Heterophil-negative infectious mononucleosis and mononucleosis-like illnesses. Laboratory confirmation of 43 cases

The utility of liver function tests and abdominal ultrasound in infectious mononucleosis - A systematic review

INTRODUCTION

A large proportion of patients with infectious mononucleosis (IM) have abnormal liver function tests (LFT) at presentation. There is no guideline regarding the management and follow-up of these patients. Some patients also have abdominal ultrasound due to deranged LFT, the need for this practice is unclear. The aim of this systematic review was to evaluate the evidence base on LFT assessment in IM, time to resolution of derangement, and the role of abdominal ultrasound (US).

METHODS

A systematic search of PubMed, EMBASE and the Cochrane library was done. Two authors independently screened records for eligibility using pre-defined criteria. We included both adult and paediatric populations. Quality assessment of included studies was done.

RESULTS

A total of 3924 patients were included from 32 studies, of which LFT values were reported on 2779 patients. A combination of typical clinical features, heterophile antibodies and EBV-specific antibodies were used to ascertain diagnosis. The following proportion of patients had abnormal LFTs: AST (57%); ALT (62%); ALP (65%); Bilirubin (16%); GGT (41%). Reported median (i.q.r.) time to resolution of LFT was 8 (6-12) weeks (n = 438). Maximum time to resolution was >6 months. Clinical hepatomegaly and splenomegaly were found in 35% and 44% of patients respectively. Enlarged liver and spleen on US were seen in 16/29 and 38/38 of patients respectively. There were no reports of decompensated liver disease.

CONCLUSION

Current evidence questions the need for routine assessment of LFTs in immunocompetent patients presenting with IM; serial LFT assessments following initial abnormalities are not required in immunocompetent patients with subclinical derangement of LFTs; routine US abdomen in IM to evaluate for derangement of LFTs is not required.

Acute systemic viral infection masquerading as an infiltrating lymphoma in an elderly patient: a case report and review of the literature

Primary Epstein-Barr virus (EBV) infection occurs mainly in adolescents and young adults, with more than 90% of adults having serological evidence of past infection. Primary infection in those over the age of 40 is associated with an atypical and often more severe presentation that can lead to more extensive and invasive, and often unnecessary, diagnostic testing. The incidence of severe EBV-related illness in older adults has been observed to be increasing in industrialized nations. The characteristic presentation of infectious mononucleosis (IM) syndrome in elderly patients (age > 65) is not clearly defined in the literature. Here, we describe a case of primary EBV infection in an 80-year-old female and review the literature regarding primary seroconversion in elderly patients.

Dendritic cell function in cytomegalovirus-infected patients with mononucleosis

Dendritic cells (DCs) are important target cells for human cytomegalovirus (HCMV) infection, and the virus has been shown to hamper the differentiation and maturation pathways of these cells in vitro. In the present study, we examined the function of monocyte-derived DCs obtained from immunocompetent individuals undergoing symptomatic HCMV infection in terms of immunophenotypic characteristics, pinocytosis, lymphocyte stimulation capacity, and cyto-chemokine secretion in comparison with DCs obtained from healthy controls. Immature and lipopolysaccharide (LPS)-stimulated DCs obtained from patients actively infected with HCMV expressed significantly lower levels of major histocompatibility complex (MHC) class II molecules. The inhibition of expression of MHC class II molecules by HCMV appeared to be functionally relevant, as mature DCs obtained from patients with HCMV mononucleosis were inefficient in stimulating proliferation of allogenic lymphocytes. Finally, the pattern of cyto-chemokines secreted by DCs obtained from patients with HCMV mononucleosis was characterized by a proinflammatory profile with an increased production of interleukin (IL)-1beta, tumor necrosis factor alpha, CC chemokine ligand 2 (CCL2) and CCL3, and reduced secretion of IL-10 upon LPS stimulation. During symptomatic HCMV infection in the immunocompetent host, DCs exhibit an impaired immunophenotype and function. These effects may contribute to the viral-induced immunomodulation, which is often observed in HCMV-infected patients.

