years) who underwent liver transplantation, between 2011 and 2019, in a single transplant center with a follow-up period of 1 year or more posttransplant and with a history of posttransplant endoscopic evaluation were included in this study. During the study period, 89 children met the inclusion criteria. Patients were followed for a median of 8.0 years. A total of 39 (44%) patients were diagnosed with EGID after transplantation. Of these, 29 (33%) had eosinophilic esophagitis (EoE), and 10 (11%) had eosinophilic gastritis, gastroenteritis or enterocolitis. In comparison with the non-EGID group, patients with EGID were younger at transplant (P ≤ 0.0001), transplanted more frequently due to biliary atresia (P ≤ 0.0001), and had higher rates of pretransplant allergy (P = 0.019). In the posttransplant period, they had higher rates of mammalian Target of Rapamycin inhibitor use (P = 0.006), Epstein-Barr virus viremia (P = 0.03), post-transplant lymphoproliferative disease (P = 0.005), and allergen sensitization (P ≤ 0.0001). In regression analysis, young age at transplant, age at diagnosis, pretransplant atopic dermatitis, and post-transplant lymphoproliferative disease were associated with an increased risk of EGID or EoE. Laboratory abnormalities such as anemia (P = 0.007), thrombocytosis (P = 0.012), and hypoalbuminemia (P = 0.031) were more commonly observed in the eosinophilic gastritis, gastroenteritis or enterocolitis group than in the EoE group. Following treatment, most patients had symptomatic resolution at 3 months and histologic resolution at 6 months postdiagnosis. Among the patients who had 5 years of follow-up, none recurred. EGID is a common posttransplant diagnosis, which seems to affect patients who are transplanted earlier and who have pretransplant atopy. Posttransplant EGID is responsive to treatment, but as histologic remission occurs after symptomatic resolution, the decision to perform control endoscopy should be delayed.

Epstein-Barr Virus and Human Adenovirus Viremia in Renal Tumors Is Associated with Histological Features of Malignancy.

Background: There is growing evidence that viral infections may impact the risk and clinical course of malignancies, including solid tumors. The aim of this study was to assess the possible association of selected chronic/latent viral infections with the clinical course of renal cell carcinoma (RCC). Methods: In this prospective study we enrolled 27 patients undergoing partial or radical nephrectomy due to the histologically confirmed RCC and followed them up for one year post-operation. Isolation of the nucleic acids was performed using the NucleoSpin Tissue Kit (Macherey-Nagel, Düren, Germany) from tumor tissue and using the EZ1 Virus Mini Kit v2.0 from plasma. The number of viral copies of human adenovirus (ADV), herpes simplex virus HSV-1 and HSV-2, Epstein-Barr virus (EBV), cytomegalovirus (CMV), BK virus (BKV) and John Cunningham virus (JCV) in the tissue and plasma was assessed with real-time PCR. Results: Viral infections were diagnosed in ten patients (37.0%), including three ADV cases (11.1%) and eight EBV cases (29.6%). Infected patients tended to be significantly older (71.3 vs. 57.6 years, p < 0.05), more commonly presented with chronic renal disease (OR 2.4, p < 0.05), diabetes (OR 4.2, p < 0.05) and overweight (OR 2.0, p < 0.05). Regarding oncological data, infected patients were found to have a higher rate of high-grade cancers (OR 5.0, p < 0.05) and a higher rate of papillary RCCs (OR 8.3, p < 0.05). Status of viral infections had no influence on the clinical cancer stage, surgical procedure or survival. Conclusions: EBV and ADV infections are common in renal cancer patients and increase the risk of high-grade RCC presence. While there is no significant impact on short term survival, further studies are needed to assess the relevance of these findings in a long run.

S2572 Post-Liver Transplantation Lymphoproliferative Disorder Presenting as Biliary Stricture

INTRODUCTION: A 63 year-old man with non-alcoholic steatohepatitis (NASH) cirrhosis who underwent orthotopic liver transplant (OLT) presented 1 year later with obstructive jaundice due to a biliary stricture. Further investigation revealed encasement of the bile duct by a tumor, later determined to be post-transplant lymphoproliferative disorder (PTLD). PTLD represents a rare cause of post-OLT biliary stricture. CASE DESCRIPTION/METHODS: Post-transplant course was complicated by Grade 2 acute rejection, necessitating high-intensity immunosuppression. He later developed laboratory derangements, intermittent fevers, weight loss, and sweating episodes which were ascribed to active cytomegalovirus (CMV) and Epstein-Barr Virus (EBV) viremia. One year post-transplantation, an acute elevation in total bilirubin prompted an MRCP which revealed a soft tissue mass arising from segment VIII of the liver, extending into the porta hepatis and encasing the common bile duct at the surgical anastomosis. Biopsy showed diffuse large B cell lymphoma, later classified as stage IV disease with diffuse lymph node and bony metastasis. His tacrolimus was discontinued and systemic chemotherapy with R-CHOP was initiated. DISCUSSION: PTLD includes a heterogenous group of lymphoproliferative disorders that occur after solid organ or allogenic hematopoietic stem-cell transplantation, generally in the setting of EBV. PTLD may occur in up to 5.5% of adults following liver transplant. The clinical presentation of PTLD is heterogenous, and may range from incidental findings to fulminant organ failure. Treatment for PTLD consists of reduction of immunotherapy and systemic chemotherapy regimens, such as R-CHOP. Biliary complications after OLT are reported in up to 40% of cases, and usually involve biliary strictures. Biliary strictures are classified as anastomotic or non-anastomotic and are usually secondary to vascular or surgical complications. Post-OLT biliary stricture resulting from PTLD is quite rare. This case demonstrates the difficulties of prevention and diagnosis of PTLD-related biliary stricture. The presence of acute rejection necessitated high-intensity immunosuppression, which predisposed the patient to both CMV and EBV. These active viral infections were used to explain persistent “B symptoms” and abnormal laboratory findings that may have actually been the direct result of PTLD. This case illustrates the need to consider PLTD-related biliary stricture in any post-OLT transplant patient presenting with obstructive jaundice.Figure 1.: This demonstrates an isointense mass on T2-weighted imaging, which involves hepatic segment 8 and extends towards the porta hepatis with resultant stricture of the post-transplant biliary anastomosis and subsequent intrahepatic biliary dilatation.Figure 2.: On diffusion weighted imaging, the mass demonstrates marked diffusion restriction, with corresponding low signal on ADC.Figure 3.: 18F-FDG PET demonstrates intense FDG uptake within the mass, with multifocal hypermetabolic metastatic disease involving several lymph node groups as well as multiple osseous structures.

