Epstein-Barr virus-associated pneumonia and bronchiolitis obliterans syndrome in a lung transplant recipient

Epstein-Barr virus (EBV) induced pneumonitis in an immunocompetent adult: A case report

Epstein Barr Virus (EBV) is one of the herpes viruses that is responsible for causing infectious mononucleosis, lymphomas, and carcinomas primarily in immunocompromised individuals. We present a case of EBV-induced pneumonitis in an immunocompetent female, successfully treated with steroids. The patient is a 70 year-old female with a history of infectious mononucleosis in her teens who presented to the emergency room with worsening shortness of breath, associated with cough and fever. She underwent extensive work up and her serologic workup revealed positive anti-EBV antibodies, pointing towards the diagnosis of EBV induced pneumonitis. EBV-induced Pneumonitis is a very rare entity and is especially hardly seen among immunocompetent individuals. This interesting case shows that in this new era of viral pneumonias, EBV induced pneumonitis should be considered among differentials when dealing with lung infections. Prompt initiation of treatment with steroids or antiviral medication may result in complete recovery. The choices among treatment options can be individualized according to the severity of disease, course of disease progression, and side effect profile of medications. In our case we were able to successfully treat the patient with high dose steroids only.

Viruses and atypical bacteria in the respiratory tract of immunocompromised and immunocompetent patients with airway infection

Respiratory tract infections (RTI) can take a serious course under immunosuppression. Data on the impact of the underlying pathogens are still controversial. Samples from the upper (n = 322) and lower RT (n = 169) were collected from 136 children and 355 adults; 225 among them have been immunocompromised patients. Exclusion criteria were presence of relevant cultivable microorganisms, C-reactive protein > 20 mg/dl, or procalcitonin > 2.0 ng/ml. Samples were tested by PCR for the presence of herpesviruses (HSV-1/-2; VZV; CMV; HHV6; EBV), adenoviruses, bocaviruses, entero-/rhinoviruses (HRV), parechoviruses, coronaviruses, influenza viruses (IV), parainfluenza viruses as well as for pneumoviruses (HMPV and RSV), and atypical bacteria (Mycoplasma pneumoniae, M.p.; Chlamydia pneumoniae, C.p.). Viral/bacterial genome equivalents were detected in more than two-thirds of specimens. Under immunosuppression, herpesviruses (EBV 30.9%/14.6%, p < 0.001; CMV 19.6%/7.9%, p < 0.001; HSV-1: 14.2%/7.1%, p = 0.012) were frequently observed, mainly through their reactivation in adults. Immunocompromised adults tended to present a higher RSV prevalence (6.4%/2.4%, p = 0.078). Immunocompetent patients were more frequently tested positive for IV (15.0%/5.8%, p = 0.001) and M.p. (6.4%/0.4%, p < 0.001), probably biased due to the influenza pandemic of 2009 and an M.p. epidemic in 2011. About 41.8% of samples were positive for a single pathogen, and among them EBV (19.9%) was most prevalent followed by HRV (18.2%) and IV (16.6%). HSV-2 and C.p. were not found. Marked seasonal effects were observed for HRV, IV, and RSV. Differences in pathogen prevalence were demonstrated between immunocompetent and immunocompromised patients. The exact contribution of some herpesviruses to the development of RTI remains unclear.

Macaca arctoides gammaherpesvirus 1 (strain herpesvirus Macaca arctoides): virus sequence, phylogeny and characterisation of virus-transformed macaque and rabbit cell lines