Cytomegalovirus mononucleosis as a cause of prolonged fever and prominent weight loss in immunocompetent adults

Four immunocompetent adults presented with protracted fever lasting > 6 weeks and severe weight loss, associated with primary cytomegalovirus (CMV) infection. Each patient had spleen enlargement, lymphocytosis and hypertriglyceridaemia, but recovered spontaneously. A further 20 immunocompetent patients with primary CMV infection were also reviewed, and all presented the usual clinical picture of CMV mononucleosis. It was concluded that CMV mononucleosis should be considered in the differential diagnosis in patients with prolonged fever and weight loss if lymphocytosis is present.

Infectious diseases manifested in the peripheral blood

Although primary diagnosis of infectious disease is uncommonly made from morphologic examination of a blood smear in the United States, knowledge of the distinctive morphologic features of various organisms, coupled with an understanding of the clinical and epidemiologic features of various disorders, permits recognition and diagnosis of uncommonly encountered infections. Furthermore, nonspecific manifestations of infection may provide an important clue in guiding a further diagnostic work-up.

Diagnostic virology

Diagnostic virology has now entered the mainstream of medical practice. Multiple methods are used for the laboratory diagnosis of viral infections, including viral culture, antigen detection, nucleic acid detection, and serology. The role of culture is diminishing as new immunologic and molecular tests are developed that provide more rapid results and are able to detect a larger number of viruses. This review provides specific recommendations for the diagnostic approach to clinically important viral infections.

Proportion positive for Epstein-Barr virus, cytomegalovirus, human herpesvirus 6, Toxoplasma, and human immunodeficiency virus types 1 and 2 in heterophile-negative patients with an absolute lymphocytosis or an instrument-generated atypical lymphocyte flag

OBJECTIVES

To determine the proportion of patients with evidence of an acute infection due to Epstein-Barr virus (EBV), cytomegalovirus (CMV), human herpesvirus 6 (HHV-6), Toxoplasma, or human immunodeficiency virus types 1 and 2 (HIV-1 and HIV-2) in heterophile-negative patients with an absolute lymphocytosis or an instrument-generated atypical lymphocyte flag, and to develop a cost-effective testing algorithm for managing such heterophile-negative patients.

DESIGN

We conducted a prospective investigation of 70 selected outpatients who tested negative for heterophile antibody in association with an absolute lymphocytosis or instrument-generated atypical lymphocyte flag. The control population consisted of 50 patients who were heterophile negative and had a normal absolute lymphocyte count and no instrument-generated atypical lymphocyte flag.

SETTING

A large outpatient laboratory system.

INTERVENTION

Viral serology for HHV-6 was performed by immunofluorescence, and all other serologies were performed by enzyme-linked immunoassay. All testing was for immunoglobulin (Ig) M antibodies, except in the case of HIV.

RESULTS

The proportion of study patients positive for EBV was 40% (28/70); for CMV, 39% (27/70); for HHV-6, 25% (16/65); for Toxoplasma, 3% (2/70); and for HIV, 0% (0/70). All 50 control patients were negative for EBV IgM antibodies. When patients with more than 1 positive viral test were excluded from analysis, positivity was 20% (9/45) for EBV, 22% (10/45) for CMV, 9% (4/45) for HHV-6, and 2% (1/45) for Toxoplasma. Utilizing hypothesis-generating logistic regression models, Downey type II atypical lymphocytes were significantly associated with EBV positivity (P =.006), while Downey type III lymphocytes were significantly associated with HHV-6 positivity (P =.016), and there was a trend for the association of Downey type I lymphocytes with CMV positivity (P =.097).

CONCLUSIONS

A positive viral serology was identified in 70% of study patients. Multiple positive serologies complicate establishing a definitive diagnosis. Potential cost savings may be associated with the use of an appropriate testing algorithm.

Infectious mononucleosis in an outpatient population: diagnostic utility of 2 automated hematology analyzers and the sensitivity and specificity of Hoagland's criteria in heterophile-positive patients

OBJECTIVES

To determine the sensitivity and specificity of 2 modern hematology analyzers in flagging heterophile-positive patients; to determine if heterophile-positive, instrument-flagged specimens contain a larger number or a different spectrum of atypical lymphocytes; to document the overall sensitivity and specificity of Hoagland's morphologic criteria in identifying heterophile-positive patients in an outpatient population with a clinical diagnosis of mononucleosis; and to examine whether individual morphologic features might aid in the diagnosis of suspected infectious mononucleosis.

