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Indari O, Ghosh S, Bal AS, James A, Garg M, Mishra A, Karmodiya K, Jha HC. Awakening the sleeping giant: Epstein-Barr virus reactivation by biological agents. Pathog Dis 2024; 82:ftae002. [PMID: 38281067 PMCID: PMC10901609 DOI: 10.1093/femspd/ftae002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 01/16/2024] [Accepted: 01/25/2024] [Indexed: 01/29/2024] Open
Abstract
Epstein-Barr virus (EBV) may cause harm in immunocompromised conditions or on stress stimuli. Various chemical agents have been utilized to induce the lytic cycle in EBV-infected cells. However, apart from chemical agents and external stress stimuli, certain infectious agents may reactivate the EBV. In addition, the acute infection of other pathogens may provide suitable conditions for EBV to thrive more and planting the roots for EBV-associated pathologies. Various bacteria such as periodontal pathogens like Aggregatibacter, Helicobacter pylori, etc. have shown to induce EBV reactivation either by triggering host cells directly or indirectly. Viruses such as Human simplex virus-1 (HSV) induce EBV reactivation by HSV US3 kinase while other viruses such as HIV, hepatitis virus, and even novel SARS-CoV-2 have also been reported to cause EBV reactivation. The eukaryotic pathogens such as Plasmodium falciparum and Aspergillus flavus can also reactivate EBV either by surface protein interaction or as an impact of aflatoxin, respectively. To highlight the underexplored niche of EBV reactivation by biological agents, we have comprehensively presented the related information in this review. This may help to shedding the light on the research gaps as well as to unveil yet unexplored mechanisms of EBV reactivation.
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Affiliation(s)
- Omkar Indari
- Infection Bioengineering Group, Department of Biosciences and Biomedical Engineering, Indian Institute of Technology Indore, Simrol Campus, Simrol, Indore 453552, India
- Department of Immunology, St. Jude Children's Research Hospital, Memphis, TN 38105, United States
| | - Subhrojyoti Ghosh
- Infection Bioengineering Group, Department of Biosciences and Biomedical Engineering, Indian Institute of Technology Indore, Simrol Campus, Simrol, Indore 453552, India
| | - Adhiraj Singh Bal
- Infection Bioengineering Group, Department of Biosciences and Biomedical Engineering, Indian Institute of Technology Indore, Simrol Campus, Simrol, Indore 453552, India
| | - Ajay James
- Infection Bioengineering Group, Department of Biosciences and Biomedical Engineering, Indian Institute of Technology Indore, Simrol Campus, Simrol, Indore 453552, India
| | - Mehek Garg
- Infection Bioengineering Group, Department of Biosciences and Biomedical Engineering, Indian Institute of Technology Indore, Simrol Campus, Simrol, Indore 453552, India
| | - Amit Mishra
- Cellular and Molecular Neurobiology Unit, Indian Institute of Technology Jodhpur, Jodhpur 342037, India
| | - Krishanpal Karmodiya
- Indian Institute of Science Education and Research (IISER), Dr. Homi Bhabha Road, Pune 411008, India
| | - Hem Chandra Jha
- Infection Bioengineering Group, Department of Biosciences and Biomedical Engineering, Indian Institute of Technology Indore, Simrol Campus, Simrol, Indore 453552, India
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Tabaja H, Kanj A, El Zein S, Comba IY, Chehab O, Mahmood M. A Review of Hemophagocytic Lymphohistiocytosis in Patients With HIV. Open Forum Infect Dis 2022; 9:ofac071. [PMID: 35308483 PMCID: PMC8926004 DOI: 10.1093/ofid/ofac071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 02/10/2022] [Indexed: 11/23/2022] Open
Abstract
We provide an elaborate review of cases published between January 2005 and April 2021 on hemophagocytic lymphohistiocytosis (HLH) in HIV patients. Seventy articles describing 81 adult patients (age ≥19 years) were included. The median age was 40 years, and 78% were males. Only 65% were known to have HIV before presentation. CD4 count was ≥200 cells/mm3 in 23%, and HIV viral load was <200 copies/mL in 41%. The lack of meticulous reporting of ≥5 of 8 criteria for HLH diagnosis was evident in a third of cases. At least 1 infectious agent-other than HIV-was believed to trigger HLH in 78% of patients. The most common were Epstein-Barr virus (26%), human herpesvirus 8 (21%), and Histoplasma capsulatum (17%). Sixty percent survived. Among those, 93% received treatment for identified secondary trigger(s), while 51% received HLH-directed therapy. There was significant heterogeneity in the treatment regimens used for HLH.