S1590 Post-Transplant Lymphoproliferative Disorder of a Pancreas Allograft Presenting as Pancreatic Necrosis

INTRODUCTION: Post-transplant lymphoproliferative disorder (PTLD) is a serious and often fatal complication of solid-organ transplants, with incidence up to 13%. PTLD can be seen in pancreas transplant recipients, but allograft involvement is rare. Epstein Barr virus (EBV) infection and high immunosuppression regimen increases the risk of PTLD. This is a case of PTLD of a pancreas allograft presenting as pancreatic necrosis. CASE DESCRIPTION/METHODS: A 41-year-old female with end-stage renal disease secondary to diabetes who received a simultaneous pancreas-kidney transplant 6 months ago presented with abdominal pain and pancytopenia concerning for PTLD. Routine testing revealed recent development of EBV viremia (greater than 30,000 copies/mL). Immunosuppressants included tacrolimus, mycophenolate, and low dose prednisone. White blood cell count and lipase values were normal. Imaging of the transplanted pancreas revealed inflammation and a 1.0 × 1.5cm peripancreatic fluid collection in the right lower quadrant, suggestive of necrosis. Based on cross-sectional imaging, Interventional Radiology deemed that the inflammation precluded adequate sampling of the allograft. Endoscopic ultrasound (EUS) with biopsy of the transplanted pancreas was requested. The transplanted pancreas was endosonographically visualized from the cecum, showing a 0.6 × 0.5cm hypoechoic heterogenous pancreatic head lesion consistent with necrosis (Figures A and B). Trans-colonic FNA was deferred due to risk of infecting the sterile necrotic cavity. Pancreatectomy was performed 1 week later due to fevers, persistent abdominal pain, and enlarging peripancreatic fluid collection. Pathology revealed extensive necrosis infiltrated by lymphocytes and plasma cells consistent with PTLD (Figure C). DISCUSSION: Our patient had a unique presentation of PTLD with necrosis of the transplanted pancreas. Early diagnosis and treatment of rejection are critical in preventing failure of the transplanted organ. Minimally invasive diagnostic methods like EUS are gaining popularity. EUS of pancreas allografts is usually performed via a trans-duodenal approach. Due to our patient's duodenojejunostomy anastomosis, EUS was performed via the colon, which is unique. Expert review of cross-sectional imaging and knowing the institutional pancreas transplant technique will help determine an effective EUS approach. Early tissue diagnosis using EUS guided sampling must be strongly considered in pancreas allografts to detect and treat post-transplant complications.Figure 1.: Endosonographic Imaging of Transplanted Pancreas.Figure 2.: Endosonographic Imaging of Transplanted Pancreas with Hypoechoic Pancreatic Head Lesion.Figure 3.: Transplanted Pancreas with Lymphocytic and Plasma Cell Infiltration Consistent with PTLD and Extensive Necrosis.

Combined immunodeficiency caused by a novel homozygous NFKB1 mutation

Genetic faults in several components of the nuclear factor-κB pathway cause immunodeficiency. Most defects lead to combined immunodeficiency with a range of severity. Heterozygous mutations in NFKB1 were associated with common variable immunodeficiency, however, homozygous mutations have not been described. We studied the molecular basis of combined immunodeficiency in a patient who presented with failure to thrive, persistent EBV viremia and hepatitis, pneumocystis jirovecii pneumonitis, and generalized lymphadenopathy. Whole genome and exome sequencing followed by Sanger confirmation were performed to identify the genetic defect. Molecular and cellular techniques were used to assess the variant impact on the nuclear factor-κB pathway and lymphocyte function. Genetic analysis revealed a novel homozygous mutation in NFKB1, c.2878G>A, p.Gly960Arg (G960R). This affected p105 phosphorylation and p50 formation on antigen and cytokine stimulation, as well as attenuating nuclear signal transmission. As a result, both T- and B-cell maturation and function were perturbed. The number of memory CD4+ T cells were reduced, while CD8+ T cells consisted predominately of expanded differentiated populations. The function of T cells were diminished as shown by reduced responses to mitogens as well as diminished cytokine secretion. B-cell maturation was also affected, with decreased IgD+CD27+ memory B cells while transitional B cells were increased, likely contributing to the reduced ability to produce specific antibodies. Homozygous G960R mutation in NFKB1 leads to a severe clinical presentation of combined immunodeficiency. This was associated with blockade of nuclear factor-κB pathway signaling, resulting in aberrations in T- and B-cell maturation and function.