DESIGN

A prospective study of patients referred with a clinical diagnosis of infectious mononucleosis who subsequently tested positive for the heterophile antibody. The control group consisted of a similar population of patients who tested negative for the heterophile antibody.

INTERVENTION

Hematology profiles of peripheral blood samples were determined with Coulter STKS and Sysmex NE-8000 analyzers. A corresponding Wright-Giemsa-stained blood smear was subsequently examined by a single skilled technologist, who performed a 200-cell white blood cell differential and a 200-cell lymphocyte differential. A specific morphologic search was made for the presence of smudge cells or lymphocytes with cloverleaf nuclei.

RESULTS

Using a combination of all flagging criteria, the 2 analyzers identified 156 (86.2%) of 181 heterophile-positive patients as meriting further review. The sensitivity and specificity values of the Coulter analyzer in predicting positive heterophile status for the blast flag were 41% and 97.1%, respectively; for the variant lymphocyte flags, 72.4% and 79.1%, respectively; and for both flags, 40% and 98.1%, respectively. For the Sysmex analyzer, the sensitivity and specificity values in predicting positive heterophile status for the blast flag were 43.4% and 88.6%, respectively; for the variant lymphocyte flag, 15.8% and 90.8%, respectively; and for both flags, 10.5% and 96%, respectively. Considering the classic criteria developed by Hoagland, a lymphocytosis of at least 50% was present in 120 (66.3%) heterophile-positive patients, while an atypical lymphocytosis of at least 10% of the total WBC count was noted in 135 patients (74.6%). The sensitivity and specificity values of a lymphocytosis > or =50% for diagnosing heterophile-positive status were 66.3% and 84.5%, respectively, while the sensitivity and specificity of an atypical lymphocytosis > or =10% were 74.6% and 92.3%, respectively. The presence of smudge cells or cloverleaf lymphocyte nuclei was verified as having high specificity but low sensitivity for suggesting a diagnosis of infectious mononucleosis.

CONCLUSION

Although a number of patients did not meet Hoagland's criteria for the diagnosis of infectious mononucleosis, the flagging systems of modern hematology analyzers successfully identified most cases as requiring further review.

Clinical features and costs of care for hospitalized adults with primary Epstein-Barr virus infection

PURPOSE

To study the clinical and laboratory features of primary infection with the Epstein-Barr virus in adults who required hospitalization and to assess the difficulty in its diagnosis, the use of diagnostic procedures, and the associated costs of care.

PATIENTS AND METHODS

We retrospectively identified all adult patients who were diagnosed with primary Epstein-Barr virus infection in our region between 1988 and 1997 using strict serologic criteria. The added costs of unnecessary diagnostic tests and treatment were estimated.

RESULTS

The analysis included 47 patients (60% men) with a mean (+/-SD) age of 30 +/- 14 years. The prime cause of admission was fever (83%). Compared with patients 35 years of age and older, those younger than 35 years were more likely to have pharyngitis (45% vs 10%) and lymphadenopathy (66% vs 17%). Younger patients also had a greater mean atypical lymphocyte count (17% +/- 14% vs 8% +/- 6%) and more abnormal hepatic enzyme levels. Inpatient work-ups resulted in 309 days of hospitalization, many diagnostic tests, and unnecessary empiric treatments (total 203 days of antibiotic therapy). Overall, unnecessary diagnostic procedures and medical treatments contributed an average of approximately $12,000 in health-care costs per patient.

CONCLUSIONS

Testing for primary Epstein-Barr virus infection should be a routine step in the investigation of fever in adults of all ages. A higher index of suspicion might prevent unnecessary, sometimes hazardous inpatient work-ups from being performed, thereby reducing health-care expenses.

Comparative evaluation of the use of immunoblots and of IgG avidity assays as confirmatory tests for the diagnosis of acute EBV infections

BACKGROUND

Despite the availability of several different markers for Epstein--Barr virus (EBV) serology, the EBV status of some patients cannot be resolved from a single serum sample with routine testing. To avoid the requirement of follow-up samples, supplementary tests have to be used in these cases.

