Elevated antibody titers to Epstein-Barr virus in Hodgkin's disease

Hodgkin's disease as an indicator of AIDS

Hodgkin's disease (HD) is not currently included within the Centers for Disease Control (CDC) classification system for AIDS. Upon HD diagnosis, HIV(human immunosuppressive virus)-positive patients are generally found within Stages III or IV of the Ann Arbor HD classification system, already exacerbating the problem of treatment. In contrast, HIV-negative patients diagnosed with HD are generally found within Stages I or II. Epidemiology and the presence of secondary lymphomas, opportunistic infections, or aggressive pathologies, accompanied by low survival rate and timing of HD diagnosis suggest that HD should be included among conditions indicating AIDS manifestation.

Hodgkin's disease in Mexico. Prevalence of Epstein-Barr virus sequences and correlations with histologic subtype

BACKGROUND

The Epstein-Barr virus (EBV) has been linked to several human malignancies, including Hodgkin's disease (HD). In addition, epidemiologic studies have shown differences in HD occurrence in different parts of the world. The authors studied 27 cases of Hodgkin's disease from Mexico to determine the prevalence of EBV in HD in this developing nation.

METHODS

The Epstein-Barr virus was investigated using in situ hybridization with the EBER1 probe. Immunohistochemical studies were performed on paraffin sections. Cases from both adult and pediatric age groups were included. Correlations with histologic subtype, clinicopathologic features, and immunophenotype were determined.

RESULTS

Epstein-Barr virus sequences were identified in 18/27 (67%) cases. Positivity correlated with histologic subtype: 0/1 lymphocyte predominant; 6/13 (46%) nodular sclerosis; 7/7 mixed cellularity (MC) (100%); and 5/6 (83%) lymphocyte depleted (LD). The proportion of cases classified as MC and LD (13 of 27) was greater than that found in the United States and other developed countries. The immunophenotypic profile was appropriate for Hodgkin's disease, with all cases of classic Hodgkin's disease positive for CD30 (Ber-H2) and 18 cases expressing CD15. One case of lymphocyte-predominant Hodgkin's disease was CD20 (L26)-positive as were three cases of classic Hodgkin's disease. Patient age ranged from 5 to 65 years, with a median of 29 years.

CONCLUSIONS

The EBV is associated highly with HD in Mexico, and this prevalence rate is found in all age groups. A strong correlation between EBV expression and histologic subtype was confirmed, with 92% of MC and LD subtypes found to be positive.

Epstein-Barr virus as an agent of haematological disease

Epstein-Barr virus (EBV) encodes genes that permit its persistence in human B lymphocytes and genes that ensure its replication in epithelial cells. Immune restraints on the virus are usually so effective that most EBV infections are limited to a minute fraction of B lymphocytes and of epithelial cells. As a result, most EBV infections are never symptomatic. Occasionally, the virus causes disease, often with the cooperation of the immune system or other less characterized cofactors. Infectious mononucleosis, a generally self-limited lymphoproliferative illness common in adolescents and young adults, is due to primary EBV infection and to the brisk cellular immune response it elicits. Lymphoproliferative disorders of EBV-infected B cells arise almost exclusively when cellular immunity is grossly compromised. EBV-positive Burkitt's lymphoma contain a translocated and deregulated c-myc oncogene and EBV-positive non-Hodgkin's lymphomas are characterized by the presence of Reed-Sternberg's and Hodgkin's cells, features that have not been directly linked to EBV. Many recent observations, however, including evidence that virus infection precedes malignant transformation and is often associated with a characteristic pattern of viral gene expression, provide continued interest in the relationship between the virus and these haematological malignancies.

Clonal analysis of Hodgkin's disease shows absence of TCR/Ig gene rearrangement, compared with T-cell-rich B-cell lymphoma and incipient adult T-cell leukemia/lymphoma

To better characterize the clonality and pathogenesis of Hodgkin's disease (HD), we used polymerase chain reaction (PCR) and Southern blot to analyze the rearrangement of immunoglobulin (Ig) and T-cell receptor (TCR) genes, the bcl-2 oncogene, and the Epstein-Barr virus (EBV) genotype. In situ hybridization studies of EBV were also done. Twenty-six cases of HD were compared with 15 cases of non-specific lymphadenitis, 7 with incipient adult T-cell leukemia/lymphoma (ATLL), and 4 T-cell rich B-cell lymphomas (TRBL), all of which histologically resembled HD. EBV genes were detected in 20 of 26 HD patients (77%) and in 7 of 15 patients with non-specific lymphadenitis (47%), 5 of 7 with incipient ATLL (71%), and 1 of 4 with TRBL (25%). In contrast to specimens of non-specific lymphadenitis, TRBL, and incipient ATLL, only one EBV genotype was evident in the specimens of HD. EBV latent membrane protein (LMP) was detected immunologically in 16 of 26 HD patients (62%), one of four TRBL (25%) and one of seven incipient ATLL (14%), but it was not evident in non-specific lymphadenitis. The LMP positive cases showed amplified EBV genomes. Only one of the 26 cases of HD had a bcl-2 gene rearrangement by PCR, but this was not seen in any other disease. The bcl-2 protein was detected immunologically in seven of the 26 HD patients (27%) and in one of the seven incipient ATLL cases (14%). EBV has been reported to upregulate bcl-2 expression, but in this study the presence of bcl-2 protein did not correlate with the presence of the t(14;18) translocation or EBV-LMP. All TRBLs showed rearrangement of the immunoglobulin genes by PCR and/or Southern blot, and the giant cells were of B-cell type. All incipient ATLLs displayed rearrangement of the TCR genes, and the giant cells were of T-cell origin. In seven of 26 HD cases, the giant cells were weakly stained with T-cell antibodies, in another seven positive with B-cell antibodies and in 18 instances polyclonally positive for both kappa and lambda. However, PCR and Southern blot displayed only two cases of TCR gene rearrangement, while two others had very weak rearrangements of immunoglobulin gene positive only by PCR. Thus the T and B-cell genotype did not correlate with the T and B-cell phenotype recorded in these cases. The absence of Ig and TCR gene rearrangements seems to be common in HD, compared with in TRBL and incipient ATLL.