Prognostic analysis of allogeneic hematopoietic stem cell transplantation for Philadelphia chromosome-positive acute lymphoblastic leukemia in complete remission in the era of tyrosine kinase inhibitors

目的探讨在酪氨酸激酶抑制剂（TKI）时代Ph染色体阳性急性淋巴细胞白血病（Ph+ALL）在完全缓解（CR）状态下行异基因造血干细胞移植（allo-HSCT）的预后和影响因素。方法回顾性分析2012年5月至2017年5月河北燕达陆道培医院收治的116例在CR状态下行allo-HSCT的Ph+ALL患者的预后及其影响因素。结果116例患者中男72例，女44例。中位年龄20（4～64）岁。同胞全相合移植21例，亲缘单倍型移植77例，非血缘移植18例。5年总生存（OS）率为73.2％（95％CI 63.8％～80.5％），其中诊断至移植间隔时间<180 d的亚组5年OS率为87.5％。5年无病生存（DFS）率为61.4％（95％CI 51.8％～69.7％）。5年细胞形态及分子学水平复发累积发生率为18.5％（95％CI 12.6％～27.3％）。5年移植相关死亡率（TRM）为19.9％（95％CI 13.8％～28.7％）。多因素分析显示，15～39岁（HR＝2.730，P＝0.044）、诊断至移植间隔时间≥180 d（HR＝4.534，P＝0.010）、发生Ⅲ～Ⅳ度急性移植物抗宿主病（aGVHD）（HR＝7.558，P＝0.000）是影响患者OS的不利因素；发生局限型慢性移植物抗宿主病（cGVHD）是影响患者OS的有利因素（HR＝0.300，P＝0.034）。而性别、起病时WBC（<30×109/L，≥30×109/L）、BCR-ABL融合基因类型、体细胞突变类型、移植前状态（CR1，>CR1）、移植前微小残留病（MRD）水平（MRD阴性，MRD阳性）、预处理方案（全身照射方案，白消安为基础方案）、预处理方案强度、移植类型、GVHD预防方案（环孢素A，他克莫司）、抗胸腺细胞免疫球蛋白的种类、巨细胞病毒和EB病毒血症的有无对OS的影响无统计学意义。结论TKI时代Ph+ALL在CR状态下行allo-HSCT时，影响生存的因素有年龄、诊断至移植间隔时间和发生重度aGVHD。

Prospective study of blood viral load of Epstein-Barr virus, herpes virus type 6 and human parvovirus B19 in Crohn's disease: Does therapy matter?

The interplay between inflammatory bowel disease (IBD) and DNA viruses, such as Epstein-Barr (EBV), human parvovirus B19 (HPVB19) and human herpes type 6 (HHV6) is scarcely studied. The main aim of this prospective study is to screen for EBV, HSV6, and HPVB19 DNA viremia in adult patients with stable Crohn's disease (CD), correlating the results with IBD treatment. From July 2015 - March 2017, 100 patients were enrolled and divided in four groups of 25 participants each, according to in course treatment. Blood collections were performed every 5 months in all patients. Antibodies for EBV and HPVB19 were screened and repeated if negative. Blood EBV DNA, HPVB19 DNA, and HHV6 DNA were quantified by quantitative real-time Polymerase Chain Reaction. Patients had evidence of EBV (100 %) and HPVB19 (70 %) past infection. Across the study timeline, EBV-DNA, HPVB19-DNA, and HHV6-DNA were detected in the blood of 25, 11, and 7 patients, respectively. Viremia was detected only once in 72 %, 73 %, and 86 % of the patients in the studied period, for EBV, HPVB19, and HHV6, respectively. We did not find significant differences between treatment groups, independently of the viral cut-off for the three viruses. The detection of EBV, HPVB19, and HHV6 viremia, in stable CD patients, was not impacted by biological/immunosuppressant therapy. Although attractive as a non-invasive technique, this approach did not prove to be useful in stable patients. More and larger studies are needed to address the relevance of these viruses on IBD course, in stable patients and during exacerbations.