OBJECTIVE

To evaluate the usefulness of avidity and immunoblot assays as supplementary tests for the diagnosis of acute EBV infections.

STUDY DESIGN

Three groups of samples for which a definite diagnosis on the EBV status could not be obtained with the routine serological tests were further examined by an EBV IgG avidity assay, by an immunoblot based on a lysate of EBV infected cells, and by a second immunoblot based on recombinant EBV antigens. The three groups consisted of 38 samples with negative/borderline EB nuclear antigen 1 (EBNA-1) antibodies, negative/borderline EBV IgM and positive EBV IgG; 10 samples with indeterminate EBNA-1 and/or EBV IgM assays because of control antigen reactions; and 4 samples with positive EBV IgM results that were not plausible.

RESULTS

The avidity assay differentiated between acute and past infections for all samples. In contrast, some cases remained unresolved with both the recombinant and the lysate immunoblot. Two samples were incorrectly classified with the lysate immunoblot. Interpretation of the lysate immunoblot banding patterns was complicated when anticellular antibodies were present.

CONCLUSION

Avidity testing appears to be the confirmatory method of choice to differentiate between acute and past EBV infections.

What every pediatrician should know about infectious mononucleosis in adolescents

Infectious mononucleosis (IM) is one of the most common diseases occurring during adolescence. Appreciation of IM's varied clinical presentations, its differential diagnosis, and the difficulties involved in making the laboratory diagnosis will enable clinicians to treat teenagers more effectively in their office practices.

Peripheral blood lymphocyte subpopulations in three infants with hepatosplenomegaly caused by cytomegalovirus infection

Mononucleosis is defined as atypical lymphocyte proliferation which causes clinical symptoms such as tonsillitis, lymphadenopathy, or hepatosplenomegaly. Mononucleosis syndrome is caused by cytomegalovirus (CMV), Toxoplasma, hepatitis virus, adenovirus, or other agents as well as by Epstein-Barr virus. The syndrome is immunologically characterized by the proliferation of activated T cells (HLA-DR+ T cells). We encountered three infants with hepatosplenomegaly who were diagnosed as primary CMV infection by the detection of anti-CMV IgM antibody. Although the patients were otherwise asymptomatic, analysis of lymphocyte subpopulations showed a decreased ratio of CD4+ to CD8+ T cells and augmented expression of HLA-DR antigen on T cells characteristic of infectious mononucleosis. We conclude that inapparent CMV disease may affect the immunologic status of infected children even if it is asymptomatic.

Mononucleosis-like illness in an infant associated with human herpesvirus 6 infection

Illnesses resembling mononucleosis, hematologically characterized by atypical lymphocytosis in the peripheral blood, are caused by other viral infections as well as by a primary Epstein-Barr virus infection. Human herpesvirus 6, a newly isolated member of the herpesvirus group, can also cause a mononucleosis-like illness. Illness associated with human herpesvirus 6 infection mostly occurs in immunocompetent adults. We observed a 3 month old infant who presented with marked atypical lymphocytosis and liver dysfunction. We examined serum samples to detect viral antibodies related to mononucleosis-like illness. Only the titers of antibody against human herpesvirus 6 were elevated. Primary human herpesvirus 6 infection cannot only cause exanthem subitum or present in an inapparent form but can also cause an illness like mononucleosis, even in an infant.

Oligoclonal T cell receptor gene rearrangements in blood lymphocytes of patients with acute Epstein-Barr virus-induced infectious mononucleosis

Gene rearrangement studies were performed on blood lymphocytes from eight patients with acute Epstein-Barr virus-induced infectious mononucleosis. The diagnosis in each case was based on characteristic clinical, hematologic, and serologic findings. The blood lymphocytes in each patient consisted predominantly of CD8+ T cells. EBV DNA was detected in seven patients by Southern blot analysis (EBV Bam HI W probe, Bam HI). A germline configuration was found for the immunoglobulin heavy and light chain genes (JH probe, Bam HI and Eco RI; C kappa probe, Bam HI; and C lambda probe, Eco RI). T cell receptor gene rearrangements were detected with J gamma and J beta 1 + 2 probes. Using a J gamma probe with two different restriction enzymes (Bgl II and Eco RI), the blood from each patient showed several bands corresponding to the polyclonal pattern previously described in the blood of normal individuals. Using J beta 1 + 2 probes with two different restriction enzymes (Bgl II and Bam HI), each case showed from 3 to about 12 extragermline bands of varying intensity and in different locations from case to case. In addition, each case showed relative deletion of the J beta 1 germline band. This oligoclonal pattern of T cell receptor gene rearrangements has not been previously reported in benign or malignant T cell populations.