Frequent detection of Epstein-Barr virus (EBV), EBER transcripts and latent membrane protein-1 (LMP-1) in tumor cells in Hodgkin's disease arising in childhood

Paraffin sections from 22 cases of Hodgkin's disease (HD) and 30 cases of non-Hodgkin's lymphomas (NHL) occurring in childhood (3-15 years old) were examined for the presence of Epstein-Barr Virus (EBV) encoded EBER mRNAS and Latent Membrane Protein-1 (LMP-1) using RNA in situ hybridization (RISH) and immunohistochemistry, respectively. In 12/22 (54%) cases of HD the EBER transcripts were detected in most Reed-Sternberg and Hodgkin (HRS) cells as well as in some scattered smaller lymphoid cells. In all these cases the LMP-1 protein was detected exclusively in HRS cells. Three additional cases of HD were found to be EBER RISH positive only in a few scattered small lymphoid cells, the LMP-1 staining being negative in these cases. The EBER and LMP-1 positivity in HRS cells were present in 0/1 of lymphocyte predominant, 4/10 (40%) of nodular sclerosis and 8/11 (72%) of mixed cellularity of HD. No EBER RISH signal was found in tumor cells of the 30 cases of NHL. In four of them only a few scattered small lymphoid cells were EBER RISH positive. LMP-1 reactivity was not detected in any NHL. These results provide evidence for an association between EBV and a sizeable proportion of childhood Hodgkin's disease and show that this association is more frequent in mixed cellularity subtype. Furthermore, the detection of the LMP-1 protein in HRS cells in view of the LMP-1 transforming potential, suggests that EBV may be involved in the pathogenesis of a substantial proportion of cases of HD occurring in childhood.

Evaluation of Epstein-Barr virus antibody patterns and detection of viral markers in the biopsies of patients with Hodgkin's disease

We assessed the relationship of Epstein-Barr virus (EBV) serology to the presence or absence of EBV genome in 39 cases of Hodgkin's disease (HD). Biopsies from patients included in 2 previous published studies, 1 involving patients from the United States (eastern Massachusetts) and 1 from Denmark, were evaluated for EBV (EBER-1) and latent membrane protein (LMP-1). The presence of EBV in Reed-Sternberg cells in the biopsies correlated with the histologic subtype of HD (mixed cellularity and lymphocyte depletion) but not with IgG antibody titers against the viral capsid antigen (VCA). These data suggest that, unlike Burkitt's lymphoma, the IgG antibody against VCA is not predictive of the presence or absence of EBV in Reed-Sternberg cells in HD. The predictive value of other antibodies should be evaluated.

Expression of EBV encoded latent membrane protein 1 (LMP-1) and bcl-2 protein in childhood and adult Hodgkin's disease: application of microwave irradiation for antigen retrieval

Surgical biopsies obtained from 32 children, and 34 adults with Hodgkin's disease (HD) were investigated for the expression of the EBV encoded Latent Membrane Protein 1 (LMP-1), bcl-2 protein, markers for HD; LeuM1 (CD15), BerH2 (CD30) and the new BLA.36, as well as for B (L26) and T lymphocytes (UCHL1). Before immunostaining, sections were subjected to an Antigen Retrieval (AR) procedure based on microwave irradiation in citrate buffer. In 13 cases staining with and without the AR procedure was compared. Immunoreactivity for LMP-1 was found in 44% of the biopsies from adults and 53% from children. We also found reactivity for the bcl-2 protein in Hodgkin's and Reed Sternberg (HRS) cells in 48% of the biopsies from adults and 45% from children. Immunoreactivity with BLA.36 was found in 94% of the biopsies from adults and 100% from children, with LeuM1 in 83% from adults and 93% from children and with BerH2 in 24% from adults and 84% from children. Nuclear PCNA staining was seen in HRS in all cases both adult and childhood. The T cell marker (UCHL1) displayed no reactivity with HRS cells. In 21% of the adult and 9% cases from the childhood cases we observed reactivity with the B cell marker (L26) in HRS cells. We can conclude that antigen retrieval improves immunostaining results of paraffin sections which were previously negative for bcl-2, LeuM1 and BerH2 antibodies. The high percentage of LMP-1 positive cases, both in adults and in children, indicates that the potential pathogenetic effect of EBV may be of similar importance both in childhood and in adult HD. The new MAb BLA.36 gave consistent immunostaining with HRS cells but also with other cell types. In a panel of markers for HRS cells BLA.36 together with LeuM1 (CD15) and BerH2 (CD30) are useful.

Is Hodgkin's disease an infectious disease?

