X-linked lymphoproliferative syndrome. Identification of a large family in Switzerland

Observation of a patient with acquired hypogammaglobulinemia associated with a mononucleosis syndrome led to the identification of one of the largest families affected by the X-linked lymphoproliferative (XLP) syndrome in the world. It is the first such family identified in Switzerland and the largest in Europe. At least nine male subjects over two generations presented phenotypic expressions consistent with the XLP syndrome. Study of the pedigree extending over seven generations suggests that the mutation occurred in the proband's great-grandmother. In the next generation, a second mutation of the X chromosome in one branch of the family resulted in expression of hemophilia A in the children. This remarkably large family, comprising six living obligate female carriers, displays a wide spectrum of the XLP syndrome and offers valuable information for future genetic linkage studies and for genetic counseling.

LYDMA-antigens and Immunity against EBV-infected Cells Epstein-Barr Virus as a Model for the Study of Host-infection Interaction

Molecular biology has shown that DNA viruses carry their own transforming genes, unlike RNA viruses (retrovirus), which use cellular “oncogenes”. Some of the products of transforming viral genes are very good potential targets for immune defence. Epstein-Barr virus (EBV) immortalization is linked to the transcriptional activation of some latently transcribed regions; the lymphocyte-determined membrane antigens (LYDMA), the product of one of these regions, are the T-cell's chosen target. EBV-induced immortalization may therefore be free from any malignant consequence as long as immortalized clones are suppressed by immunosurveillance. In vivo, LYDMA-positive clones may be susceptible to immune control; LYDMA-negative clones can transform to neoplastic cells

Epstein-Barr virus infections in families: the role of children with infectious mononucleosis

We performed a prospective evaluation of Epstein-Barr virus (EBV) infections in 78 families with a childhood index case of EBV-infectious mononucleosis (EBV-IM). During the acute index episode, adult family (household) contacts, compared with control adults, had a greater rate of oropharyngeal EBV excretion and high serum antibody responses, which suggested a recent antecedent reactivation of an old EBV infection. The increased prevalence of oropharyngeal EBV and acute serological responses found in sibling family contacts during the early surveillance period suggested that these contacts had experienced an increased rate of primary-type EBV infections shortly before or concurrent with the index case. Although nonimmune sibling contacts seroconverted at a slow rate, five of nine manifested IM with their eventual documented primary EBV infection. This study noted significant intrafamilial EBV activity surrounding an episode of childhood EBV-IM. Reactivation of an old EBV infection in adults may be an important source of virus for susceptible children within these families. Siblings of a childhood case of EBV-IM appear to be at increased risk for manifesting IM with their primary EBV infection.

Clonal origins of lymphoproliferative disease induced by Epstein-Barr virus

Analysis of immunoglobulin gene rearrangements in 16 B-cell lineages clonally propagated from two mononucleosis patients supported the notion that mononucleosis is a polyclonal B-lymphoproliferative disorder. Three of seven cell clones from a patient with a fatal B lymphoma revealed the same pattern of immunoglobulin gene rearrangement, indicating that this patient's disease was oligoclonal. The three similar clones were propagated from two sites (blood and spleen), indicating that they represent a metastatic cell lineage which arose during the patient's fatal B lymphoproliferation.

X-linked lymphoproliferative syndrome. A new kindred with variable phenotypic expression

A kindred with five affected maternally related male members showed variable phenotypic expression of the X-linked lymphoproliferative syndrome. In one of the children, agammaglobulinemia developed following infectious mononucleosis. His brother had aplastic anemia in infancy and 21/2 years later died of overwhelming pneumonia resulting from ornithosis. A third brother died of reticulum cell sarcoma. Two maternally related male cousins died of reticulum cell sarcoma of the neck.

Heterochromatin and nucleolus organizer regions in cells of patients with malignant and premalignant lymphatic diseases