Fine-needle aspiration of lymph nodes in patients with acute infectious mononucleosis

We studied lymph node fine-needle aspirations from 10 patients with primary Epstein-Barr virus (EBV) infections (infectious mononucleosis). There were five males and five females, aged 15-54 yr. The diagnoses were confirmed by blood morphology and heterophil antibody (HA) and EBV-specific serologic studies. Nine patients were HA-positive, nine were viral capsid antigen (VCA)-IgM-positive, and all 10 were VCA-IgG-positive and anti-EBV nuclear antigen (EBNA)-negative. Five patients were referred for fine-needle aspiration biopsies for clinically suspected malignant lymphoma (ML). Four of these patients had been tested for HA prior to fine-needle aspiration, with negative results in three cases. The heterophil-positive patient was referred for fine-needle aspiration due to very impressive unilateral cervical adenopathy. Cytologically, all cases showed atypia consisting of greater numbers of large immunoblastic lymphocytes than are usually seen in the reactive lymph node. Two cases were cytologically suspicious for malignant lymphoma but included a considerable background of polymorphic immunoblasts. We suggest that polymorphic immunoblastic proliferations in lymph node cytology are suggestive of infectious mononucleosis. Since several reactive and neoplastic processes mimic this pattern, cases not followed by both confirmatory serologic studies and resolution of adenopathy should be pursued by excisional lymph node biopsy.

Differential interleukin-2 and interferon-gamma production by human lymphocyte cultures exceptionally resistant to Epstein-Barr virus immortalization

Epstein-Barr virus (EBV) readily immortalizes human peripheral blood lymphocytes (PBL) in vitro. However, during the past several years, we found that PBL from two exceptional EBV-seropositive healthy adult individuals were refractory to immortalization by EBV. We report here a study aimed at learning about the immunobiological features which differentiate these EBV-resistant (R) PBL from others which are susceptible (S) to EBV immortalization. Results of this investigation indicate that: (a) Following EBV infection, R-PBL produced significantly higher amounts of interferon gamma (IFN-gamma) than S-PBL. There were however no differences in regard to interferon alpha production between these two types (R and S) of EBV-infected cultures. (b) R-PBL had a maximal interleukin-2 (IL-2) production by S-PBL occurred at least 48 hr later, i.e., at Day 7. (c) The percentage of non-B cells expressing the IL-2 receptor was also higher in EBV-infected R-PBL than S-PBL. (d) In contrast, expression of IL-2 receptors after EBV infection was higher on B cells from S-PBL than on B cells from R-PBL. Interestingly, no differences were noted in regard to IL-2 receptor expression between R-PBL and S-PBL treated with mitogens (i.e., phytohemagglutinin and pokeweed mitogen). (e) Finally, using anti-IL-2 and anti-IFN-gamma antibodies in EBV-infected R-PBL cultures, we were able to obtain EBV-induced immortalization of these cultures. Taken together, these results suggest that an early IL-2 synthesis and high IFN-gamma production by EBV-infected PBL play an important role against lymphocyte immortalization by EBV.

Rapid diagnosis of acute Epstein-Barr virus infection by an indirect enzyme-linked immunosorbent assay for specific immunoglobulin M (IgM) antibody without rheumatoid factor and specific IgG interference