Several lines of evidence question the concept of Hodgkin's disease (HD) starting as a true malignant disorder of the lymphatic system: (i) In early stages HD exerts pronounced clinical and biological features of an atypic immune response. (ii) Despite extensive investigations, the Hodgkin/Reed-Sternberg (H/RS) cells have not been unequivocally determined as the definite malignant cell population in HD. (iii) The epidemiological pattern of HD strongly resembles that of an infectious disease. (iv) About 50% of HD cases can be linked to infection with Epstein-Barr virus. Hodgkin's disease in early stages might thus be understood as the unsuccessful attempt of the organism to eliminate a cell expressing a putative (cellular or viral) target antigen. A stepwise transformation of this antigen-carrying cell, possibly triggered by an inherent genetic instability, might then lead to outgrowth of a malignant cell clone in late stages of the disease.

The association between Epstein-Barr virus and Chinese Hodgkin's disease

Epstein-Barr virus (EBV) can be detected in Hodgkin and Reed-Sternberg (HRS) cells in about one-half of cases of Hodgkin's disease (HD) in Western countries. To determine whether EBV is also associated with HD in a developing country such as China, we studied paraffin sections from 28 Chinese cases of HD for expression of latent membrane protein-I (LMP-I) and EBV-encoded small RNA (EBER-I), using immuno-histology and RNA/RNA in situ hybridization respectively. The cases were selected from a large series of Chinese lymphomas following histological and immunophenotypical revision. EBV gene expression was found in HRS cells in 17/28 cases, and was related to histological sub-type, being present in 10/11 of mixed cellularity, 6/14 nodular sclerosis, 0/1 lymphocytic predominance, 0/1 lymphocytic depletion, and 1/1 unclassified HD. The 2 methods for detecting EBV gene expression gave similar results, except in one case of nodular sclerosis, in which HRS cells were negative for EBER-I, but weakly positive for LMP-I. In 5/12 cases with EBER-negative HRS cells, rare small or medium-sized lymphocytes expressed EBER-I but not LMP-I. These results suggest that (i) Chinese HD is frequently associated with EBV; (ii) the proportional frequency and sub-type distribution of EBV-positive HD are similar in China and in the West; (iii) both LMP-I immunohistology and EBER in situ hybridization reliably detect EBV in HRS cells in routine biopsies, but the former is simpler and less resource-consuming to perform.

Epstein-Barr virus in Hodgkin disease. Relation to age and subtype

BACKGROUND

Epstein-Barr virus (EBV) has been associated with Hodgkin disease (HD), but its relationship to the age of the patients and the histologic subtype is not well defined. The possibility that other lymphotropic herpesviruses, such as cytomegalovirus (CMV) and human herpesvirus type 6 (HHV-6) could be involved in the pathogenesis of HD is also unclear.

METHODS

Paraffin-embedded material from 77 cases of HD was studied. This consisted of 24 specimens from children (mean age, 11.4 years), 36 from young adults (mean age, 28.8 years), and 17 from older adults (mean age, 53.8 years). EBV was detected in Hodgkin and Reed-Sternberg cells (HR-S) by a sensitive in situ hybridization technique based on the detection of Epstein-Barr-encoded RNA. Viral activity was subsequently demonstrated in HR-S cells by using monoclonal antibodies to EBV latent membrane protein.

RESULTS

EBV was found in a total of 25 of 77 cases (32%). There was no significant difference in EBV positivity between the different age groups. However, the prevalence of EBV varied between different subtypes: 68% of mixed cellularity cases were found to be positive by contrast with 24% nodular sclerosis, 0% lymphocyte predominant, and 14% lymphocyte depleted. Analysis of the histologic reports of a further 783 cases of HD to determine the age distribution of the different subtypes revealed an absence of an older adult second peak in the age distribution curve. In situ hybridization for CMV and HHV-6 was negative in all cases.

CONCLUSIONS

It was concluded that EBV is predominantly associated with mixed cellularity HD, and there is no correlation with the age of the patient.

Recent results on the biology of Hodgkin and Reed-Sternberg cells. I. Biopsy material

The most recent sophisticated investigations have provided new and revealing, but also contradictory and controversial information on the biological nature and the cellular origin of Hodgkin and Reed-Sternberg cells (H-RS). Immunophenotypic analyses have shown variable phenotypic antigen expression; but, on balance the data suggest a lymphoid cell expressing T- and/or B-cell-associated markers and certain activation antigens while lacking immunological features of monocytes-macrophages or other lineages. Molecular genetic studies have demonstrated heterogenous findings with respect to rearrangements of T-cell receptor and immunoglobulin genes. Only a small percentage of the cases has rearrangements; this might be due to the threshold of sensitivity of the method combined with the scarcity of the malignant cells. Epstein-Barr virus (EBV) genomes are clonally integrated in the H-RS cells of about half the cases. The significance of these findings--whether EBV is a causative agent or an epiphenomenon--remains to be elucidated. H-RS cells express mRNA and proteins of various cytokines and cytokine receptors implying a predominant role for cytokines in the pathophysiology of HD. The mononuclear and polynuclear H-RS cells are capable of DNA synthesis and nuclear division; the lack of cellular division leads to multinuclearity through the process of endomitosis. Mutations and expression of only a limited number of oncogenes have been tested thus far. Whether the bcl-2 oncogene is involved in HD remains a matter of debate. Aneuploidy and non-random chromosomal abnormalities are the results of cytogenetic analyses of H-RS cells. However, no chromosomal marker specific for HD has yet been found. Thus, while studies of EBV involvement, growth factor production, oncogene expression and chromosomal abnormalities contributed a fair amount of new data on the nature of H-RS cells, only immunophenotyping and genotyping provided some indication of the cellular derivation: an activated lymphoid cell that possibly expresses oncogenes, that probably is infected with EBV, that most likely produces cytokines, that certainly has multiple karyotypic abnormalities.

