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Müller-Scholden L, Deinlein F, Eyrich M, Schlegel PG, Wiegering V, Wölfl M. Case Report: Multifocal EBV-Associated Diffuse Large B-Cell Lymphoma in a Patient With 6-MP Associated Lymphopenia With TPMT Deficiency. Front Pediatr 2022; 10:881612. [PMID: 35601437 PMCID: PMC9120811 DOI: 10.3389/fped.2022.881612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 04/07/2022] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION EBV associated lymphoproliferative disorders (EBV LPD) are a known complication following solid organ or hematopoietic stem cell transplantation. The disturbance of the immune system leads to a lack of control of latent EBV-infected B-cells, as control by T-cells is mandatory to prevent uninhibited cell proliferation. EBV LPD in other settings is less frequent and etiology and pathogenesis are not completely understood. CASE PRESENTATION We present the case of an 18-year old adolescent suffering from lymphoblastic T-cell lymphoma who developed a life-threatening EBV associated B-cell lymphoma while he was under therapy with 6-MP (6- mercaptopurine). An underlying homozygous TPMT (thiopurine S-methyltransferase) deficiency with subsequent insufficient degradation of 6-MP was identified as contributory for the development of a distinct lymphopenia leading to EBV LPD. The patient was successfully treated by discontinuation of 6-MP and initiating rituximab monotherapy. DISCUSSION Rare cases of EBV LPD during therapy with 6-MP are reported in patients with leukemia, but no data about TPMT pharmacogenomics are available. In contrast the disease development in the presented case may be explained by the iatrogenic immunosuppression in the context of TPMT deficiency. While using 6-MP testing of genetic variations is not required for every protocol, although the use of thiopurines in patients with TPMT deficiency can cause severe immunosuppression. Our case suggests that insufficient degradation of 6-MP can have significant consequences despite dose reduction. CONCLUSION When using thiopurines, TPMT genetics should be initiated and strict drug monitoring and dose adjusting must be performed by a specialized center.
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Affiliation(s)
- Lara Müller-Scholden
- Pediatric Oncology, Hematology and Stem Cell Transplantation Program, University Children's Hospital Würzburg, Würzburg, Germany
| | - Frank Deinlein
- Pediatric Oncology, Hematology and Stem Cell Transplantation Program, University Children's Hospital Würzburg, Würzburg, Germany
| | - Matthias Eyrich
- Pediatric Oncology, Hematology and Stem Cell Transplantation Program, University Children's Hospital Würzburg, Würzburg, Germany
| | - Paul Gerhardt Schlegel
- Pediatric Oncology, Hematology and Stem Cell Transplantation Program, University Children's Hospital Würzburg, Würzburg, Germany
| | - Verena Wiegering
- Pediatric Oncology, Hematology and Stem Cell Transplantation Program, University Children's Hospital Würzburg, Würzburg, Germany
| | - Matthias Wölfl
- Pediatric Oncology, Hematology and Stem Cell Transplantation Program, University Children's Hospital Würzburg, Würzburg, Germany
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Shahid S, Rossi C, Vyas P, Bollard C, Dave H. Iatrogenic immunodeficiency-associated lymphoproliferative disorder in a child with B-cell acute lymphoblastic leukemia. Pediatr Hematol Oncol 2019; 36:309-316. [PMID: 31314679 DOI: 10.1080/08880018.2019.1637982] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Iatrogenic immunodeficiency-associated lymphoproliferative disorders (LPDs) are a group of lymphoid proliferations or lymphomas that are well known to be associated with an immunosuppressed state. These disorders most commonly occur following hematopoietic or solid organ transplantation (called post-transplant lymphoproliferative disorders or PTLD), but cases have also been described during the treatment of autoimmune and rheumatologic disorders by immunosuppressive and immunomodulatory medications. These disorders are strongly associated with infection by the Epstein-Barr virus (EBV) as a result of impaired immune function in the immunosuppressed state. While this phenomenon has been well documented in autoimmune conditions, cases affecting pediatric patients while on anti-leukemia chemotherapy are lacking. In this report, we describe a case of a pediatric immunosuppressed patient with recurrent sinusitis found to have a nasopharyngeal mass consistent with EBV-positive B-cell lymphoproliferative disorder resembling a polymorphic PTLD during the maintenance phase of B-cell Acute Lymphoblastic Leukemia (ALL) therapy. The patient was successfully treated with rituximab without any cytotoxic chemotherapy, highlighting the importance of recognizing this clinical entity in non-transplant patients with hematologic malignancies.