An indirect enzyme-linked immunosorbent assay (ELISA) for detection of Epstein-Barr virus-specific immunoglobulin M (IgM) antibody was developed with commercial reagents. Sera containing rheumatoid factor (RF) (as little as 0.5 IU/ml) coupled with specific IgG resulted in false-positives in the ELISA. This interference was eliminated by the use of anti-human IgG antibodies to remove RF and IgG. Thus, pathogen-specific IgG complexes to which IgM-RF could be bound during the subsequent test were inhibited, and competition between specific IgG and IgM was also prevented. Of the 1,672 serum specimens tested, 353 were found to be Epstein-Barr virus IgM antibody positive by indirect immunofluorescence (IF). Compared with the IF test, the ELISA showed 96.6% sensitivity, 99.7% specificity, and 99% accuracy. Further evidence indicated that most of the 12 ELISA false-negatives were IF false-positives. There was a linear correlation between mean ELISA values and increasing IF titers (r = 0.96). However, the IF test has the disadvantages that it lacks automated reading and requires considerable technical expertise, both of which restrict the range of laboratories performing the test. The indirect ELISA has the advantages that it is simple and rapid and can be automated. All the reagents used in this assay are commercially available, have been prestandardized, and are stable.

Elevated Toxoplasma IgG antibody in patients tested for infectious mononucleosis in an urban emergency department

There are many infectious causes of fatigue, sore throat, and fever, including mononucleosis and toxoplasmosis. Toxoplasma antibody testing is rarely performed in most emergency departments; as a result, toxoplasmosis is diagnosed infrequently. We obtained Toxoplasma IgG IFA titers on ED patients who had mononucleosis testing performed to determine the frequency of toxoplasmosis in this population. Two hundred sixty patients were included in our study. Eleven (4.2%) had a positive mononucleosis test, and 14 (5.4%) had a positive Toxoplasma titer. In the detection of toxoplasmosis, Toxoplasma IgG titers of 1:1,024 or greater have been shown to be a sensitive means of detecting infection in the first six months. Further testing with IgM titers is needed to establish a positive diagnosis when necessary. We found more patients with elevated Toxoplasma IgG titers than with positive heterophil antibody titers in an ED population tested for mononucleosis over a two-year period. We conclude that toxoplasmosis may be as common as mononucleosis in our ED and that clinicians should consider this pathogen when working up patients with appropriate symptoms.

Epstein-Barr virus: the hematologic and oncologic consequences of virus-host interaction

Varicella-zoster virus (VZV) and Epstein-Barr virus (EBV) are two of the human herpesviruses. The others include herpes simplex virus (HSV) type 1, HSV type 2, and cytomegalovirus (CMV). In a series of two articles, we review the clinical diseases caused by VZV and EBV infections; we pay particular attention to the manifestations of these two viral infections in immunosuppressed and immunocompromised patients. In addition to the clinical reviews, each of the two articles begins with a brief discussion of the molecular aspects of VZV and EBV, respectively; this introduction describes features of the genome and immunogenic viral proteins which have clinical relevance. A model for pathogenesis is included. The first review concerns VZV infections. Recent data about the DNA sequence of the entire VZV genome are included, as well as a review of the VZV glycoproteins. Primary VZV infection (chickenpox) and VZV reactivation (zoster) are described in detail in both healthy individuals and people with cancer. The decade-long VZV vaccine trials in children with leukemia receive special emphasis because they have engendered considerable interest and debate. The second review (published here) covers EBV infections. This virus has been implicated in the causation of a wide variety of human hematological and oncological disorders, besides classical infectious mononucleosis. In particular, Burkitt's lymphoma, nasopharyngeal carcinoma, and lymphoproliferative disorders are strongly associated with EBV infection of the transformed cells. In addition, immunologically mediated cytopenias occasionally follow EBV infection. Finally, treatment regimens with antiviral chemotherapy and other agents are discussed for both VZV and EBV infections.

Cytomegalovirus mononucleosis in children compared with the infection in adults and with Epstein-Barr virus mononucleosis

We report clinical and laboratory findings in 11 previously healthy children with cytomegalovirus (CMV) mononucleosis and compare them with those of 18 adults with CMV mononucleosis and with those of 22 age-matched children with Epstein-Barr virus (EBV) mononucleosis. Exudative pharyngitis was more common in children whereas prolonged fever was more common in adults. Prominent lymphadenopathy and exudative pharyngitis, however, were less frequent in children with CMV mononucleosis than in those with EBV mononucleosis. Nevertheless, children with CMV mononucleosis are more likely to resemble those with EBV mononucleosis than adults with CMV mononucleosis.