Viral involvement in Hodgkin's disease

The etiology of Hodgkin's disease (HD) is unknown, but a growing body of evidence suggests that the Epstein-Barr virus (EBV) plays a role in a proportion of cases. Clonal EBV genomes have been detected in affected tissues, and EBV has been localized to Reed-Sternberg (RS) cells, the putative malignant cells in HD. EBV latent genes, including the EBER RNAs and the latent membrane protein, LMP-1, are expressed by RS cells. These data suggest that EBV is playing a role in the pathogenesis of HD; however, it is clearly not involved in all cases. Using in situ hybridization, we can detect EBV within the RS cells in approximately 40% of cases. Epidemiological data suggest that HD is a heterogeneous condition and the distribution of EBV-associated cases is not random. Studies from several groups indicate that mixed cellularity cases are more likely to be EBV-associated than nodular sclerosis cases. Our data further suggest that the majority of pediatric and older cases of HD are EBV-associated, whereas the RS cells in young adult cases only rarely harbor EBV. We therefore speculate that another virus is responsible for the young adult peak in incidence which is seen in developed countries.

Antibodies to human herpes virus-6 and clinical course in patients with Hodgkin's disease

Serial serum samples from 37 patients with Hodgkin's disease (HD) and 39 healthy controls were studied for antibodies to human herpes virus-6 (HHV-6) using ELISA and indirect immunofluorescent antibody (IFA) tests and to the Epstein-Barr virus (EBV) using a radio-complement fixation assay. Antibodies to HHV-6 in the pre-treatment sera from the HD patients were not significantly different from those of controls, but significant changes in titers related to clinical course were noted among the HD patients. HHV-6 IFA titers increased significantly in the course of follow-up in patients who relapsed and decreased significantly over time in patients who did not. These serologic studies support tissue-based investigations indicating that EBV plays a greater etiologic role in HD than HHV-6, although HHV-6 serology may be of prognostic value or may assist in identifying individuals with immunologic abnormalities. The identification of diverse HHV-6 antibody patterns using different assays may reflect the presence of a number of antibodies with varying implications, similar to those identified for EBV.

Demonstration of Epstein-Barr virus genome in neoplastic cells of Hodgkin's disease by in situ hybridization, in paraffin-embedded tissue using biotinylated probes. A study of 46 cases

Paraffin-embedded tissue specimens from 46 cases of Hodgkin's disease (HD) were studied by in situ hybridization with biotinylated probes for the presence of EBV genomes. EBV specific DNA sequences were detected in the nuclei of Reed-Sternberg (RS) and Hodgkin cells (H), in 14 of these 46 cases. There was no correlation between positive hybridization and morphological subtype or site of tumor. By demonstrating an exclusive localization of the viral DNA in the tumor cells of HD, our study adds to the growing body of evidence to suggest an involvement of EBV in the pathogenesis of at least some cases of HD.

Hodgkin's disease

The epidemiological features of Hodgkin's disease (HD) suggest that it is a heterogeneous condition which may have different aetiologies in different age groups. The risk factors for the development of HD in young adults suggest that delayed exposure to a common infectious agent may be involved in this age group. Seroepidemiological studies have shown that HD patients have elevated antibody titres to Epstein-Barr virus (EBV) and the elevated titres have been shown to precede the diagnosis of HD. Recent molecular studies provide support for the idea that EBV is involved in the pathogenesis of HD. EBV genomes are consistently found in a proportion of tumour biopsies, the EBV-infected cells are clonal and the EBV genomes have been localized to Reed-Sternberg cells. Furthermore, EBV latent gene products are expressed by the Reed-Sternberg cells. The majority of HD samples from patients aged greater than 50 years and less than 15 years are EBV positive, whereas the minority (less than 15%) of samples from young adults contain detectable EBV DNA. The results suggest that EBV plays a role in HD in children and older adults but that other agents, possibly other viruses, are involved in young adults.

Epstein-Barr virus infections and Hodgkin's disease: a study of fixed tissues using the polymerase chain reaction

Epstein-Barr viral (EBV) infections are associated with Hodgkin's disease (HD). To better characterize this relationship, fixed tissues of infectious mononucleosis, normal and reactive lymph nodes, lymph nodes with progressively transformed germinal centers, and biopsy specimens with the different subtypes of HD were analyzed by polymerase chain reaction (PCR). The presence or absence of EBV, the relative amounts of EBV, and the presence of multiple EBV genotypes as defined by amplification of a polymorphic EBV locus were determined for each specimen. Epstein-Barr virus could be detected from all specimens with infectious mononucleosis (eight of eight cases), generally in relatively large amounts, with multiple EBV genotypes evident in two cases. Epstein-Barr virus could not be detected from normal or reactive lymph nodes (none of 39 cases). Small amounts of EBV could be detected from a minority of cases with progressively transformed germinal centers (two of 16 cases), with multiple EBV genotypes evident in one case. Variable amounts of EBV could be detected from approximately half of the specimens with HD (26 of 50 cases). Epstein-Barr virus was most often detected in the subtypes of mixed cellularity (12 of 15 cases), nodular sclerosis (seven of 14 cases), and lymphocyte depletion (five of seven cases) compared with nodular lymphocyte predominance HD (two of 14 cases). In contrast to specimens with infectious mononucleosis and progressively transformed germinal centers, only one EBV genotype was evident in the specimens with HD. These findings are consistent with the hypothesis that some cases of HD may be directly associated with EBV.