Pediatric post-transplant lymphoproliferative disorder identified on random gastrointestinal biopsies shows non-mass-forming PTLD with clonal plasma cells: report of 2 cases

EBV-related lymphoproliferations in post-transplant settings range from non-destructive hyperplasia to polymorphic post-transplant lymphoproliferative disorder (PTLD) to overt lymphoma. Here we present two unusual cases of pediatric non-mass-forming gastrointestinal (GI) PTLDs with mixed pathologic features of non-destructive and polymorphic categories. Both patients were EBV naive and presented within 1 year of transplant with non-specific gastrointestinal symptoms (diarrhea, abdominal pain, and food intolerance) with hypoalbuminemia, cytopenia, and EBV viremia. No mass lesions were found on imaging and endoscopy. Random GI biopsies showed a non-mass-forming, but polymorphic-appearing lymphoid infiltrate with EBV positivity, monotypic plasma cells, and clonal B cells. Cyclophosphamide, steroids, and rituximab treatment had good clinical response in all cases, including one case which had poor response initially with rituximab alone. Based on these cases, we conclude that GI PTLD in children can present with vague abdominal symptoms, cytopenia, and hypoalbuminemia, and can be non-mass-forming and non-destructive. A high level of suspicion with random GI biopsies and clinicopathologic and laboratory correlation are required. Since these patients have no mass lesions, evaluating symptomatic relief, EBV viral load, improvement in cytopenia(s), serum albumin levels, and/or resolution of other systemic symptoms may be needed to monitor response to therapy.

First-in-human data of ALLO-501 and ALLO-647 in relapsed/refractory large B-cell or follicular lymphoma (R/R LBCL/FL): ALPHA study.

8002 Background: Allogeneic (off the shelf) chimeric antigen receptor (CAR) T cell therapy addresses the logistical challenges and variable product quality of autologous CAR T therapy. ALLO-501 is a genetically modified anti-CD19 CAR T cell product in which the TCR alpha constant gene is disrupted to reduce the risk of graft-versus-host disease (GvHD) and the CD52 gene is disrupted to permit the use of ALLO-647, an anti-CD52 mAb, for selective and prolonged host lymphodepletion. Methods: This is an open-label, Phase 1 trial (NCT03939026) in adults with R/R LBCL/FL who have received ≥ 2 prior lines of therapy; prior anti-CD19 cell therapy is allowed. Patients (pts) receive fludarabine (flu) 90 mg/m2, cyclophosphamide (cy) 900 mg/m2, and ALLO-647 39 or 90 mg followed by ALLO-501 at 1 of 3 dose levels (DL) in a 3+3 design: 40, 120, and 360 × 106 CAR+ T cells. Results: As of 20 January 2020, 12 pts were enrolled: 9 received ALLO-501 at 3 DLs (4, 4 &amp; 1 pts in DL1, DL2 and DL3 respectively), 1 pt discontinued due to kidney injury prior to lymphodepletion and 2 are starting treatment. Of the 9 treated pts aged 42 to 70 years: 5 had LBCL, 2 were female, 3 had primary refractory disease, and 3 had prior autologous stem cell transplants. The median number of prior lines of therapies was 3 (range 2 to 4). All treated pts received 39 mg of ALLO-647. No DLTs or GvHD have been observed to date. Most common Grade (Gr) ≥ 3 adverse events were neutropenia (55.6%), leukopenia (33.3%) and anemia (22.2%). Two pts (22.2%) developed cytokine release syndrome (1 Gr1 and 1 Gr2) that resolved within 72 hrs without steroids or tocilizumab. One pt developed Gr1 neurotoxicity that resolved without treatment. Infections included upper respiratory tract infection (Gr2), CMV (Gr3) and EBV viremia (Gr1), all reported in a single pt and resolved. One pt had a Gr2 infusion reaction to ALLO-647 which resolved with antihistamines. The overall response rate is 78% (95% exact CI: 40%, 97%): 3 complete and 4 partial responses. With a median follow up of 2.7 mos, 4 pts have ongoing responses and 3 pts progressed at 2, 4 and 6 mos. ALLO-501 cell expansion by qPCR was observed in 4 of 6 pts in varying degrees. Conclusions: These early data suggest that ALLO-501 and ALLO-647 have a manageable safety profile. ALLO-647 may be an effective and selective lymphodepleting agent with CD52 gene editing, and ALLO-501 shows evidence of clinical activity in pts with advanced NHL. Enrollment is ongoing, and updated safety, efficacy, PK/PD data will be presented including pts treated with increasing doses of ALLO-647. Clinical trial information: NCT03939026 .

Molecular Detection of Epstein - Barr virus and Human Herpesvirus-6 in a Sample of Iraqi Patients with Acute Leukemia

The pathogenic roles of human herpesvirus-6 (HHV-6) and Epstein-Barr virus (EBV) in acute leukemia have been of great interest. Patients with leukemia should be evaluated for viral infection, so they could be diagnosed for optimal therapy. In the current study, we aimed to determine the frequency of HHV-6 and EBV in a sample of Iraqi patients with acute leukemia in children and adults before chemotherapy. Fluorescent probe-based quantitative polymerase chain reaction (Q-PCR) method was used to quantify copies of HHV-6 and EBV DNA in 20 cases of acute lymphoblastic leukemia (AML), and 40 cases of hematological stable control subjects. Also, the effects of viral infection on hematological parameters were investigated. Results show that (47.5%) 19 out of 40 of patients at diagnosis recorded positive to one of the investigated viruses. Thirteen (32.5%) and 12 (30%) out of 40 patients with acute leukemia had positive EBV and HHV-6 viremia, respectively, while none of control group shows positive result with highly significant differences between patients and control groups (P&lt;0.001). The mean EBV and HHV-6 viral load was (7737.615±9106.838 copies/ml) and (94393.58±214528.9 copies/ml), respectively. In this study, there was no significant association between viral infection and hematological parameters (P&gt;0.05).In conclusion, infections or co-infections with EBV and HHV-6 could be a factor in the development of acute leukemia but further studies are required to establish whether there is a real association.