Epstein-Barr virus serology in bone marrow transplantations: a one-year retrospective study with detection of EBV IgM-VCA-specific antibodies

The specific antibody response to Epstein-Barr virus (EBV) antigens of 41 bone marrow transplant recipients with leukemia or aplastic anemia was examined retrospectively by immunofluorescence test (IF) over 1 year. We observed high titers (greater than 640) of IgG-viral capsid antigen (VCA) with emergence of IgG-early antigen (EA) and frequent absence or low levels of Epstein-Barr nuclear antigen (EBNA) antibodies. After absorption to remove rheumatoid factor (RF), five of the 41 recipients had IgM-VCA antibody to EBV, which appeared between weeks 26 and 48 after BMT and persisted for 1-4 months. No heterophil antibodies were detected in these sera, and none of the five recipients had a history of infectious mononucleosis.

Epstein-Barr virus infections and DNA hybridization studies in posttransplantation lymphoma and lymphoproliferative lesions: the role of primary infection

Fourteen patients who developed B cell lymphomas or lymphoproliferative lesions after kidney, liver, heart, or heart-lung transplantation in Pittsburgh during 1981-1983 had active infection with Epstein-Barr virus (EBV) of the primary (six patients), reactivated (seven patients), or chronic (one patient) type. In transplant patients without tumors, the incidence of EBV infection was 30% (39 of 128). Only three of these patients had primary infections. Thus the frequency of active infection was significantly higher in patients with tumors, and patients with primary infections were at greater risk of developing tumors. Five of 13 tumors tested contained EBV nuclear antigen (EBNA) and nine of 11 contained EBV genomes detected by DNA-DNA hybridization with BamHI K, BamHI W, or EcoRI B cloned probes. All EBNA-positive tumors, except one, were also positive by hybridization. Only one tumor was negative for both EBNA and EBV DNA. These data suggest that EBV plays an etiologic role in the development of these lesions.

A modified immunofluorescence test for Epstein-Barr virus-specific IgM antibody

The fluorescent antibody (FA) test for Epstein-Barr virus (EBV)-specific IgM antibody was improved by the use of sodium butyrate to induce a higher level of EBV antigen expression in P3HR-1 slide preparations and by removal of rheumatoid factor (RF) and IgG antibodies from test sera by means of adsorption with suspensions of Sepharose-IgG and Streptococcus pyogenes strain AR1. This method was compared with the Paul-Bunnell test (PB) on 1106 sera submitted to a routine virus diagnostic laboratory for infectious mononucleosis serology and 96.4% of sera showed concordant results. Thus the EBV-IgM-FA method was suitable for routine diagnostic use. However, it proved helpful to test EBV-IgM positive sera by PB to assist in the detection of cross-reacting IgM antibodies sometimes present.

Diagnosis of Hodgkin's disease hampered by an Epstein-Barr virus infection treated with acyclovir

We report a case of Hodgkin's disease associated with Epstein-Barr virus (EBV) infection in a 75-year-old male. The patient was given a 5-day course of acyclovir to which he responded well, with partial resolution of the lymphoma and return to well-being. A biopsy from the lymphoma after acyclovir treatment showed a change in the histological picture with a reduction in the number of giant cells. Relationships between EBV infection and Hodgkin's lymphoma are discussed.

Haemolytic anaemia in previously healthy adult patients with CMV infections: report of two cases and an evaluation of subclinical haemolysis in CMV mononucleosis

Whereas haemolytic anaemia is commonly encountered in infants and young children with cytomegalovirus (CMV) infections, it is an infrequent complication of CMV-induced infections in previously healthy adults. The data from 2 such patients are presented. One patient's Hb fell to a level of 36 g/l, and she required prednisone and blood transfusions. Her direct antihuman globulin test (DAT) was positive (IgG), and her red blood cell survival (51Cr) revealed a T 1/2 of 5 d. Both saline-agglutinating and low-molecular-weight cold agglutinins (CA) (4 degrees C) that reacted against both cord and adult cells were identified. In the second case, a moderate haemolytic anaemia (lowest Hb 87 g/l) was accompanied by negative DAT and CA studies. 20 other patients with CMV-mononucleosis were evaluated for evidence of subclinical haemolysis. Reticulocyte counts greater than 3.0% were noted in 9 of these patients. Haptoglobin values were below 0.5 g/l in 13 patients, and a positive DAT was recorded in 3/10 cases. This study documents haemolysis in many non-immunosuppressed adult patients with CMV infections. The mechanism responsible remains obscure.