Peripheral blood lymphocytes (short-term cultures) and permanent lymphoid cell lines (long-term cultures) of patients with Hodgkin disease (5), lymphoma (1), plasma cell leukemia (1), angioimmunoblastic lymphadenopathy (1), and infectious mononucleosis (3) were investigated for C-band variants and nucleolus organizer region (NOR)-activities by C-banding and silver-staining, and compared to those of healthy adults (5) and newborn children (3). Heterochromatin polymorphisms were found in malignant diseases (33%) as well as in controls (29%). In the lymphoma patients, heterochromatin of class 3 (Patil and Lubs 1977) was seen more frequently than in the controls (83%:57%). No marker C-band variants could be detected in any of the lymphatic diseases. There was no difference in the heterochromatin polymorphism between short-term cultures (predominantly T-cells) and long-term cultures (B-cells), and there was little but inconsistant difference in the NOR-activities. Silver-staining showed differences between healthy adults (8.8 AgNORs; SD:0.5) and newborn children (6.9; SD:0.4). In the lymphoma patients we found 8.3 (SD:0.7) AgNORs. Thus, using silver staining there was no detectable increase in the number of active NORs in cells of patients with malignant diseases as an expression of increased nucleolus activation in malignancies. The remarkably low NOR-activity in infectious mononucleosis (6.7; SD:1.0) may reflect an influence of acute virus infection (Epstein-Barr virus) on NOR-activity.

A population-based case-control study of EBV and other viral antibodies among persons with Hodgkin's disease and their siblings

The Epstein-Barr virus (EBV) has been consistently found to be associated with Hodgkin's disease (HD) in two ways: cases generally have elevated titer distributions of antibodies against the viral capsid antigen, and the occurrence of HD among persons with a history of EBV infectious mononucleosis is two or three times higher than expected. We evaluated this association by measuring the prevalence and level of antibodies against EBV and related viruses among 304 cases of HD interviewed in a population-based study in comparison to 285 of their siblings. The most significant finding was that antibody titers to the viral capsid antigen of EBV were elevated (greater than or equal to 1:320) in 39% of the cases and in only 14% of the sibling-controls; the relative risk adjusted for age and sex was 4.1. The geometric mean titer was three-fold higher among cases (175.6 vs. 58.1) Subjects who reported a history of IM had a higher distribution of titers than those who did not. Cases also had elevated titers against the early antigen of EBV - the D Component being most prominent. A significantly higher proportion of cases has elevated titers against CMV, relative risk = 3.4, but the prevalence of CMV antibody was relatively low and not consistently higher among cases. The findings support the hypothesis that EBV may play a role in the pathogenesis of HD among persons with elevated titers. The findings neither confirm nor deny a possible role of CMV.

Delayed onset of infectious mononucleosis associated with acquired agammaglobulinemia and red cell aplasia

In 1974, an 11-year-old white boy with the X-linked lymphoproliferative syndrome developed hyper-IgM after becoming infected with Epstein-Barr virus. However, he failed to develop normal immune responses against the virus. In December 1981, when red cell aplasia occurred, he was given packed erythrocytes and gammaglobulin. Nine weeks later, acute infectious mononucleosis developed. Concurrently, his T4/T8 helper/suppressor ratio decreased from 2.7 to 0.2, and IgM antibodies to Epstein-Barr virus appeared. Subsequently, circulating B cells became undetectable in his blood, and agammaglobulinemia appeared. Red cell aplasia abated transiently. This patient's course was complicated by Haemophilus influenzae and Mycobacterium tuberculosis pneumonias, and red cell aplasia and agammaglobulinemia have persisted. Epstein-Barr virus acting as a slow virus probably induced the red cell aplasia and agammaglobulinemia because of the aberrant immune responses to Epstein-Barr virus. Immunodeficient responses to Epstein-Barr virus should be sought in other patients with the diseases documented in our patient.

Expression of cellular myc and mos genes in undifferentiated B cell lymphomas of Burkitt and non-Burkitt types

Burkitt lymphomas contain reciprocal translocations between chromosome 8 and one of the chromosomes containing the immunoglobulin gene loci, prompting speculation that consequent activation of a crucial gene(s) on chromosome 8 might be involved in the generation of these tumors. Recently the human counterparts of the retroviral oncogenes v-myc and v-mos have been mapped to chromosome 8. We have, therefore, analyzed the level of transcription of the cellular myc and mos genes in a variety of undifferentiated B cell lymphomas of Burkitt and non-Burkitt type that possess either an 8;14 or an 8;22 translocation. These lines expressed 2- to 5-fold more myc-specific RNA than do B cell lines without a translocation. Tumor cell lines of American origin with an 8;14 or 8;22 translocation expressed similar amounts of myc-specific RNA. Tumor cell lines of African origin contained slightly higher levels of myc-specific RNA than did those of American origin. However, level of expression does not appear to correlate with the presence or absence of Epstein-Barr virus. Therefore, a major increase in the transcription of this gene secondary to translocation is unlikely to be the cause of Burkitt lymphoma. There was no evidence of mos-related transcripts in any of the cell lines tested.