Expression of Epstein-Barr virus latent gene products in tumour cells of Hodgkin's disease

The Epstein-Barr virus (EBV)-encoded latent gene products, latent membrane protein (LMP) and EBV nuclear antigen 2 (EBNA 2), seem to have important roles in EBV-induced cell transformation in vitro, and have been implicated as important effector molecules in EBV-associated lymphomagenesis. Because up to 35% of Hodgkin's disease (HD) samples have been reported to contain EBV genomes, the expression of LMP and EBNA 2 in these tumours was investigated. 84 cases of HD were studied with monoclonal antibodies and immunohistochemical labelling of acetone-fixed cryostat sections. LMP, but not EBNA 2, was demonstrated in Reed-Sternberg (RS) cells of 40 cases (48%); the two proteins were easily detected in transformed lymphocytes of positive control acute infectious mononucleosis tonsils. LMP expression in RS cells varied according to the histological subtype of HD (1/10 cases [10%] of lymphocyte predominance subtype, 16/50 cases [32%] of nodular sclerosis, 23/24 [96%] cases of mixed cellularity type). That the LMP antibodies showed no substantial cross-reactivity with negative control tissues shows that they are useful probes for the diagnosis of latent EBV infection in tissue sections. The findings suggest that EBV is associated with more cases of HD than was previously recognised, that in positive cases RS cells express a latent infection protein phenotype (LMP+, EBNA 2-) which differs from that of other EBV-associated lymphomas, and that LMP expression is related to histologically aggressive subtypes of HD.

High frequency of Epstein-Barr virus genome detection in Hodgkin's disease of HIV-positive patients

Lymph nodes obtained from 7 HIV-positive and 20 HIV-negative patients with Hodgkin's disease were examined for the presence of Epstein-Barr virus antigens and genome. EBV antigens were observed in only 2 out of 20 HIV-negative patients, whereas lymph nodes of HIV-positive patients did not reveal evidence of EBV antigens. By in situ hybridization and Southern blot analysis, EBV genome was found in 5 out of 7 HIV-positive patients; the EBV genome was detected in the nucleus of Reed-Sternberg and Hodgkin's cells. EBV DNA was observed by in situ hybridization and Southern blot analysis in only 3 out of 20 HIV-negative patients with Hodgkin's disease. In both groups, Reed-Sternberg and Hodgkin's cells were negative for C3d EBV receptor. Our results show a statistically significant increased expression of EBV DNA in HIV-positive patients with Hodgkin's disease, as compared with HIV-negative patients with HD.

Demonstration of Epstein-Barr viral DNA in formalin-fixed, paraffin-embedded samples of Hodgkin's disease

The presence of Epstein-Barr virus (EBV) DNA in formalin-fixed, paraffin-embedded samples of Hodgkin's disease (HD) was investigated by Southern blot hybridization using a specific EBV Bam H1W fragment probe. DNA from 16 samples of HD in children and young adults was compared with that from ten samples in adults older than 45 years. A further eight cases of DNA extracted from fresh samples of HD were also studied, in order to compare the results obtained with fresh and fixed tissue samples. Hybridization was demonstrated in 15 of the 34 cases of HD studied in contrast to 3 or the 34 control specimens of non-Hodgkin's lymphoma, non-neoplastic lymph nodes, and carcinomas. No differences between the two age groups compared were found. The results of this study suggest that there is a definite association between EBV and HD, although the exact nature of this association remains to be established. It has also been shown that DNA of sufficient quality for the detection of EBV DNA can be extracted from formalin-fixed, paraffin-embedded material, and that comparable results can be obtained using DNA extracted from fresh and fixed tissue.

The seroepidemiology of human herpesvirus-6 (HHV-6) from a case-control study of leukaemia and lymphoma

Sera from an epidemiological case-control study of leukaemias and lymphomas conducted between 1980 and 1986 were examined for reactivity to human herpesvirus-6 (HHV-6) by an indirect immunofluorescence assay. Statistical analyses of the data revealed higher HHV-6 seroprevalence and antibody titres in the cases, particularly evident in the disease subtypes acute myeloid leukaemia, Hodgkin's disease (HD), and low-grade non-Hodgkin's lymphoma. Within the control group alone, HHV-6 seroprevalence was placed at 55% at a serum dilution of 1:40. The controls also displayed higher seropositivity in females as compared with males. Further analyses suggest an association of increased HHV-6 seropositivity and geometric mean titre ratio with HD among young adults lacking social contact in the family group. This finding might indicate late exposure to HHV-6 in such persons and could possibly signify late exposure to a number of viruses, including those hypothesized as playing a role in the aetiology of HD. Previous reports have nominated Epstein-Barr virus as a possible candidate. Our results suggest that HHV-6 should be included in further investigations of the aetiology of HD.