Liver disease in cytomegalovirus mononucleosis: a light microscopical and immunoperoxidase study of six cases

Six liver biopsies from previously healthy adult patients with cytomegalovirus (CMV) mononucleosis were studied by routine light microscopy and by the immunoperoxidase technique for CMV antigen. Light microscopical findings consisting of a mononuclear portal and sinusoidal infiltrate, increased hepatocellular mitotic activity and minimal hepatocellular necrosis were consistently found. Less common features were granuloma formation and bile duct epithelial damage. Typical CMV nuclear inclusions and CMV antigen were identified in only one case, a patient with marked leukopenia secondary to CMV who had received corticosteroid therapy. The other five cases contained no inclusions and CMV antigen could not be identified by immunoperoxidase staining. This data suggests that, as with hepatitis B, viral antigen is not identifiable in acute CMV hepatitis in the immunocompetent host, perhaps due to active destruction of infected cells. The immunoperoxidase technique for CMV appears to be of little value in the diagnosis of acute CMV hepatitis.

Transfusion-associated cytomegalovirus infection and acquired immune deficiency syndrome in an infant

An infant who received multiple blood transfusions in the neonatal intensive care unit developed a transfusion-associated CMV infection at age 11 weeks and thereafter was noted to have hepatosplenomegaly, mitogen hyporesponsiveness, persistent viruria, an abnormal distribution of T-lymphocyte subpopulations, and poor growth. He has had recurrent opportunistic infections, including Pneumocystis carinii pneumonia. Six donors of blood products received by this infant were investigated; one was found to have chronic lymphadenopathy, weight loss, intermittent diarrhea, lymphopenia, and a profound depression of lymphocytes with a helper/inducer surface phenotype (T4 positive). Family members have an abnormal distribution of T cell subpopulations similar to those reported in asymptomatic homosexuals. The course of disease in our patient suggests that acquired immune deficiency syndrome may be transmitted to young infants via blood products.

Epstein-Barr virus, fatal infectious mononucleosis, and Hodgkin's disease in siblings

Epstein-Barr virus (EBV) infection in a family resulted in a fatal disseminated heterophil negative infectious mononucleosis syndrome in a nine-year-old girl. This was followed closely by a similar disease process in her six-year-old brother which evolved over a one-year period into Stage IIIB Hodgkin's disease. Finally, three years after the index EBV case in the daughter, the mother was diagnosed with a non-Burkitt's-type undifferentiated lymphoma that proved rapidly fatal. The EBV involvement in the sister and brother was well documented serologically and virologically. The pathologic diagnosis was established and confirmed by more than one pathologist. There was no obvious evidence for either a specific or general immune defect in any of the family members tested. The progression of the six-year-old boy's EBV infection from a benign, yet disseminated disease process into a histopathologically confirmed case of Hodgkin's disease offers a strong suggestion that this virus was not behaving solely as a passenger. Especially relevant is the fact that the boy never fully recovered from his EBV infection and essentially became persistently infected with the virus as evidenced by his EBV-EA serology and virology results.

Bone marrow findings in infectious mononucleosis and mononucleosis-like diseases in the older adult

The bone marrow findings in 5 older adults with infectious mononucleosis or mononucleosis-like illnesses are presented. These individuals were initially considered to have lympho-proliferative disorders which often have similar constitutional signs and symptoms. All had atypical lymphocytosis of the peripheral blood. In addition, there were also abnormalities in the bone marrow. The most common findings included focal collection of lymphocytes and the presence of granulomas. The granulomas were small without caseous necrosis and giant cells were infrequent. This is in contrast to the idea that the bone marrow is normal in infectious mononucleosis and gives support to performing core biopsies as the aspirate smears in these individuals did not demonstrate the focal lymphocytosis or granulomas. Whereas, infectious mononucleosis and mononucleosis-like illness may be uncommon in the older individual, they certainly are not rare and it is important to differentiate these benign disorders from the more serious lymphoproliferative diseases. Heterophil test and/or Epstein Barr titers are important confirmatory tests.