Epstein-Barr virus genome-positive tubulointerstitial nephritis associated with immune complex-mediated glomerulonephritis in chronic active EB virus infection

A chronic EBV infection causing persistent facial erythema multiforme and a retrospective literature review: A case report

RATIONALE

Epstein-Barr virus (EBV) infection is associated with a variety of diseases and can involve multiple organs and systems, with complex and nonspecific clinical manifestations that are easily misdiagnosed. Chronic EBV infection with persistent erythema multiforme (EM) on the cheek as the main manifestation is very rare and has been reported rarely.

PATIENT CONCERNS

This article reports a case of an adolescent female with chronic EBV infection who presented with chronic symmetrical erythema lesions on the face for 4 years, exacerbated with photophobia, lacrimation, Henoch-Schonlein purpura (HSP)-like rash, decline in granulocyte and erythrocyte lineages, hematuria, and proteinuria for 1 week.

DIAGNOSES

The disease was initially misdiagnosed as systemic lupus erythematosus (SLE) and later confirmed as chronic EBV infection by skin biopsy. In the case, EBV infection not only caused chronic facial EM, but also induced acute HSP and purpura nephritis (hematuria and proteinuria type).

INTERVENTIONS

The child was treated with 1 week of glucocorticosteroids in adequate doses combined with acyclovir antiviral therapy and 3 sessions of hemoperfusion. After discharge, she took prednisone acetate (15 mg twice a day) orally for 1 month and then discontinued.

OUTCOMES

She was discharged with her rash relieved and normal blood routine test and urine routine test. After 13 months of long-term follow-up, her facial erythema and hyperpigmentation became lighter, and there was no new rash on the whole body, and no abnormality in continuous monitoring of complete blood count and urine test.

LESSONS

This case suggests the need to be alert for chronic EBV infection in adolescent females with chronic facial EM rash and multiple organs and systems injury, in addition to connective tissue diseases such as SLE.

EBV load is associated with cfDNA fragmentation and renal damage in SLE patients

BACKGROUND

For long Epstein-Barr virus (EBV) has been suspected to be involved in the pathogenesis of systemic lupus erythematosus (SLE). The aim of this study was to verify the association between EBV, cell-free DNA (cfDNA) and kidney disease in SLE.

METHODS

Blood samples were obtained from 43 SLE patients and 50 healthy individuals. EBV load was measured via real-time PCR assay. Sizing and quantification of plasma cfDNA was performed on Bioanalyzer. We proposed that the uniformity of cfDNA fragmentation can be described using cfDNA fragmentation index.

RESULTS

SLE patients with chronic kidney disease (CKD +) had higher EBV load compared to CKD(-) patients (P = 0.042). Patients with high cfDNA level had higher EBV load (P = 0.041) and higher cfDNA fragmentation index (P < 0.001) compared to patients with low cfDNA level. Among patients with high cfDNA level, EBV load was higher in CKD(+) group compared to CKD(-) group (P = 0.035). EBV load was positively correlated with the fragmentation index in all SLE patients (P = 0.028, R² = 0.13), and the correlation was even more pronounced in CKD (+) patients (P < 0.001, R² = 0.20).

CONCLUSIONS

We showed that EBV load was associated with non-uniform cfDNA fragmentation, higher cfDNA levels, and kidney disease in SLE patients. Although the causality of this relationship could not be determined with the current study, it brings rationale for further investigations on the role of EBV and cfDNA interplay in SLE pathogenesis.

Epstein-Barr virus-related hemophagocytic lymphohistiocytosis complicated with coronary artery dilation and acute renal injury in a boy with a novel X-linked inhibitor of apoptosis protein (XIAP) variant: a case report

Background

X-linked lymphoproliferative disease (XLP) is a rare inherited X-linked primary immunodeficiency diseases (PID). One such disease, X-linked inhibitor of apoptosis protein (XIAP) deficiency, is characterized by Epstein–Barr virus-related hemophagocytic lymphohistiocytosis (EBV-HLH). However, EBV-HLH with coronary artery dilation and acute renal injury (AKI) in children is unusual.