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Affiliation(s)
- Sanam Shahid
- Children's National Health System , Washington , D.C
| | | | - Pranav Vyas
- Children's National Health System , Washington , D.C
| | | | - Hema Dave
- Children's National Health System , Washington , D.C
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Lu BY, Kojima L, Huang MS, Friedmann AM, Ferry JA, Weinstein HJ. Facial manifestations of Epstein-Barr virus-related lymphoproliferative disease in childhood acute lymphoblastic leukemia in remission: Two atypical presentations. Pediatr Blood Cancer 2016; 63:2042-5. [PMID: 27392033 DOI: 10.1002/pbc.26102] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 05/01/2016] [Accepted: 05/22/2016] [Indexed: 11/09/2022]
Abstract
Epstein-Barr virus-related lymphoproliferative disease (EBV-LPD) rarely occurs in patients with acute lymphoblastic leukemia (ALL), who have not received hematopoietic transplantation. We describe EBV-LPD manifesting as facial lesions in two children with ALL in remission. One patient was a 16-year-old male with T-cell ALL with an EBV-positive angiocentric polymorphous lip lesion presenting as right-sided facial swelling. The other patient was a 12-year-old male with B-cell ALL with an EBV-positive polymorphous lymphoplasmacytic infiltrate presenting as bilateral dacryoadenitis. Neither patient had known primary immunodeficiencies. Both cases improved with immunosuppressant de-escalation. These cases suggest that immunosuppression induced by maintenance chemotherapy is sufficient to promote EBV-LPD.
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Affiliation(s)
- Benjamin Y Lu
- Division of Pediatric Hematology & Oncology, Massachusetts General Hospital for Children, Harvard Medical School, Boston, Massachusetts
| | - Lisa Kojima
- Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mary S Huang
- Division of Pediatric Hematology & Oncology, Massachusetts General Hospital for Children, Harvard Medical School, Boston, Massachusetts
| | - Alison M Friedmann
- Division of Pediatric Hematology & Oncology, Massachusetts General Hospital for Children, Harvard Medical School, Boston, Massachusetts
| | - Judith A Ferry
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Howard J Weinstein
- Division of Pediatric Hematology & Oncology, Massachusetts General Hospital for Children, Harvard Medical School, Boston, Massachusetts.
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4
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Atabay B, Türker M, Oztürk C, Sütçüoğlu S, Oniz H, Ozer EA. Central nervous system involvement of epstein barr virus associated lymphoproliferative disorder in a child with acute lymphoblastic leukemia: successful treatment with rituximab and interferon-alpha. Turk J Haematol 2014; 30:58-62. [PMID: 24385755 PMCID: PMC3781665 DOI: 10.4274/tjh.2011.0047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Accepted: 05/21/2012] [Indexed: 12/01/2022] Open
Abstract
Central nervous system (CNS) involvement of Epstein-Barr virus (EBV)-associated lymphoproliferative disease is a rare and serious complication in children with leukemia. Although rituximab therapy seems to be promising in these cases, persistent hypogammaglobulinemia may appear after treatment due to complete depletion of normal B lymphocytes in the peripheral blood. Here we report isolated CNS involvement of EBV-associated lymphoproliferative disorder in a 4-year-old boy with acute leukemia. The patient was treated with rituximab and interferon alpha; however, persistent hypogammaglobulinemia developed as a complication. Given the rarity of the complication in children receiving these agents, our experience with such a case may be helpful to others. Conflict of interest:None declared.