Herpesvirus Macaca arctoides (HVMA) has the propensity to transform macaque lymphocytes to lymphoblastoid cells (MAL-1). Inoculation of rabbits with cell-free virus-containing supernatant resulted in the development of malignant lymphomas and allowed isolation of immortalised HVMA-transformed rabbit lymphocytes (HTRL). In this study, the HVMA genome sequence (approx. 167 kbp), its organisation, and novel aspects of virus latency are presented. Ninety-one open reading frames were identified, of which 86 were non-repetitive. HVMA was identified as a Lymphocryptovirus closely related to Epstein-Barr virus, suggesting the designation as 'Macaca arctoides gammaherpesvirus 1' (MarcGHV-1). In situ lysis gel and Southern blot hybridisation experiments revealed that the MAL-1 cell line contains episomal and linear DNA, whereas episomal DNA is predominantly present in HTRL. Integration of viral DNA into macaque and rabbit host cell genomes was demonstrated by fluorescence in situ hybridisation on chromosomal preparations. Analysis of next-generation sequencing data confirmed this finding. Approximately 400 read pairs represent the overlap between macaque and MarcGHV-1 DNA. Both, MAL-1 cells and HTRL show characteristics of a polyclonal tumour with B- and T-lymphocyte markers. Based on analysis of viral gene expression and immunohistochemistry, the persistence of MarcGHV-1 in MAL-1 cells resemble the latency type III, whereas the expression pattern observed in HTRL was more comparable with latency type II. There was no evidence of the presence of STLV-1 proviral DNA in MAL-1 and HTRL. Due to the similarity to EBV-mediated cell transformation, MarcGHV-1 expands the available in vitro models by simian and rabbit cell lines.

Detection of Epstein-Barr virus DNAemia after lung transplantation and its potential relationship with the development of post-transplant complications

BACKGROUND

Recent studies suggest that Epstein-Barr virus DNAemia (EBVd) may act as a surrogate marker of post-transplant immunosuppression. This hypothesis has not been tested so far in lung transplant (LT) recipients.

METHODS

We included 63 patients undergoing lung transplantation at our center between October 2008 and May 2013. Whole blood EBVd was systematically assessed by real-time polymerase chain reaction assay on a quarterly basis. The occurrence of late complications (overall and opportunistic infection [OI] and chronic lung allograft dysfunction [CLAD]) was analyzed according to the detection of EBVd within the first 6 months post transplantation.

RESULTS

Any EBVd was detected in 30 (47.6%) patients. Peak EBVd was higher in patients with late overall infection (2.23 vs. 1.73 log10 copies/mL; P = 0.026) and late OI (2.39 vs. 1.74 log10 copies/mL; P = 0.004). The areas under receiver operating characteristic curves for predicting both events were 0.806 and 0.871 respectively. The presence of an EBVd ≥2 log10 copies/mL during the first 6 months post transplantation was associated with a higher risk of late OI (adjusted hazard ratio [aHR] 7.92; 95% confidence interval [CI] 2.10-29.85; P = 0.002). Patients with detectable EBVd during the first 6 months also had lower CLAD-free survival (P = 0.035), although this association did not remain statistically significant in the multivariate analysis (aHR 1.26; 95% CI 0.87-5.29; P = 0.099).

CONCLUSIONS

Although preliminary in nature, our results suggest that the detection of EBVd within the first 6 months after transplantation is associated with the subsequent occurrence of late OI in LT recipients.

Diagnostic value of antineutrophil cytoplasmic antibodies in children with bronchiolitis obliterans

BACKGROUND

Diagnosis of childhood bronchiolitis obliterans (BO) is difficult owing to non-specific clinical presentations and limited investigational options. There is a lack in established serum biomarkers for BO. While the diagnostic value of antineutrophil cytoplasmic antibodies (ANCAs) has been discussed, little is known about this in BO. We aimed to investigate the serological profiles of ANCAs against myeloperoxidase (MPO-ANCA) and proteinase-3 (PR3-ANCA) in BO and acute pneumonia.

METHODS

In this study, 42 BO children (BO group) and 43 with mild acute pneumonia (pneumonia group) were included, based on rigorous diagnostic criteria and additional constraints for minimizing selection bias. Serum MPO-ANCA and PR3-ANCA levels were measured on the first (baseline) and the last day of hospitalization (on discharge) by enzyme linked immunosorbent assay.

RESULTS

Although the BO children had a longer hospital stay, the overall rate of positivity (≥180 AAU/mL) and median serum level of MPO-ANCA were higher in the BO group compared with the pneumonia group, either at baseline (69.1% vs. 9.3%, 292.00 vs. 104.75 AAU/mL, both P<0.001) or on discharge (61.9% vs. 9.3%, 310.50 vs. 95.42 AAU/mL). Similar was found for PR3-ANCA (38.1% vs. 4.7%, 106.66 vs. 54.56 AAU/mL at baseline; 35.7% vs. 2.3%, 97.98 vs. 57.23 AAU/mL on discharge, both P<0.001). There were a higher rate of dual-positivity and a lower rate of dual-negativity to both ANCAs in the BO group than those in the pneumonia group (all P<0.001).