Case presentation

We report the case of a young boy aged 17 months with a novel XIAP variant. He was initially diagnosed with EBV-HLH based on the HLH-2004 diagnostic criteria and the condition was accompanied by coronary artery dilation and acute renal injury. The comprehensive genetic analysis of peripheral blood-derived DNA revealed a hemizygous variant of the XIAP gene [c.116G > C(p.G39A)], which was inherited from his mother (heterozygous condition). After combined treatment with rituximab, intravenous immunoglobulin, corticosteroids, antiviral drugs, and mycophenolate mofetil (MMF) in addition to supportive therapy, his clinical manifestations and laboratory indexes were improved. The patient achieved complete remission with MMF treatment in the 8-month follow-up.

Conclusions

We report the [c.116G > C(p.G39A)] variant in the XIAP gene for the first time in a case of XLP-2 associated with EBV-HLH. For male patients with severe EBV-HLH, the possibility of XLP should be considered and molecular genetic testing should be used early in auxiliary diagnosis. Reports of EBV-HLH with coronary artery dilation and AKI in children are rare. In the patients with EBV-HLH, color Doppler echocardiography and urine tests should be monitored regularly. If necessary, renal biopsy can be performed to clarify the pathology. Treatment with rituximab, immunosuppressors and supportive therapy achieved a good effect, but long-term follow-up is required.

Acute kidney injury in an adult patient with IgA nephropathy and chronic replicative Epstein-Barr virus infection

Most of the adult population are infected with Epstein-Barr virus (EBV), but as EBV replication is usually under immune system control, the majority of individuals remain asymptomatic. On the other hand, some individuals continuously retain a high EBV antibody titer and a high EBV DNA load in their blood, suggesting a defect of EBV replication control. To date, only a limited number of reports have addressed the relationship between this chronic form of EBV infection and renal involvement. Here, we describe an 80-year-old woman who developed acute kidney injury shortly after an episode of mosquito bites, accompanied by a severe skin rash, which raised a suspicion of chronic EBV infection. She was subsequently diagnosed as having chronic replicative EBV infection. Renal biopsy revealed a diagnosis of IgA nephropathy with crescent formation. Although the relationship between IgA nephropathy and EBV infection has been discussed, no substantial understanding has yet emerged. The patient's characteristic clinical course suggested that the renal failure may have been partly attributable to chronic EBV infection. This case suggests that physicians may need to consider the possibility that chronic EBV infection may affect the clinical course of IgA nephropathy, or exacerbate the disease.

Anti-neutrophil cytoplasmic antibody-associated vasculitis associated with infectious mononucleosis due to primary Epstein-Barr virus infection: report of three cases

Although the aetiology of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis remains unclear, it is generally believed that environmental factors such as infections contribute to its development of ANCA-associated vasculitis. Prior Epstein–Barr virus (EBV) infection is reported to be a trigger of systemic vasculitis. We herein report three cases of ANCA-associated vasculitis presenting with infectious mononucleosis due to primary EBV infection. The causal link between the two pathologies could not be proved, but primary EBV infection may play a role in the initiation or exacerbation of ANCA-associated vasculitis. Future studies are necessary to determine the interaction between these diseases conditions.

An adult case of fulminant Epstein-Barr virus infection with acute tubulointerstitial nephritis

Epstein-Barr virus (EBV) infection is common in adolescence, but fulminant infection is very rare. A 40-year-old man presented with high fever and sore throat. Symptoms, including cervical lymphadenopathy, jaundice, atypical lymphocytosis, respiratory distress and oliguria, suggested infectious mononucleosis with multiple organ failure that required mechanical ventilation and renal replacement therapy. Virus markers were consistent with primary EBV infection. Renal function was gradually improved by corticosteroid therapy. Renal biopsy revealed acute tubulointerstitial nephritis. In situ hybridizaion EBV-encoded RNA 1 did not show the presence of virus in the kidney, but acute kidney injury may be explained by cytotoxic/suppressor T lymphocyte infiltration.