A Multicenter Survey on Post-Transplant Lymphoproliferative Disorders in Pediatric Heart Transplant Recipients: A Case for Development of Consensus Guidelines for Screening, Surveillance and Treatment?

Post-transplant lymphoproliferative disorders (PTLD) are a significant cause of morbidity and mortality following pediatric orthotopic heart transplant (OHT), with a reported incidence of 5-20%. In the absence of accepted guidelines, we sought to identify the overall trends in North American pediatric transplant centers in the screening, diagnosis, treatment, and follow-up of PTLD. All 56 Pediatric Heart Transplant Society (PHTS) institutions were asked to complete an anonymous survey in March 2019. No identifiable patient information was shared. From 56 PHTS centers, 22 responses were received (39.3%). 100% indicated that PTLD cannot be diagnosed solely based on elevated EBV load. All respondents routinely screen for Epstein Barr virus (EBV) by qualitative or quantitative EBV PCR, but the frequency of screening varies widely - some screen each visit, others once annually. Twelve of 19 (63.2%) obtain CT and/or PET evaluation for PTLD when EBV load is substantially or persistently elevated, whereas 5 of 19 (26.3%) also require clinical suspicion that PTLD is developing before obtaining imaging. Most centers require a positive biopsy to establish a diagnosis of PTLD (14 of 18, 77.8%), but many will reduce immune suppression in response to a persistently elevated EBV load without pathologic evidence of PTLD (16 of 22, 72.7%). Beyond reduction in immune suppression, rituximab is the most commonly used treatment agent used (9 of 13, 69.2%). Subspecialty consultation with pediatric oncology (17 of 17, 100%) and infectious disease (ID, 8 of 17, 47.1%) are common, but the timing of such consultation varies widely, some triggered by the diagnosis of EBV viremia (2 oncology, 5 ID), others only in rituximab-refractory PTLD (1 oncology). Our survey highlights significant practice variation amongst PHTS institutions in screening, diagnosing and treating PTLD in pediatric OHT patients. Reduction in immune suppression prior to pathologic diagnosis of PTLD is common but not universal. Treatment with rituximab is most often reserved until after establishing the PTLD diagnosis. This study highlights the need for multi-center collaboration to develop evidence-based guidelines for screening, treatment and surveillance of pediatric PTLD.

Kaposi Sarcoma-Associated Herpesvirus Infection and Endemic Burkitt Lymphoma

Endemic Burkitt lymphoma (eBL) is associated with Epstein-Barr virus (EBV) and Plasmodium falciparum malaria coinfections. However, the role of Kaposi sarcoma-associated herpesvirus (KSHV), also endemic in Africa, has not been evaluated as a cofactor in eBL pathogenesis. Multiplexed seroprofiles for EBV, malaria, and KSHV were generated for 266 eBL patients, 78 non-eBL cancers, and 202 healthy children. KSHV and EBV loads were quantified by PCR. KSHV seroprevalence did not differ by study group but was associated with age. Seropositivity, defined by K8.1/LANA or in combination with 5 other KSHV antigens (ORF59, ORF65, ORF61, ORF38, and K5) was associated with antimalarial antibody levels to AMA1 (odds ratio [OR], 2.41, P < .001; OR, 2.07, P < .001) and MSP1 (OR, 2.41, P = .0006; OR, 5.78, P < .001), respectively. KSHV loads did not correlate with antibody levels nor differ across groups but were significantly lower in children with detectable EBV viremia (P = .014). Although KSHV-EBV dual infection does not increase eBL risk, EBV appears to suppress reactivation of KSHV while malaria exposure is associated with KSHV infection and/or reactivation. Both EBV and malaria should, therefore, be considered as potential effect modifiers for KSHV-associated cancers in sub-Saharan Africa.

Abatacept for Gvhd Prophylaxis after Hematopoietic Cell Transplantation (HCT) for Pediatric Sickle Cell Disease (SCD): A Sickle Cell Transplant Advocacy and Research Alliance (STAR) Trial