Hodgkin's disease and Epstein-Barr virus. Altered antibody pattern before diagnosis

In patients with Hodgkin's disease, titers of IgG antibody against viral capsid antigen of Epstein-Barr virus and the prevalence of antibodies against early antigen are higher than expected. To evaluate whether this condition antedates diagnosis, we identified 43 persons with Hodgkin's disease, from whom blood had been drawn and stored for an average of 50.5 months before diagnosis, and 96 controls from the same populations, from whom blood had been drawn at the same time. The relative risks of Hodgkin's disease associated with elevated levels of IgG and IgA antibodies against capsid antigen were 2.6 (90 percent confidence interval, 1.1 to 6.1) and 3.7 (1.4 to 9.3), respectively. For Epstein-Barr nuclear antigen, the relative risk was 4.0 (1.4 to 11.4), and for early antigen D it was 2.6 (1.1 to 6.1). However, the prevalence of IgM antibody against capsid antigen was substantially lower in patients with Hodgkin's disease (0.22 [0.04 to 1.3]). These associations were stronger in serum samples obtained at least three years before diagnosis than in serum samples obtained closer to diagnosis. We conclude that the development of Hodgkin's disease may in some patients be preceded by enhanced activation of Epstein-Barr virus. Whether Epstein-Barr virus has a direct role in the pathogenesis of the disease or is simply a marker for a more fundamental factor affecting the immune control of latent infections is unknown.

The concurrence of Saethre-Chotzen syndrome and malignancy in a family with in vitro immune dysfunction

The occurrence among 13 siblings of a malformation-mental retardation syndrome and diverse malignancies was investigated for etiologic relationship by clinical, genetic, immunologic, and virologic techniques. Three sisters and their father had Saethre-Chotzen syndrome, an autosomal dominant trait with craniosynostosis and asymmetric facies. One affected sister also had nasopharyngeal carcinoma; tow nondysmorphic brothers had Hodgkin's disease, and another had seminoma with teratocarcinoma of the testis. Decreased in vitro lymphocytic proliferation to various mitogens was observed in both available siblings with tumor, one sibling with Saethre-Chotzen syndrome, and two clinically normal siblings and their father. Both parents and all siblings had normal karyotypes and no increase of antibodies to Epstein-Barr virus. The malformation syndrome and the various neoplasias segregated independently of each other and of 47 genetic markers, including histocompatibility antigens (HLA). This study illustrates an approach to defining etiology when rare disorders cluster in a family and suggests that the occurrence of malignancies in this family may be related to subclinical immune dysfunction. Whether the Saethre-Chotzen syndrome predisposed to malignancy, perhaps through impaired immunity, awaits additional observations.

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.

Epstein-Barr virus markers in a series of Burkitt's lymphomas from the West Nile District, Uganda

In an epidemiological survey in the West Nile District of Uganda, 70 pathologically confirmed BL cases were detected over a 5-yr period; this corresponded to an annual incidence rate of 1.6 per 100,000 general population or about 5 per 100,000 children in the age group 5-14 yr. Of the confirmed cases which were examined by EBV/DNA molecular hybridization, 96% were found to contain an average of 38 EBV genome equivalents per tumour cell, whereas none of the examined unconfirmed cases did. Duplicate hybridization assays in two laboratories were in close agreement. Serological testing showed that 91% of the confirmed BL cases had elevated EBV/VCA titres (greater than or equal to 160) and 64% were EA(D)-positive (greater than or equal to 10). Most of the cases with high EBV/genome content had high VCA titres, but there was a poor correlation between the two parameters among all cases. This study confirms that in high BL incidence areas the association between EBV and this lymphoma is almost constant, whereas it is exceptional in low-incidence areas. This further supports the aetiological implication of EBV in the endemicity of this tumor in equatorial Africa.

Discordant Epstein-Barr virus nuclear antigen (EBNA) antibody patterns in nasopharyngeal carcinoma

Epstein-Barr virus nuclear antigen (EBNA) preparations from three sources were tested with sera from normal individuals and patients with Hodgkin's disease, breast carcinoma, Burkitt's lymphoma, and American and Chinese nasopharyngeal carcinoma. Individual sera with discordant antibody patterns were noted in all groups. Sera from both NPC groups gave significantly higher anti-EBNA titers on cell lines converted with P3HR-1 or B95-8 virus compared with anti-EBNA titers on Raji cells. Anti-EBNA titers of Chinese NPC sera showed no correlation among the three EBNA sources, while all other groups had highly correlated titers. Cross-absorption experiments present evidence for more than one antigenic determinant on EBNA. These results suggest an additional parameter for distinguishing Chinese NPC from other EBV-related disorders.

Early antigen titers in pediatric patients with acute cervical lymphadenitis

Eight pediatric patients with acute cervical lymphadenitis or neck mass, alone or in association with nonspecific upper respiratory complaints, were screened for the presence of a primary or reactivation Epstein-Barr virus infection. All were found to have elevated antibodies to the early antigen (EA) and 75% (6) of these were found to be reactivations. Only one had a positive heterophile. Half of the patients had elevation of the EA-specific IgA, and 75% (6) had elevation of viral capsid antigen-specific IgA. All had elevated levels of soluble immune complexes. There was not a direct relationship between the EA titer or soluble immune complex level and severity of disease.