A case of mononucleosis infectiosa presenting with cholemic nephrosis

A 38-year-old male was admitted with fever, progressive jaundice, cervical lymphadenopathy, hepatomegaly and acute oliguric renal failure. Epstein-Barr virus (EBV) infection was diagnosed by detection of EBV-DNA in plasma and confirmed by EBV seroconversion. Kidney biopsy revealed acute tubular necrosis and abundant casts, consisting of bilirubin pigment. With conservative treatment, the patient fully recovered from cholemic nephrosis, an uncommon condition, not described after EBV infection before.

Epstein-Barr virus infection in sarcomatoid renal cell carcinoma tissues

OBJECTIVE

To determine whether Epstein-Barr virus (EBV) infection is related to renal cell carcinoma (RCC) tissues.

MATERIALS AND METHODS

We investigated EBV infection and its genotypes in 73 cases of different types of RCC and 18 of non-neoplastic kidney. EBV infection and its genotypes were determined by EBV-encoded RNAs in situ hybridization (EBER-ISH) and polymerase chain reactions for EBV-encoded nuclear antigen 1 (EBNA-1) and EBNA-3C. The immunophenotype and EBV status of the EBV-infected cells were examined by double-labelling of EBER-ISH and/or immunohistochemistry for lymphoid cell markers, EBV proteins, and CD21.

RESULTS

EBER-ISH signals were detected in five of 73 RCC tissues (6.8%), but in none of 18 non-neoplastic kidneys. Interestingly, EBER-ISH was positive only in five of the 10 sarcomatoid RCCs, and of these, four also showed amplification of EBNA-1. EBV was located exclusively in the tumour-infiltrating B lymphocytes of sarcomatoid RCCs. The genotype of EBV was determined as type 1. A few EBV-infected B cells expressed BZLF1 (an EBV immediate-early gene product) while none expressed EBNA-2 or latent membrane protein 1. This indicates that the B cells are of EBV latency type I, often replicating EBV. EBV infection did not affect the survival rates of patients with sarcomatoid RCC (P = 0.635, Kaplan-Meier analysis, log-rank test).

CONCLUSION

EBV is present only in tumour-infiltrating B lymphocytes of sarcomatoid RCCs. The present study suggests that sarcomatoid RCC modulates a function of EBV-specific T cells controlling EBV replication, or stimulates differentiation of memory B cells into plasma cells.

Glomerulonephritis in a patient with chronic active Epstein-Barr virus infection

Renal involvement is rare in chronic active Epstein-Barr virus (EBV) infection. We report an 11-year-old girl who had focal mesangial proliferative glomerulonephritis with cellular crescents and renal tubular atrophy with foam cells in the lumen at the time of the first admission. However, the patient was not diagnosed with chronic active EBV infection until the third admission, 18 months later, because she did not exhibit typical clinical manifestations of infectious mononucleosis, i.e., fever, lymphadenopathy, hepatomegaly, or increased atypical lymphocytes. We performed in situ hybridization of EBV in renal biopsy and renal autopsy tissue and found EBV genome-positive cells in the enlarged vascular areas surrounding the renal tubules in both specimens. The relationship between mesangial proliferative glomerulonephitis with crescents and chronic active EBV infection is unknown.

Epstein-Barr virus-associated acute renal failure: diagnosis, treatment, and follow-up

We retrospectively reviewed our experience of Epstein-Barr virus (EBV)-associated acute renal failure. Of 165 previously healthy children hospitalized with serologically proven primary EBV infection, 8 had acute renal failure, of whom 5 (group A) did not have virus-associated hemophagocytic syndrome (VAHS), while 3 (group B) did have VAHS. All had complications in four or more organ systems. Two patients in group A had renal biopsies showing acute tubulointerstitial nephritis, and the clinical and laboratory findings in the other 3 group A patients were consistent with acute tubulointerstitial nephritis. Acyclovir was used in 1 patient, but she died of hepatic failure and pulmonary hemorrhage. The other 4 spontaneously recovered renal function after supportive care, including hemodialysis in 1 patient. Our experience does not support the routine use of corticosteroids or antiviral agents in these patients. Children in group B had a relatively normal urinalysis. Renal biopsies were not performed, but their presentations were compatible with acute tubular necrosis. We conclude that EBV should be considered as a possible etiological agent in all children presenting with acute renal failure of unknown cause. The diagnosis depends on a high index of suspicion and careful serological evaluation in atypical cases.

