Long-term survival benefit of ruxolitinib in a patient with relapsed refractory chronic active Epstein-Barr virus

Cytokine Storm Syndromes Associated with Epstein-Barr Virus

Epstein-Barr virus (EBV) is a ubiquitous and predominantly B cell tropic virus. One of the most common viruses to infect humans, EBV, is best known as the causative agent of infectious mononucleosis (IM). Although most people experience asymptomatic infection, EBV is a potent immune stimulus and as such it elicits robust proliferation and activation of the B-lymphocytes it infects as well as the immune cells that respond to infection. In certain individuals, such as those with inherited or acquired defects affecting the immune system, failure to properly control EBV leads to the accumulation of EBV-infected B cells and EBV-reactive immune cells, which together contribute to the development of often life-threatening cytokine storm syndromes (CSS). Here, we review the normal immune response to EBV and discuss several CSS associated with EBV, such as chronic active EBV infection, hemophagocytic lymphohistiocytosis, and post-transplant lymphoproliferative disorder. Given the critical role for cytokines in driving inflammation and contributing to disease pathogenesis, we also discuss how targeting specific cytokines provides a rational and potentially less toxic treatment for EBV-driven CSS.

A rare B-cell type chronic active Epstein-Barr virus infection patient mimicking lymphoma on 18F-FDG PET/CT and literature review

A 13-year-old girl suffered from worsen snoring and persistent bilateral nasal congestion for one year. Paranasal sinus computed tomography (CT) and magnetic resonance imaging (MRI) found nasopharyngeal passages and sinus were occupied with soft tissues and bilateral neck enlarged lymph nodes 6 months ago. Tumor markers were normal. The titers of anti-Epstein-Barr virus (EBV) IgM, anti-EBV IgG, early antigen (EA) IgG, and Epstein-Barr nuclear antigen (EBNA) IgG increased. 2-Deoxy-2-[fluorine-18]-fluoro-D-glucose (¹⁸F-FDG) positron emission tomography combined with CT (PET/CT) revealed thickened soft tissues in nasopharynx and oropharynx, enlarged multiple lymph nodes in the neck, bilateral armpits, abdominal cavity and retroperitoneum, and pelvic cavity, diffuse thickening of the gastric wall of the antrum with hypermetabolism. According to the age, situation, regions, and abnormal FDG uptake, an initial diagnosis of EBV-related lymphoma was made. However, the pathological results of the nasopharyngeal mass and the abdominal lymph node confirmed the final diagnosis of a B-cell type chronic active Epstein-Barr virus disease (CAEBV), a rare type of EBV associated lymphoproliferative disorder (LPD). After receiving adoptive immune cells therapy, the EBV load decreased. At present, the patient is being followed up.

Early Use of Low-Dose Ruxolitinib: A Promising Strategy for the Treatment of Acute and Chronic GVHD

Janus kinases (JAK) are a family of tyrosine kinases (JAK1, JAK2, JAK3, and TYK2) that transduce cytokine-mediated signals through the JAK–STAT metabolic pathway. These kinases act by regulating the transcription of specific genes capable of inducing biological responses in several immune cell subsets. Inhibition of Janus kinases interferes with the JAK–STAT signaling pathway. Besides being used in the treatment of cancer and inflammatory diseases, in recent years, they have also been used to treat inflammatory conditions, such as graft-versus-host disease (GVHD) and cytokine release syndrome as complications of allogeneic hematopoietic stem cell transplantation and cell therapy. Recently, the FDA approved the use of ruxolitinib, a JAK1/2 inhibitor, in the treatment of acute steroid-refractory GVHD (SR-aGVHD), highlighting the role of JAK inhibition in this immune deregulation. Ruxolitinib was initially used to treat myelofibrosis and true polycythemia in a high-dose treatment and caused hematological toxicity. Since a lower dosage often could not be effective, the use of ruxolitinib was suspended. Subsequently, ruxolitinib was evaluated in adult patients with SR-aGVHD and was found to achieve a rapid and effective response. In addition, its early low-dose use in pediatric patients affected by GVHD has proved effective, safe, and reasonably preventive. The review aims to describe the potential properties of ruxolitinib to identify new therapeutic strategies.

Kinases as Potential Therapeutic Targets for Anti-coronaviral Therapy

The global coronavirus disease-19 (COVID-19) has affected more than 140 million and killed more than 3 million people worldwide as of April 20, 2021. The novel human severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has been identified as an etiological agent for COVID-19. Several kinases have been proposed as possible mediators of multiple viral infections, including life-threatening coronaviruses like SARS-CoV-1, Middle East syndrome coronavirus (MERS-CoV), and SARS-CoV-2. Viral infections hijack abundant cell signaling pathways, resulting in drastic phosphorylation rewiring in the host and viral proteins. Some kinases play a significant role throughout the viral infection cycle (entry, replication, assembly, and egress), and several of them are involved in the virus-induced hyperinflammatory response that leads to cytokine storm, acute respiratory distress syndrome (ARDS), organ injury, and death. Here, we highlight kinases that are associated with coronavirus infections and their inhibitors with antiviral and potentially anti-inflammatory, cytokine-suppressive, or antifibrotic activity.

Ruxolitinib in Patients With Chronic Active Epstein-Barr Virus Infection: A Retrospective, Single-Center Study

Background: Chronic active Epstein-Barr virus (CAEBV) infection is one of the EBV-positive T- or NK-cell lymphoproliferative diseases. There is no safe and effective treatment currently and the only proven curable therapy is allogeneic hematopoietic stem cell transplantation (allo-HSCT). The JAK1/2 inhibitor, ruxolitinib, is now considered a novel therapy in inflammatory disease, and hypercytokinemia is an important feature of CAEBV.

Method: All patients who suffered active CAEBV and were treated with ruxolitinib as compassionate use in our center from Sep 1, 2017, and Apr 30, 2019, were retrospectively analyzed.

Results: In general, seven out of nine patients responded to ruxolitinib. Six out of seven patients became afebrile within 48 h. The AST/ALT level of three out of four patients decreased after ruxolitinib treatment. Two patients with cytopenia recovered. No significant decrease in the EBV-DNA copy number was observed (p = 0.161). For those seven patients who responded to ruxolitinib, the median continuing period in remission was 7.1 weeks (range, 3.4–101.0 weeks). Two patients achieved long-term stable remission with ruxolitinib monotherapy. None of these patients discontinued ruxolitinib due to the possible toxicity.

Conclusion: Ruxolitinib is an effective and rather safe option for controlling the inflammatory symptoms of active CAEBV, especially in patients with CAEBV who have failed previous treatments or have relapsed. It can also play a promising role in improving the quality of daily life of patients and successfully bridging to allo-HSCT.

The potential of JAK/STAT pathway inhibition by ruxolitinib in the treatment of COVID-19

Ruxolitinib is the first approved JAK1 and JAK2 inhibitor, and is known to interfere with the JAK / STAT signaling pathway, one of the critical cellular signaling pathways involved in the inflammatory response. This review presents an overview of SARS-CoV-2 and the COVID-19 pandemic, and then focuses on the potential efficacy of ruxolitinib in this infection. The potential targets of ruxolitinib were determined by using genetic alterations that have been reported in COVID-19 patients. The potential effectiveness of ruxolitinib is suggested by evaluating the interactions of these potential targets with ruxolitinib or JAK/STAT pathway.