Patients with severe sickle cell disease (SCD) experience organ damage, poor quality of life and premature mortality. Hematopoietic cell transplantation (HCT) is curative in SCD. Excellent outcomes have been achieved in young children with HLA matched related donors (MRD), with low rates of acute and chronic graft versus host disease (GVHD). Adolescent patients with SCD receiving MRD HCT and patients with SCD receiving matched unrelated donor (MUD) HCT, remain at highest risk for GVHD and resulting morbidity and mortality. Building on the encouraging experience with abatacept (CTLA-4Ig) for GVHD prophylaxis in URD HCT for hematologic malignancies, we launched an early phase, multicenter trial (n=25) through the Sickle Cell Transplant Advocacy and Research Alliance (STAR) of abatacept in pediatric SCD patients at high risk for GVHD. Patients with severe sickle cell disease were eligible if they were receiving a MRD HCT and either they or their donor were at least 10 years or if they were receiving a MUD HCT. Twenty-five patients have been enrolled to date with 23 patients completing conditioning and HCT. All patients received reduced intensity conditioning (RIC) with distal alemtuzumab, fludarabine, thiotepa and melphalan and marrow grafts. Four doses of abatacept (10 mg/kg/dose IV on days -1,+5,+14, +28) were added to standard GVHD prophylaxis using tacrolimus and methotrexate. Abatacept dosing was extended to eight doses for the last 11 patients (+60, +90, +120, +150). Tacrolimus was tapered at day 180 if no GHVD was present. The median age at HCT was 11 (3-21 years); 13 received a MRD HCT and 10 a MUD HCT. All patients engrafted with neutrophils at a median of 21 days (range 13-26) and platelets at a median of 23 days (13-55). As of 10/1/2019, median follow up is 804 days (range 46 – 1139). The mean myeloid and T-cell chimerisms at one (n=17) and two years (n=10) were 97.9 +/- 4.9 and 94.2 +/- 10.0 and 96.6 +/- 8.9 and 97.5 +/-4.3, respectively. Three evaluable patients at 2 years did not have chimerism studies sent. There have been 4 cases of EBV viremia (1 PTLD) and 6 cases of CMV viremia (1 disease). Grades 3-4 acute GVHD was seen in one patient and chronic/overlap in 5 patients with two patients currently receiving sytemic immune suppression. There has been no cerebral hemorrhages but one patient developed non-infectious encephalopathy of unclear etiology. The overall and sickle cell free survival at 2 years post HCT in evaluable patients (N=13) is 100% and 100%, respectively. The preliminary results in first 23 patients enrolled to date suggest that incorporating abatacept into GVHD prophylaxis is a safe and efficacious approach to improving outcomes in HCT for pediatric SCD.

Single Center Experience with Hematopoietic Cell Transplantation in Young Children with Chronic Granulomatous Disease

Rationale Chronic granulomatous disease (CGD) is a primary immune deficiency due to defects in the phagocyte oxidative burst leading to life-threatening infections and inflammatory disorders. Due to high mortality and morbidity, hematopoietic cell transplantation (HCT) is now considered a potentially curative option. We evaluated outcomes of HCT at our institution over 13 years. Methods Retrospective chart review of CGD HCTs performed at John Hopkins All Children's Hospital between August 2005-October 2018. Results Eight patients (median age=2.2 years, range=1.1-4.3 years) with CGD underwent HCT: 6 patients had X-linked (CYBB, gp91phox), 2 patients had autosomal recessive (CYBA, p22phox). Pre-HCT infections were controlled including; pneumonia (n=3, 2 Aspergillus, 2 requiring lobectomy) and staphylococcal lymphadenitis/skin abscesses(n=3). Five of eight (62%) had inflammatory disease pre-HCT: lung granulomas (n=2), autoimmune hepatitis (n=3), and colitis (n=2). Myeloablative conditioning was used in 3 and reduced intensity/toxicity (RIC) in 5. Four received matched related donor and 4 received matched unrelated-donor HCTs. Median neutrophil engraftment was 18.5 days (range=10-21 days). Overall survival was 87.5%. One patient died (day +21) from disseminated Trichosporon. All patients achieved primary engraftment; 42% (3/7) maintained full donor chimerism (≥99%) with normalization of DHR, median follow-up 4.3 years (range=4-8.3 years); 42% (3/7) are mixed chimera (58-84% myeloid donor), median follow-up of 0.9 years (range=0.8-1.2 years). One patient who received RIC (Fludarabine/Melphalan/Campath) had secondary graft failure 1 year after HCT, has since developed inflammatory colitis, uveitis, and pneumonitis and is awaiting second HCT. There was no grade III-IV GVHD; 2 had acute grade I GVHD. Post-HCT complications included EBV viremia (without PTLD) in 1, pericarditis in 1, autoimmune cytopenias in 1 and hypothyroidism in 1. Conclusions Patients with CGD are at high risk of early mortality. HCT is a viable treatment option but has considerable risk, often deterring providers and patients from pursuing HCT early. Our institution's experience shows safety and efficacy with early HCT approach.

Epstein-Barr virus infection in ulcerative colitis: a clinicopathologic study from a Chinese area

Background:Opportunistic Epstein–Barr virus (EBV) infection in patients with ulcerative colitis (UC) has attracted increasing attention. This study aimed to evaluate the clinicopathological characteristics and clinical outcomes of UC with intestinal EBV infection and to explore the predictive value of blood EBV DNA for the presence of EBV in the intestine.Methods:Both peripheral blood and intestinal biopsies from 92 consecutive UC inpatients were included in this study. Normal colonic mucosal tissues from 20 colon cancer patients were used as controls. EBV testing and assessment were performed by EBV-DNA polymerase chain reaction (PCR), EBV-encoded small RNA in situ hybridization (EBER-ISH) and immunohistochemistry.Results:A total of 36 patients (39.1%) had UC with superimposed EBV colitis [EBER greater than 2/high-power field (HPF)]. EBER counts and disease activity were significantly correlated (p < 0.05). The major endoscopic findings revealed more irregular and longitudinal ulcers in patients with superimposed EBV colitis (p = 0.016, p = 0.021, respectively). Age, steroid dependence, and irregular ulcerations were identified as possible risk factors. The best EBER cut-off point for outcome prediction was 2.5/HPF. At a cut-off value of 2035 copies/ml, the sensitivity and specificity of the blood EBV-DNA PCR analysis for predicting EBV presence in the intestine were 76.5% and 68.5%, respectively. EBV-infected cells in UC with high EBV concentrations mainly included B lymphocytes by clinicopathology, and the infection might have progressed from the latent to the lytic phase of the EBV life cycle.Conclusion:The EBER count is positively correlated with disease activity. The best cut-off point for outcome prediction is 2.5/HPF. A high EBV viremia load may effectively predict EBV presence in the colonic mucosa.