CONCLUSIONS

Detection of MPO- and PR3-ANCA can help diagnosis of childhood BO.

Infectious Triggers of Chronic Lung Allograft Dysfunction

Survival after lung transplantation is limited in large part due to the high incidence of chronic rejection, known as chronic lung allograft dysfunction (CLAD). Pulmonary infections are a frequent complication in lung transplant recipients, due both to immunosuppressive medications and constant exposure of the lung allograft to the external environment via the airways. Infection is a recognized risk factor for the development of CLAD, and both acute infection and chronic lung allograft colonization with microorganisms increase the risk for CLAD. Acute infection by community acquired respiratory viruses, and the bacteria Pseudomonas aeruginosa and Staphylococcus aureus are increasingly recognized as important risk factors for CLAD. Colonization by the fungus Aspergillus may also augment the risk of CLAD. Fostering this transition from healthy lung to CLAD in each of these infectious episodes is the persistence of an inflammatory lung allograft environment.

Viremia after lung transplant: a cohort study on risk factors and symptoms associated with detection of Epstein-Barr virus

Background-The frequency and impact of detection of Epstein-Barr virus in the blood of lung and heart-lung transplant recipients in the postoperative period is poorly characterized.Objective-To investigate the frequency of virus detection, associated clinical symptoms and risk factors, and influence of virus detection on outcome.Methods-A cohort of 98 lung transplant recipients were monitored for Epstein-Barr virus in blood before transplant and during their posttransplant hospital stay (median 4 weeks, range 1-21 weeks). Patients were followed up for retransplant or death for a median of 17 months.Results-Epstein-Barr virus DNA was detected in 15 recipients (18.1%) before and in 39 recipients (41.5%) after transplant. Median viral load after transplant was 2300 copies per milliliter of blood (range, 900-45 000 copies/mL). Detection of Epstein-Barr virus DNA before transplant and mechanical ventilation before transplant were associated with detection of Epstein-Barr virus DNA after transplant. Shortness of breath, fatigue, and hoarseness were associated with detection of viral DNA after transplant. The incidence of retransplant or death was not increased in recipients who had viral DNA detected in their blood.Conclusions-Epstein-Barr virus DNA in the blood before transplant and mechanical ventilation before transplant were associated with detection of viral DNA after transplant. Detection of viral DNA after transplant was frequent and clinically relevant.

Analysis of different DNA vaccines for protection of experimental influenza A virus infection

Influenza viruses cause acute respiratory infections in humans that result in significant excessive morbidity and mortality rates every year. Current vaccines are limited in several aspects, including laborious manufacturing technology, non-sufficient efficacy, and time-consuming adjustments to new emerging virus variants. An alternative vaccine approach utilizes plasmid DNA encoding influenza virus antigens. Previous experiments have evaluated the protective efficacy of DNA vaccines expressing variable as well as conserved antigens. In this present study, several different combinations of influenza A virus (IAV) HA, NA, M1, M2, NS1, NS2, and NP sequences were cloned into the plasmid pVIVO, which allows the independent expression of two genes separately. These DNA vaccines were administered to induce protection against a lethal IAV infection, and to reduce immunopathology in lung tissue of surviving animals. The highest efficacy was provided by vaccines expressing HA and NA, as well as a mixture of plasmids encoding HA, NA, M1, M2, NS1, NS2, and NP (Mix). Three days post-infection, more than a 99.99% reduction of viral load and no inflammation was achieved in lung tissue of pVIVO/HA-NA-vaccinated mice. Animals vaccinated with pVIVO/HA-NA, pVIVO/HA-M2, or vaccine Mix, survived a lethal challenge with minor or no obvious pathologic abnormities in the lungs. All other surviving mice revealed extensive changes in the lung tissue, indicating possibly an ongoing bronchiolitis obliterans. In addition, pVIVO/HA-NA and the vaccine Mix were also protective against a heterologous IAV infection. Taken together, next to all combinations of different DNA vaccines, the intramuscular application of pVIVO/HA-NA was the most efficient procedure to decrease virus replication and to prevent immunopathology in lung tissue of IAV-infected mice.