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Affiliation(s)
- Hussam Tabaja
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Amjad Kanj
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Said El Zein
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Isin Yagmur Comba
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Omar Chehab
- Division of Internal Medicine, John Hopkins, Baltimore, Maryland, USA
| | - Maryam Mahmood
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA
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Fazal F, Gupta N, Mittal A, Ray A. Haemophagocytic lymphohistiocytosis in human immunodeficiency virus: a systematic review of literature. Drug Discov Ther 2020; 14:226-231. [PMID: 33116036 DOI: 10.5582/ddt.2020.03069] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Diagnosis and management of hemophagocytic lymphohistiocytosis (HLH) in patients with human immunodeficiency virus (HIV) infection are scarcely described in the published literature. The aim of this systematic review was to delineate the triggers of HLH in patients with HIV and understand the role of steroids in the management. We conducted a comprehensive search of English medical literature via the Medline ⁄ PubMed database using different synonyms of "HIV" AND "HLH". The review was registered in PROSPERO (CRD42018099987). The titles and abstracts of the 185 articles between January 1986 and April 2018 were reviewed. The final analysis was done from 42 articles with 52 patients. HLH was associated with malignancy in 17 patients, while infection was found in 25 patients. No cause was identified in eight patients, out of which four had acute HIV infection. Death was reported in 21 patients. Presence of either malignancy (p = 0.051) or opportunistic infection (p = 0.69) was not associated with increased chances of death by univariate analysis. A total of 26 patients were treated with steroids, while etoposide was used in only four patients. Administration of steroids as a treatment of HLH was associated with more chances of death (p = 0.048). Malignancy and Opportunistic infections are important triggers for HLH in patients with HIV. Acute HIV by itself can act as a trigger for HLH. Evidence on the use of steroids as a treatment of HLH in patients with HIV is not convincing.
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Affiliation(s)
- Farhan Fazal
- Department of Medicine, Kasturba Medical College, Mangalore, India
| | - Nitin Gupta
- Department of Infectious Diseases, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India
| | - Ankit Mittal
- Department of Medicine and Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | - Animesh Ray
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
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Parsi M, Dargan K. Hemophagocytic Lymphohistiocytosis Induced Cytokine Storm Secondary to Human Immunodeficiency Virus Associated Miliary Tuberculosis. Cureus 2020; 12:e6589. [PMID: 32051801 PMCID: PMC7001132 DOI: 10.7759/cureus.6589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rarely diagnosed fatal inflammatory disease associated with an overactive immune system. It occurs in a host of conditions, with human immunodeficiency virus (HIV) being a rare but serious cause, usually occurring in patients with acquired immunodeficiency syndrome (AIDS). The diagnosis of HLH can be very difficult, as it presents with vague signs and symptoms, which can be present in multiple diseases. This case highlights the diagnostic dilemma faced when treating this potentially fatal condition. Usually, treating the underlying trigger for HLH is sufficient to counteract the overwhelming inflammatory response; however, this can prove to be difficult, as demonstrated in our patient. We present a case of miliary tuberculosis in the setting of HIV/AIDS, complicated by HLH in a young male patient. Whether it was due to delays in treatment or the rapidly fulminant nature of the disease, our patient had a poor clinical outcome. Although rare, tuberculosis-associated HLH must be considered as a cause of secondary HLH in all patients, especially those who are immunosuppressed.
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Affiliation(s)
- Meghana Parsi
- Internal Medicine, Crozer-Chester Medical Center, Upland, USA
| | - Kinjal Dargan
- Hematology/Oncology, Cooper University Medical Center, Camden, USA
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Altook R, Ruzieh M, Singh A, Alamoudi W, Moussa Z, Alim H, Safi F, Duggan J. Hemophagocytic Lymphohistiocytosis in the Elderly. Am J Med Sci 2018; 357:67-74. [PMID: 30278875 DOI: 10.1016/j.amjms.2018.07.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 07/10/2018] [Accepted: 07/10/2018] [Indexed: 12/25/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare disease of massive, dysregulated cytokine release and secondary multiorgan failure and is associated with high mortality. Primary HLH occurs predominately in infants and young children with a genetic predisposition. Acquired HLH is less well characterized and usually occurs in younger adults in the setting of severe inflammation triggered by infection or malignancy. Little is known about the disease in elderly. We report 3 patients >50 years old who presented with multiorgan failure and shock without an identifiable source and were ultimately diagnosed with acquired HLH. We performed a literature review of HLH in adults >50 years of age and identified an additional 68 cases. Mean age was 62 years, with male predominance. Most cases were triggered by infection (49%) followed by malignancy (27%). Nineteen patients were treated with the HLH-94 protocol, 11 received corticosteroids and the remainder received non-HLH specific interventions. Overall mortality was 62%.