Pre-Transplant MRD Negativity Predicts Favorable Outcomes of CAR-T Therapy Followed By Haploidentical HSCT for Relapsed/Refractory Acute Lymphoblastic Leukemia: A Multi-Center Retrospective Study

Patients with relapsed/refractory acute lymphoblastic leukemia (R/R ALL) usually have a very poor prognosis and an expected survival of less than 6 months.The complete remission (CR) rates in the setting of the first salvage chemotherapy are about 30% to 46% and these rates drop sharply to 18% to 25% after the second salvage chemotherapy. Chimeric antigen receptor T cells (CAR-T) can induce high CR rates of 70-95% (MRD negative CR rates of 60-90%) among patients with R/R ALL. Howeve, relapse after CAR-T treatment is supposed a main obstacle for long-term outcome. Some reports have described relapse rates of 20-70% when the follow-up was long enough. It remains controversial whether these patients should receive allo-HSCT after CAR-T treatment or not. We designed a multi-center retrospective study to assess the efficacy and safety profiles of CAR-T therapy followed by haplo-HSCT. A total of 31 patients treated with CAR-T therapy followed by haplo-HSCT were included. Eleven patients who progressed to MRD positive or relapse subsequently underwent haplo-HSCT (MRD positive or relapse group) and the rest 20 patients with MRD negativity received haplo-HSCT (MRD negative group). The median time from CAR-T infusion to haplo-HSCT was 83 (range 62-114) days. After a median follow-up period of 288 (range 189-554) days post-transplantation, the 100-day cumulative incidence (CI) of grade III~IV aGVHD was 0% and 10.5% in the MRD positive or relapse group and MRD negative group, respectively (P&gt;0.05)(Figure 1a). One and 2-year CIs of cGVHD requiring systemic steroid therapy were 52.3% and 31.1% (P&gt;0.05), 52.3% and 39.7% (P&gt;0.05) in the MRD positive or relapse group and MRD negative group, respectively(Figure 1b).The 1-year cumulative incidence of CMV viremia was 90.9%, 68.4% and 77.8% in the MRD positive or relapse group, MRD negative group and the whole population respectively (P&gt;0.05). The 2-year cumulative incidence of CMV viremia was 90.9%, 78.9% and 85.2% in the MRD positive or relapse group, MRD negative group and the whole population respectively (P&gt;0.05). The 1-year cumulative incidence of EBV viremia was 90.9%, 79.6% and 84.2% in the MRD positive or relapse group, MRD negative group and the whole population, respectively (P&gt;0.05). And the 2-year cumulative incidence of EBV viremia was 90.9%, 89.8% and 89.5% in the MRD negative or relapse group, MRD negative group and the whole population, respectively (P&gt;0.05). Onset of CMV and EBV viremia occurred in 33.5 (26.3-50.0) days and 44.0 (28.5-57.0) days after transplantation in 24 and 25 patients, respectively. Median peak CMV DNA and EBV DNA load were 1.5X104 (2.6X103-3.4X104) copies/ml and 2.2X104 (1.1X104, 4.1X104) copies/ml, respectively. One and 2-year CIs of relapse were 84.8% and 6.7% (p&lt;0.001), 100% and 15.2% (p&lt;0.01%) in the MRD positive or relapse group and MRD negative group, respectively (Figure 1d). One-year GVHD and relapse free survival (GRFS), leukemia free survival (LFS) and overall survival (OS) in the MRD positive or relapse group and MRD negative group were 18.2% and 58.9% (P=0.024), 15.2% and 93.3% (P&lt;0.001), 43.6% and 100% (P=0.002), respectively (Figure 1f). Two-year GRFS, LFS and OS in the MRD positive or relapse group and MRD negative group were 0% and 50.5% (P=0.007), 0% and 84.8% (P&lt;0.001), 14.5% and 83.3% (P&lt;0.001), respectively (Figure 1c,e,f). No patient died of therapy-associated complications. Relapse or MRD positivity at the time of haplo-HSCT is the only independent factor associated with poor LFS [hazard ratio (HR): 23.6, 95% confidence interval (CI): 2.78-201.63, P=0.004] and OS [HR: 10.4, 95% CI: 1.12-94.45, P= 0.037]. In conclusion, our trial provided data to illustrate the safety and efficacy profiles of a novel combining therapeutic strategy against R/R ALL by using the combination of CAR-T cells for re-induction followed by haplo-HSCT for consolidation. We confirmed that achieving pre-transplant MRD negativity after CAR-T treatment is a suitable basis for haplo-HSCT. Our study results imply that CAR-T therapy followed by haplo-HSCT could further improve LFS and OS without increasing risks of treatment-related toxicity in such a previously heavily treated population. Further evaluation is needed from larger scale studies with a more homogeneous patient population and longer follow-ups. Figure 1 Disclosures Blaise: Jazz Pharmaceuticals: Honoraria; Sanofi: Honoraria; Molmed: Consultancy, Honoraria; Pierre Fabre medicaments: Honoraria. Mohty:Jazz Pharmaceuticals: Honoraria, Research Funding.