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Affiliation(s)
- Berna Atabay
- Tepecik Training and Research Hospital, Department of Pediatrics Clinic, İzmir, Turkey
| | - Meral Türker
- Tepecik Training and Research Hospital, Department of Pediatrics Clinic, İzmir, Turkey
| | - Can Oztürk
- Tepecik Training and Research Hospital, Department of Pediatrics Clinic, İzmir, Turkey
| | - Sümer Sütçüoğlu
- Tepecik Training and Research Hospital, Department of Pediatrics Clinic, İzmir, Turkey
| | - Haldun Oniz
- Tepecik Training and Research Hospital, Department of Pediatrics Clinic, İzmir, Turkey
| | - Esra Arun Ozer
- Tepecik Training and Research Hospital, Department of Pediatrics Clinic, İzmir, Turkey
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5
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Drut R, Drut RM. Angiocentric immunoproliferative lesion and angiocentric lymphoma of lymph node in children. A report of two cases. J Clin Pathol 2005; 58:550-2. [PMID: 15858132 PMCID: PMC1770650 DOI: 10.1136/jcp.2004.022475] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIM To report two examples of an angiocentric immunoproliferative lesion (AIL) and angiocentric angiodestructive lymphoma (AL) presenting in lymph nodes in children. Most commonly involving extranodal sites, AIL/AL rarely presents in the spleen and lymph nodes. METHODS/RESULTS Case 1 presented as a cervical lymphadenopathy in a 3 year old girl being treated for pre-B cell acute lymphoblastic leukaemia. Histological and immunohistochemistry studies revealed an Epstein-Barr virus positive (EBV+), large B cell (CD20 and CD30+) AIL with large areas of necrosis, the whole resembling lymphomatoid granulomatosis. Case 2 presented as a large supraclavicular lymphadenopathy in a 13 year old boy. Histology and immunohistochemistry revealed an EBV-, large T cell (CD45RO, CD56, and CD30+) AL, presenting the features of so called angiocentric T cell/natural killer cell lymphoma, nasal type. CONCLUSIONS The term AIL/AL refers to a heterogeneous group of conditions not unique to a particular type of lymphoid cell. These lesions are easily recognised by the histopathologist because of their extremely unusual angiocentric pattern. Although rare, AIL/AL may present as nodal lesions in children ab initio.
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Affiliation(s)
- R Drut
- Department of Pathology, Hospital de Niños Superiora Sor María Ludovica, 1900, La Plata, Argentina.
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6
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Meerbach A, Gruhn B, Wutzler P. Recent developments in the prevention and treatment of Epstein–Barr virus-associated lymphoproliferative diseases. Expert Opin Ther Pat 2005; 14:527-47. [DOI: 10.1517/13543776.14.4.527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Lehrnbecher T, Trusen A, Deinlein F, Höcht B, Marx A, Kühl J. B-Cell lymphoproliferative disorder not associated with Epstein-Barr Virus in a child with relapsed acute lymphoblastic leukemia. MEDICAL AND PEDIATRIC ONCOLOGY 2003; 40:13-7. [PMID: 12426680 DOI: 10.1002/mpo.10202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Lymphoproliferative disorder (LPD) is described in only a few children receiving chemotherapy for cancer. In all of them, an association between LPD and EBV (Epstein-Barr Virus) was found. We report on a patient who developed LPD not associated with EBV while receiving chemotherapy for relapsed acute lymphoblastic leukemia (ALL). Despite discontinuation of chemotherapy, administration of intravenous immunoglobulins and surgery the patient died. Growing experience with this disorder may allow better treatment options in the future and will show whether LPD not associated with EBV requires different therapeutic strategies.
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Heath JA, Broxson EH, Dole MG, Filippa DA, George D, Lyden D, Dunkel IJ. Epstein-Barr virus-associated lymphoma in a child undergoing an autologous stem cell rescue. J Pediatr Hematol Oncol 2002; 24:160-3. [PMID: 11998794 DOI: 10.1097/00043426-200202000-00022] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Epstein-Barr virus-associated lymphoproliferative disease (EBV-LPD) is a serious disorder seen in various states of immunodeficiency, often with a fatal outcome. In this article, a patient with EBV-lymphoma after autologous stem cell rescue for treatment of a nonhematologic solid tumor is described. The child, a 4-year-old boy, had unilateral retinoblastoma with metastatic spread to the central nervous system. He had previously received both local tumor bed and craniospinal radiation therapy together with intensive myeloablative alkylator chemotherapy before autologous stem cell rescue. Histologically confirmed lymphoma with evidence of active EBV proliferation developed within cervical lymph nodes 3 weeks after his first autologous stem cell rescue. A complete clinical remission of the lymphadenopathy was obtained after infusions of rituximab (an anti-CD20 monoclonal antibody), acyclovir, and high-titer anticytomegalovirus immunoglobulin. The patient died approximately 6 months later of persistent and progressive retinoblastoma without any clinical evidence of lymphoma. It is concluded that EBV-LPD should be included in the differential diagnosis in patients in whom lymphadenopathy develops after autologous stem cell rescue.