In vitro susceptibilities of normal human skin fibroblasts to oncoviruses, and the decreased susceptibility to HSV of fibroblasts from untreated Hodgkin's patients

Fibroblast cultures established from the skin of 56 healthy controls and 15 untreated Stages I and II Hodgkin's patients (HD) were studied in their 3rd, 4th and 5th in vitro passage with respect to transformation with Simian sarcoma virus (SSV) and SV40 and with respect to replication of herpes simplex virus (HSV) Types 1 and 2, pox virus and interferon release. Susceptibility to the 5 viruses varied independently, except for an inverse correlation between susceptibility to SSV and HSV. HD cultures showed a depressed replication of both types of HSV. There was a borderline (P = 0.02) correlation between magnitude of HSV replication and presence of HL-A type B-w44, but this does not explain the HD control difference. Furthermore, the level of serum antibodies to HSV common antigen was not related to magnitude of in vitro replication. The results thus speak against generally enhanced cellular susceptibility to HSV as a reason for the high titres of serum antibodies to HSV in HD patients.

Presence of elevated antibody titres to Epstein-Barr virus before Hodgkin's disease

Sera taken 12 and 21 months before the diagnosis of Hodgkin's disease in two patients showed higher antibody levels to several Epstein-Barr-virus (EBV) antigens than did sera from eight matched controls. In one case the titres of all EB antibodies except that to nuclear antigen were raised in a serum sample obtained 45 months after the diagnosis was made. Antibody levels to herpes simplex, cytomegalovirus, and varicella zoster viruses were normal in both cases. A third patient with histiocytic lymphoma had normal EBV and other herpes antibody titres in a serum sample taken 40 months before diagnosis.

Infection of rhesus monkeys and chimpanzees with Epstein-Barr virus

Seventy-two nonhuman primates were entered into a long-term study to evaluate the pathogenicity of Epstein-Barr virus (EBV). Infectious virus was inoculated into 42 rhesus monkeys, 4 chimpanzees and 1 cynomolgus monkey. Immunostimulation or immunosuppression was attempted in 34 of these animals to enhance the oncogenic potential of the virus. Eleven inoculated animals were followed for more than 3 years and two were observed for 8 years. No tumors were observed in any of the animals; however, serological evaluation of the 47 inoculated primates and 25 matched controls indicated that at least 14 rhesus monkeys and the cynomolgus monkey were successfully infected with EBV. The potential use of rhesus monkeys as a model for EBV-induced disease in humans is discussed.

[In vitro studies on two cell lines from patients with Hodgkin's disease (author's transl)]

Two cell lines (Ma,Bi) were established in vitro from pleura effusions from two patients with Hodgkin's disease. After some months the monolayer line Ma spontaneously became nonadherent and proliferated in suspension. Immunological properties, enzyme activities, surface characteristics and chromosomal analyses suggested that the culture Ma is composed of lymphoid cells and macrophages. Line Bi propagated attached to the glass and had properties typical for macrophages only.

The relation between Epstein-Barr virus antibodies and clinical symptomatology and immunodeficiency in patients with Hodgkin's disease

Anti-Epstein-Barr virus (EBV) titers were measured in the sera of 37 patients with Hodgkin's disease and in 40 normal controls. The patients were grouped according to histologic type, clinical symptomatology (relapse or remission), and their immune state (immunodeficient or non-immunodeficient). Anti-Epstein-Barr nuclear antigens (EBNA) and antiviral capside antigens (VCA) titers were higher in patients with Hodgkin's disease than in the controls. Anti-EBNA titers were significantly higher in patients with lymphocyte predominance, and anti-VCA titers were significantly higher in patients with mixed cellularity. Patients in clinical relapse had higher anti-EBV antibody titers than patients in remission or those in the control group. Immunodeficent pateints had significantly higher anti-VCA titers than either the non-immuno-deficient or the control cases. We believe high anti-EBV titers are related to immunodeficiencies. The relationship between Hodgkin's disease and EBV is discussed.

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.

Elevated titer of antibodies to Simian sarcoma virus envelope antigen (gp70) and normal response to influenza virus in untreated Danish Hodgkin's patients

Untreated Danish Hodgkin's disease (HD) patients and paired age- and sex-matched controls were tested for serum antibodies to Epstein-Barr virus (EBV), six strains of influenza virus and Simian sarcoma virus/Simian sarcoma-associated virus [SSV(SSAV)] antigens. HD sera showed significantly elevated titers against EBV and both increased incidence and mean titer of antibodies to the envelope glycoprotein of SSV(SSAV), whereas testing against the influenza viruses revealed no differences between HD and controls. A focus reduction assay demonstrated a low incidence in HD and controls of sera with neutralizing effects against SSV(SSAV) and the "baboon" C-type virus component of the human HL-23 virus complex, which seemed coupled to HL-A type W19.

Longitudinal study of Epstein-Barr virus antibody titers and excretion in pediatric patients with Hodgkin's disease

Nineteen pediatric patients with Hodgkin's disease (HD) who had experienced primary Epstein-Barr virus (EBV) before, or in one case after, diagnosis, were studied longitudinally for changes in the titers and spectra of EBV-related antibodies, excretion of EBV into the oropharynx, the number of EBV-carrying lymphoid cells in the peripheral blood, and clinical signs and symptoms suggestive of reactivation of the latent virus. The incidence and geometric mean titers of IgG antibodies to viral capsid antigen (VCA) in the HD patients at the time of diagnosis and in the controls were similar. The anti-VCA titers of the patients rose above control levels during and after therapy and remained elevated for up to 7 years of observation. At no time were heterophil or VCA-specific IgM antibodies detected. Antibodies to EBV-induced early antigens were more common in patients (ultimately 80%) than in controls (9%). In contrast, antibody levels to EBV-associated nuclear antigen were disproportionally low in the patients. Excretion of EBV was noted at increased frequency in the patients but the number of circulating, EBV-carrying lymphoid cells was the same as in controls. No discrete clinical syndrome was associated with rising antibody titers or viral excretion. While these results are best explained by a presumed reactivation of the persistent EBV infection by immunosuppressive effects of HD or its therapy, they have not provided direct evidence for this suggestion.