Epstein-Barr virus, fatal infectious mononucleosis, and Hodgkin's disease in siblings

Epstein-Barr virus (EBV) infection in a family resulted in a fatal disseminated heterophil negative infectious mononucleosis syndrome in a nine-year-old girl. This was followed closely by a similar disease process in her six-year-old brother which evolved over a one-year period into Stage IIIB Hodgkin's disease. Finally, three years after the index EBV case in the daughter, the mother was diagnosed with a non-Burkitt's-type undifferentiated lymphoma that proved rapidly fatal. The EBV involvement in the sister and brother was well documented serologically and virologically. The pathologic diagnosis was established and confirmed by more than one pathologist. There was no obvious evidence for either a specific or general immune defect in any of the family members tested. The progression of the six-year-old boy's EBV infection from a benign, yet disseminated disease process into a histopathologically confirmed case of Hodgkin's disease offers a strong suggestion that this virus was not behaving solely as a passenger. Especially relevant is the fact that the boy never fully recovered from his EBV infection and essentially became persistently infected with the virus as evidenced by his EBV-EA serology and virology results.

Phenotypical, functional and chromosomal studies of lymphocytes from patients with infectious mononucleosis

The present study describes the T lymphocytosis in infectious mononucleosis (IM), using rosette techniques, lymphocyte transformation tests, Con A suppressor tests, and chromosomal analysis. Blood was drawn from twelve patients with IM during acute illness and during convalescence. We found a T lymphocytosis with a normal sheep erythrocyte receptor affinity of T cells, using three different E-rosette techniques. The percentage of T cells with Fc receptors for IgM (T mu) was reduced during acute illness, but normal in convalescence. The percentage of T cells with Fc receptors for IgC (T gamma) was normal during illness and slightly reduced afterwards. Owing to the T lymphocytosis the total number of T gamma lymphocytes was significantly increased during IM. The lymphocyte reactivity in vitro after mitogen stimulation (PHA, Con A, PWM) was in the lower end of the normal range. We found no evidence of increased suppressor-cell activity activity during IM, using a Con A suppressor cell assay. No chromosomaL defects were observed in lymphocytes from blood.

Familial chronic mononucleosis

A syndrome of chronic mononucleosis occurred in two members of a family. Symptoms were chronic malaise and fatigue; recurrent upper respiratory tract infections; and mild, variable immune abnormalities. Intermittently positive heterophil titers were present for more than 2 years after acute infectious mononucleosis. Epstein-Barr-virus-specific antibodies were persistently abnormal. In the proband, the R component of the early antigen complex was present for 3 years and she never developed normal antibodies to Epstein-Barr nuclear antigen. Her brother had low to absent Epstein-Barr nuclear antigen titers, and antibodies to both the R and D component of the early antigen complex. Primary and acquired immunodeficiency states can show abnormal Epstein-Barr-virus-specific serologic findings that may reflect an attempt by the host to limit virus spread in the presence of deficient immune responses. This action may result in alterations of the Epstein-Barr virus-latent state, and lead to a chronic active infection and a syndrome of chronic mononucleosis.

Epstein-Barr virus-induced diseases in boys with the X-linked lymphoproliferative syndrome (XLP): update on studies of the registry

Analyses of 100 subjects with the X-linked lymphoproliferative syndrome (XLP) in 25 kindreds revealed four major interrelated phenotypes: infectious mononucleosis, malignant B-cell lymphoma, aplastic anemia, and hypogammaglobulinemia. Eighty-one of the patients died. Two male subjects were asymptomatic but showed immunodeficiency to Epstein-Barr virus (EBV). Seventy-five subjects had the infectious mononucleosis phenotype and concurrently, 17 subjects of this group had aplastic anemia. All subjects with aplastic anemia died within a week. Aplastic anemia did not accompany hypogammaglobulinemia or malignant lymphoma phenotypes. Hypogammaglobulinemia had been detected before infectious mononucleosis in three subjects, after infectious mononucleosis in five subjects, and was not associated with infectious mononucleosis in 11 boys with hypogammaglobulinemia. In nine subjects infectious mononucleosis appeared to have evolved into malignant lymphoma; however, the majority of patients with malignant lymphoma showed no obvious antecedent infectious mononucleosis. One subject had infectious mononucleosis following recurrent malignant lymphoma. Twenty-six of 35 lymphomas were in the terminal ileum. Results of immunologic and virologic studies of 15 survivors revealed combined variable immunodeficiency and deficient antibody responses to EBV-specific antigens. Mothers of boys with XLP exhibited abnormally elevated titers of antibodies of EBV. Subjects of both sexes with phenotypes of XLP should be investigated for immunodeficiency to EBV. Persons with inherited or acquired immunodeficiency may be vulnerable to life-threatening EBV-induced diseases.