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MESH Headings
- Acyclovir/therapeutic use
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Murine-Derived
- Antineoplastic Agents, Phytogenic/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Antiviral Agents/therapeutic use
- Carboplatin/administration & dosage
- Central Nervous System Neoplasms/drug therapy
- Central Nervous System Neoplasms/radiotherapy
- Central Nervous System Neoplasms/secondary
- Child, Preschool
- Combined Modality Therapy
- Cyclophosphamide/therapeutic use
- Disease Progression
- Epstein-Barr Virus Infections/complications
- Epstein-Barr Virus Infections/drug therapy
- Etoposide/administration & dosage
- Eye Enucleation
- Eye Neoplasms/drug therapy
- Eye Neoplasms/pathology
- Eye Neoplasms/radiotherapy
- Eye Neoplasms/surgery
- Fatal Outcome
- Hematopoietic Stem Cell Transplantation
- Herpesvirus 4, Human/isolation & purification
- Humans
- Immunocompromised Host
- Immunoglobulins, Intravenous/therapeutic use
- Immunosuppressive Agents/adverse effects
- Immunosuppressive Agents/therapeutic use
- Immunotherapy
- Lymphoma, Large B-Cell, Diffuse/drug therapy
- Lymphoma, Large B-Cell, Diffuse/etiology
- Lymphoma, Large B-Cell, Diffuse/therapy
- Lymphoma, Large B-Cell, Diffuse/virology
- Male
- Meningeal Neoplasms/drug therapy
- Meningeal Neoplasms/radiotherapy
- Meningeal Neoplasms/secondary
- Meningeal Neoplasms/therapy
- Methylprednisolone/therapeutic use
- Neoplasm Recurrence, Local
- Neoplasms, Second Primary/drug therapy
- Neoplasms, Second Primary/etiology
- Neoplasms, Second Primary/therapy
- Neoplasms, Second Primary/virology
- Optic Nerve Neoplasms/radiotherapy
- Optic Nerve Neoplasms/secondary
- Radiotherapy, Adjuvant
- Retinoblastoma/drug therapy
- Retinoblastoma/radiotherapy
- Retinoblastoma/secondary
- Retinoblastoma/surgery
- Retinoblastoma/therapy
- Rituximab
- Thiotepa/therapeutic use
- Vincristine/therapeutic use
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Affiliation(s)
- John A Heath
- Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
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Bernard F, Sarran N, Margueritte G, Barneon G, Astruc J. Successful treatment of an Epstein-Barr virus-associated B-cell lymphoproliferative disease in a child with acute lymphoblastic leukemia using an anti-CD20 monoclonal antibody. MEDICAL AND PEDIATRIC ONCOLOGY 2001; 36:329-31. [PMID: 11452947 DOI: 10.1002/1096-911x(20010201)36:2<329::aid-mpo1077>3.0.co;2-f] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- F Bernard
- Department of Pediatric, Hematology Oncology, Arnaud de Villeneuve Hospital, Montpellier, France.
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10
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Sung L, Dix D, Allen U, Weitzman S, Cutz E, Malkin D. Epstein-Barr virus-associated lymphoproliferative disorder in a child undergoing therapy for localized rhabdomyosarcoma. MEDICAL AND PEDIATRIC ONCOLOGY 2000; 34:358-60. [PMID: 10797360 DOI: 10.1002/(sici)1096-911x(200005)34:5<358::aid-mpo9>3.0.co;2-k] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- L Sung
- Division of Hematology and Oncology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Ontario, Canada
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