Seroepidemiological studies of human papilloma virus (HPV-1) infections

At least two groups of human papilloma viruses can be distinguished serologically: on the one hand HPV 1-3, which are closely related but differ in the restriction enzyme pattern of their DNA, and on the other hand HPV-4. The age distributions of patients with warts induced by HPV 1-3 or by HPV-4, respectively, differ markedly. HPV 1-3 predominates between 5 and 15 years of age, whereas HPV-4 could be isolated more often between the ages of 20-25 years. The large number of HPV-1-3-induced warts in children is paralleled by a high percentage of HPV-1 antibody-positive sera in the same age group (about 50%). With increasing age the percentage of HPV-1 antibody-positive sera decline gradually. This pattern of seroreactivity was compared to that of patients with various papillomas and with several malignant tumors. There is no evidence to suggest a link between HPV 1-3 and condylomata acuminata, laryngeal papillomas or any of the malignant tumors tested.

Herpesvirus group antibodies in children with Hodgkin's disease

During the period of three years ((1972-1974), serum samples from 60 patients (children and adolescents) with lympho-hematopoietic system diseases were examined for antibodies to all four human herpesviruses. Among these were 26 active Hodgkin's disease (AHD) patients and 6 HD patients with a minimum five years' remission. Simultaneously matched controls (age, sex) of AHD patients were examined. Antibody levels against the viral capsid antigen of Epstein-Barr virus (EBV/VCA) in AHD patients were significantly higher, with overrepresentation of higher titres (greater than or equal to 1:160), than in matched controls. The lowest EBV/VCA antibody titres were in the leukemia-non-Hodgkin's lymphoma patients. We could not prove any significant relationship between cytomegalovirus or herpes simplex virus type 1 antibody titres and AHD or any other disease of lympho-hematopoietic system. The varicella-zoster virus antibody titres in AHD patients were significantly higher than in matched controls. No significant differences in antibodies against EBV/VCA and the other human herpes viruses between the evolution and remission period of AHD patients could be detected. No differences in EBV/VCA antibody titres were observed between the healthy school-children aged 10 to 15 years who were and who were not in contact with a HD patient.

Epidemiology of hodgkin's disease in the young

Many features of Hodgkin's disease (HD) among adolescents and young adults suggest that it has an infectious etiology. However, the proposal that HD is a contagious disease which can be transmitted by patients or their close contacts has not been substantiated. An alternative infectious disease model is suggested by analogy with paralytic poliomyelitis (PP). For both diseases, the peak age of incidence is delayed as living conditions improve. For both, increased risk is associated with higher social class and small family size. Like PP, HD may be a rare manifestation of a common infection with the probability of disease development increasing as age at infection is delayed. This analogy is supported by the report that the risk of HD is higher for persons who had a low frequency of childhood infectious diseases. If this model is valid, HD patients represent no hazard to their contacts. However, the incidence of HD among young adults may increase in the coming decade because of the current high standard of living and small family size.

Lymphocyte responses to EBV-associated antigens in infectious mononucleosis, and Hodgkin's and non-Hodgkin's lymphoma patients, with the leukocyte adherence inhibition assay

The leukocyte adherence inhibition (LAI) assay was utilized as a test for cellular immunity to Epstein-Barr virus (EBV) antigens in 22 patients with infectious mononucleosis (IM), 47 patients with lymphoma, 101 carcinoma patients, and 84 subjects without cancer. Response to EB virion ("v") antigen was generally present at the time of diagnosis in the IM patients but the response to EB soluble ("S") antigen was delayed. An increased CMI response to "v" antigen was found in patients with IM, Hodgkin's disease and non-Hodgkin's lymphoma as compared to controls with and without cancer. Patients with Hodgkin's disease had depressed responses to the EBV-associated "S" antigen. The finding of increased LAI responses to "v" antigen in Hodgkin's disease patients with high EBV antibody titers conflicts with previous reports attributing high antibody responses against EBV to a generalized depressed cell-mediated immunity.

Establishment of peripheral lymphoid cell cultures from patients with Hodgkin's disease depending on Epstein-Barr-Virus-reactivity and cellular immunity

Peripheral blood lymphocytes from 43 patients with Hodgkin's disease were studied for spontaneous growth in longterm cultures in vitro. The rate of culture establishment in Hodgkin's patients was dependant on a positive Epstein-Barr-Virus (EBV)-seroreactivity and intact delayed hypersensitivity reaction to tuberculin. Localized and inactive disease, as well as the absence of atypical mononuclear cells in the peripheral blood had a favourable influence on the longterm in vitro growth. The overall establishment rate in Hodgkin patients was 18 out of 60 attempts (30%), 16 out of 34 (47%) in patients without treatment, only 2 out of 26 (7.7%) attempts during treatment. These results were compared with culture attempts of peripheral blood cells from healthy individuals and umbilical cord blood lymphocytes. Only 12 out of 60 attempts in healthy donors (18.2%) and 0 out of 49 attempts with umbilical cord blood lymphocytes were successful.