Glomerulonephritis and malignancy: a population-based analysis

BACKGROUND

An association between glomerulonephritis and malignant tumors has previously both been found and discarded in clinical series, but to our knowledge never has been tested in a population-based setting.

METHODS

The Danish Kidney Biopsy Registry includes all kidney biopsies performed from 1985. Using a unique personal identification number, each person in the registry to the National Population Registry and the Danish Cancer Registry were linked. Cancer occurrence after the biopsy was compared in patients with morphological, glomerular diseases with that of the general Danish population, taking into account sex, age, calendar period and time since biopsy, and the 95% confidence interval (95% CI) for the observed-to-expected rates was calculated, assuming a Poisson distribution. Cancer occurrence was stratified to <1 year, 1 to 4, and >or=5 years after a biopsy.

RESULTS

A total of 102 de novo cancers were found in 1958 patients. These cancers represent a two- to threefold excess of the expected number at <1 and 1 to 4, but not >or=5 years after a biopsy. Non-Hodgkin's lymphomas were observed six to eight times more than expected. Cancer excess was seen in glomerulonephritides with a known or suspected virus etiology.

CONCLUSIONS

The excess cancer rate could be the result of underlying undiagnosed tumors whose antigens have initiated glomerulonephritis, or the immunosuppressive therapy that initiated or energized tumor cells. Based on the findings in our study, there is some support for an association to persistent viruses causing first the glomerulonephritides and then the malignancies, perhaps through a common pathogenesis. This calls for other studies to be done that are specifically designed to investigate this issue, with more data on patient characteristics and confounders.

An atypical pattern of Epstein-Barr virus infection in a case with idiopathic tubulointerstitial nephritis

Recently, Epstein-Barr virus (EBV) received attention because a latent form of its infection in renal proximal tubular epithelial cells was found to cause idiopathic, chronic tubulointerstitial nephritis. In this report, we describe the case of a patient with a replicative form of EBV infection, chronic active EBV infection (CAEBV), who developed acute tubulointerstitial nephritis and minimal change nephrotic syndrome. A renal biopsy revealed papillary infoldings of atypical tubular epithelium and adjacent dense infiltration of lymphocytes. Using in situ polymerase chain reaction methods, we detected the EBV genome in some of the infiltrating lymphocytes, but not in the tubular epithelial cells. EBV-infected T cells are thought to activate other educated T cells, as well as secrete an unrestricted variety of cytokines, thus playing a pivotal role in CAEBV and its end organ disease. Therefore, in our case, the CAEBV activated, educated T cells may have followed the EBV-infected lymphocytes as they infiltrated into the peritubular interstitium, and promoted focal tubular epithelial atypia and minimal change nephrotic syndrome. The long-term observation of such patients is important because CAEBV may progress into lymphoproliferative diseases.

Acute renal failure: unusual complication of Epstein-Barr virus-induced infectious mononucleosis

A 17-year-old boy with juvenile rheumatoid arthritis presented with jaundice, confusion, hemolytic anemia, thrombocytopenia, and acute renal failure secondary to titer-confirmed acute Epstein-Barr virus (EBV). Renal biopsy specimen revealed interstitial nephritis with an inflammatory infiltrate composed of cytotoxic/suppressor T cells, and interstitial mononuclear cell nuclei expressed EBV encoded RNA-1 (EBER-1) mRNA. Methylprednisolone treatment resulted in rapid improvement.