Results of a Multicentre, Randomized, Controlled Open-Label Study on the Use of Anti-T-Lymphocyte Globulin (ATLG) and Rituximab for Immunomodulation of Graft-Versus-Host Disease (GvHD) and Graft Failure (GF) in Patients with Non-Malignant Disorders

BACKGROUND: Allogeneic hematopoietic stem-cell transplantation (allo-HSCT) is increasingly used to treat a wide range of non-malignant disorders. However, the optimal strategy to be employed for GvHD prevention remains a matter of debate. In particular, the use of ATLG for the prevention of immune-mediated complications in patients transplanted from a matched-related donor (MRD) is still controversial. In the matched unrelated donor (MUD) setting, there is retrospective evidence that Rituximab used as prophylaxis of EBV viremia may protect from acute GvHD (aGvHD) development, but the clinical benefit of pre-transplant Rituximab has never been assessed in prospective randomized studies. METHODS: We conducted a multicentre, randomized, open-label, trial (NCT01810926) in 5 Italian centres enrolling patients with non-malignant haematological and inherited metabolic disorders transplanted from either a MRD or a MUD, selected using high-resolution typing for HLA-class I/II loci and stringent criteria of HLA-compatibility (&gt;9/10). All patients received the same myeloablative regimen consisting of Treosulfan, Thiotepa and Fludarabine. Enrolled patients were randomized (1:1) to receive either standard or intensified GvHD prophylaxis. Cyclosporine-A plus short-term methotrexate was the standard GvHD prophylaxis in MRD HSCT recipients. In the experimental arm, patients were additionally given ATLG (Grafalon®, Neovii, 5 mg/kg/day on day -4,-3, and -2). In patients transplanted from a MUD, standard GvHD prophylaxis consisted of Cyclosporine-A plus short-term methotrexate and ATLG (10 mg/kg on day -4,-3 and-2). In the experimental arm, patients were additionally given Rituximab 200 mg/sq on day -1 (Mabthera®, Roche). In MRD group randomization was stratified by disease (hemoglobinopathies vs. other conditions) and in the MUD group by center. For patients given MRD HSCT, the primary end-point was the probability of survival (SUR) free from: a) primary and secondary GF, b) grade II-IV aGvHD, c) chronic GvHD (cGvHD), d) death, whichever occurred first. For patients transplanted from a MUD, the primary end-point was the SUR probability free from: a) grade II-IV aGvHD, b) EBV viremia (&gt;1,000 copies of viral DNA/ml whole blood), whichever occurred first. Secondary endpoint was overall SUR (OS). Statistical analyses were conducted according to intention-to-treat. FINDINGS: Between August 2011 and February 2018, 126 patients were enrolled. Patient and disease characteristics by randomized treatment are shown in Table 1. Median age at HSCT was 6.1 years in the MRD group (range 0.8-38) and 4.9 years in the MUD group (range 0.9-20.7). Median follow-up was 3.6 years. Among the 51 MRD-HSCT recipients, 25 were randomly assigned to the ATLG group and 26 to the NO-ATLG group. No death and no cases of grade II-IV aGvHD were observed in either of the two randomization arms. Two GF occurred in each of the two arms, while 1 and 2 cases of cGvHD occurred in the ATLG and NO-ATLG groups, respectively. Consequently, no statistically significant difference in the probability of SUR without events was observed (p=0.75) and the 3-years estimates (±SE) were 86.9%±7.1% vs. 83.8%±7.5%, respectively. In the MUD setting, 38 patients were allocated in the Rituximab group and 37 in the NO-Rituximab group. Although no statistically significant difference in OS (p=0.21) was observed between the two arms (3-years estimates: 94.1%±4.1% for Rituximab, 85.7%±5.9% for No-Rituximab), patients receiving Rituximab had a better probability of SUR without events (73.0%±7.3% vs 26.5%±7.3%, respectively; p=0.0002), entirely due to a lower incidence of EBV viremia. One case of fatal post-transplant lymphoproliferative disorder was observed in the No-Rituximab arm. Eight patients developed grade II-IV aGvHD in each of the two arms. No patient has persistent dependence on ivIG replacement therapy. CONCLUSIONS Our data indicate that, in patients with non-malignant disorders given a MRD HSCT, the addition of ATLG does not confer any advantage in the prevention of both acute and chronic GvHD, as well as of GF. In MUD-HSCT recipients, the administration of a fixed dose of pre-transplant Rituximab as part of the conditioning regimen does not affect the risk of aGvHD and transplant-related mortality, while it significantly reduces the incidence of episodes of EBV-viremia, without impairing B-cell recovery. Disclosures Algeri: Bluebird bio: Consultancy, Honoraria; Miltenyi: Honoraria; Atara Biotherapeutics: Consultancy, Honoraria. Merli:Novartis: Honoraria; Sobi: Consultancy; Amgen: Honoraria; Bellicum: Consultancy. Locatelli:Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees; bluebird bio: Consultancy; Miltenyi: Honoraria; Bellicum: Consultancy, Membership on an entity's Board of Directors or advisory committees; Amgen: Honoraria, Membership on an entity's Board of Directors or advisory committees.