A non-x-linked syndrome with susceptibility to severe Epstein-Barr virus infections

Three siblings developed severe (two) or fatal (one) infectious mononucleosis. This family differed from previously described kindreds with a susceptibility to overwhelming Epstein-Barr virus infections in that: (1) both males and females were affected; (2) they had a history of the recurrent bacterial infections; (3) they produced the full spectrum of antibodies to EBV in the expected range of titers; and (4) survivors recovered completely. Two of these youths, but not their parents or an unaffected sibling with mild IM, had a deficiency of natural killer activity that did not respond to preincubation of their peripheral blood mononuclear cells with interferon. NK activity may have an important role in controlling infections with EBV.

X-linked lymphoproliferative syndrome. An immunodeficiency disorder with acquired agammaglobulinemia, fatal infectious mononucleosis, or malignant lymphoma

The X-linked lymphoproliferative syndrome (XLP) is characterized by a combined variable immunodeficiency with vulnerability to Epstein-Barr virus (EBV)-induced fatal or chronic infectious mononucleosis, acquired agammaglobulinemia, aplastic anemia, or malignant B cell lymphomas. Diagnosis of XLP requires documentation of two or more maternally related males with these phenotypes. Epstein-Barr virus must be demonstrated in circulating blood, lymphoid tissues, or saliva of infected males. Characteristically, the patients have low-titer antibodies to EBV and often lack anti-EB nuclear-associated antibody due to T cell defects. Thymus gland is often depleted and epithelium may be destroyed. Thymic-dependent regions in lymph nodes and spleen are depleted and immunoblastic transformation with plasma cell differentiation is seen. The carrier females exhibit partial immune deficiency and have paradoxically elevated antibodies to EBV. Our registry of XLP provides consultation and comprehensive study of persons and families with the syndrome.

Intrafamilial transmission of Epstein-Barr virus infections

Intrafamilial transmission of Epstein-Barr virus infections was studied in 35 familial. After infectious mononucleosis was diagnosed in an index child, all siblings were tested for antibodies to EBV. Susceptible children were retested in four to eight weeks. In five families, a concurrent seroconversion was detected in an asymptomatic younger child. Two of 35 seronegative siblings developed clinical IM, confirmed serologically, during the study period. Overall, there evidence of spread in 7 (20%) of the 35 families. We conclude that there is significant intrafamilial transmission of IM. Our findings are compatible with an incubation period of four to six weeks.

X-linked lymphoproliferative syndrome registry report

Immune deficiency, especially to the Epstein-Barr virus, and increased susceptibility to fatal infectious mononucleosis, acquired agammoglobulinemia, and lymphoma are the cardinal features of the X-linked lymphoproliferative syndrome. Since the establishment of the XLP Registry in September, 1978, 59 affected males in seven unrelated kindreds were comprehensively studied. A spectrum of lymphoproliferative phenotypes was observed. Thirty-four patients (57%) died from infectious mononucleosis, eight (14%) had fatal infectious mononucleosis with lymphoma (immunoblastic sarcoma), nine (15%) had depressed immunity following EBV infection, and eight (14%) developed lymphoma. Several patients with XLP lacked EBV antibodies despite infection by EBV. The results of this study suggest that EBV can be an oncogenic agent in patients who are immune deficient with XLP.

Infectious mononucleosis and agranulocytosis

Infectious mononucleosis is often complicated by haematological abnormalities but agranulocytosis is so rare that a causal relationship has been questioned. We here describe 2 sisters, 3 and 5 years old, who both developed agranulocytosis or profound granulocytopenia 4-5 weeks after the acute onset of mononucleosis. No contributory cause could be found and we conclude that a constitutional disposition may be responsible for this complication.

Hodgkin's disease and infectious mononucleosis

Sequential sero-positive infectious mononucleosis is described in 3 sibs, 2 of whom subsequently developed Hodgkin's disease. EB virus antibodies were present in the serum of both cases.