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Affiliation(s)
- Reyna Altook
- Department of Internal Medicine, University of Toledo, Toledo, Ohio
| | - Mohammed Ruzieh
- Penn State Heart and Vascular Institute, Penn State University, Hershey Pennsylvania.
| | - Avneet Singh
- Department of Internal Medicine, University of Toledo, Toledo, Ohio
| | - Wael Alamoudi
- Department of Internal Medicine, University of Toledo, Toledo, Ohio
| | - Zeinab Moussa
- Department of Internal Medicine, University of Toledo, Toledo, Ohio
| | - Hussam Alim
- Department of Internal Medicine, University of Toledo, Toledo, Ohio
| | - Fadi Safi
- Pulmonary and Critical Care Division, Department of Internal Medicine, University of Toledo, Toledo, Ohio
| | - Joan Duggan
- Infectious Disease Division, Department of Internal Medicine, University of Toledo, Toledo, Ohio
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Epperla N, Harrington AM, Hemauer K, Shah NN. Extracavitary primary effusion lymphoma associated with hemophagocytic lymphohistiocytosis. Am J Hematol 2016; 91:1161-1164. [PMID: 27414752 DOI: 10.1002/ajh.24475] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 07/07/2016] [Accepted: 07/12/2016] [Indexed: 11/07/2022]
Affiliation(s)
- Narendranath Epperla
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | | | - Kathleen Hemauer
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nirav N Shah
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
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Azevedo L, Gerivaz R, Simões J, Germano I. The challenging diagnosis of haemophagocytic lymphohistiocytosis in an HIV-infected patient. BMJ Case Rep 2015; 2015:bcr-2015-211817. [PMID: 26511991 DOI: 10.1136/bcr-2015-211817] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The differential diagnosis of febrile pancytopenia in the setting of HIV infection can be challenging. The authors report a case of a 34-year-old man with advanced HIV infection (TCD4=8 cells/mm(3)) and a 2-month history of fever, weight loss and asthaenia. On observation, he was emaciated, hyperthermic and pale, with a haemorrhagic oropharyngeal lesion, penile violaceous lesions and palpable hepatosplenomegaly. Blood tests showed pancytopenia, hyperferritinaemia and hypertriglyceridaemia; imaging confirmed hepatosplenomegaly and a bone marrow biopsy revealed HIV-associated dyshematopoiesis. Biopsy of the aforementioned lesions displayed Kaposi sarcoma; extensive investigation was negative for other opportunistic infections or lymphoproliferative disease. Despite only a posteriori histological documentation, haemophagocytic lymphohistiocytosis (HLH) was considered; chemotherapy and antiretrovirals were started, with excellent response. There was, however, disease relapse requiring an intensification course, with sustained remission at 18-month follow-up. HLH is a rare disease, with non-specific presentation, requiring a high index of suspicion since treatment delay can be fatal.
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Affiliation(s)
- Luísa Azevedo
- Department of Internal Medicine, Centro Hospitalar Lisboa Central EPE, Lisboa, Portugal
| | - Rita Gerivaz
- Department of Hematology, Centro Hospitalar Lisboa Central EPE, Lisboa, Portugal
| | - Joana Simões
- Department of Internal Medicine, Centro Hospitalar Lisboa Central EPE, Lisboa, Portugal
| | - Isabel Germano
- Department of Internal Medicine, Centro Hospitalar Lisboa Central EPE, Lisboa, Portugal
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Townsend JL, Shanbhag S, Hancock J, Bowman K, Nijhawan AE. Histoplasmosis-Induced Hemophagocytic Syndrome: A Case Series and Review of the Literature. Open Forum Infect Dis 2015; 2:ofv055. [PMID: 26380347 PMCID: PMC4567100 DOI: 10.1093/ofid/ofv055] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 04/14/2015] [Indexed: 12/31/2022] Open
Abstract
Background. Histoplasmosis-associated hemophagocytic lymphohistiocytosis (HLH) is a relatively rare disorder for which data are limited regarding optimal treatment and clinical outcomes in adults. We describe the clinical features, treatment, and outcomes of patients with histoplasmosis-associated HLH at our institution. Methods. We performed a retrospective chart review of all inpatients at Parkland Hospital diagnosed with HLH associated with Histoplasma capsulatum from 2003 to 2013. Results. Eleven cases of histoplasmosis-associated HLH over this time period were identified. Nine of eleven cases were males (82%). Nine of these patients had human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS), 1 was a renal transplant patient on immunosuppressants, and the other had no documented immunocompromise. The most common HLH criteria were splenomegaly (n = 10), fever (n = 10), and ferritin >500 ng/dL (n = 9). Urine Histoplasma antigen was positive in every patient tested (n = 9 of 9), and most antibodies for Histoplasma were positive if checked (n = 4 of 5). A majority of patients received liposomal amphotericin B (n = 9) with an average treatment duration of 11 days, and 5 patients also received prednisone, intravenous immunoglobulin (IVIG), or both. Overall, 5 patients died within 30 days (45.5%), and 7 patients died within 90 days (63.6%). Of the 5 patients that received immunosuppression, 4 died (80%), whereas in the group not given additional immunosuppression (n = 5), 2 died (40%). Conclusions. Histoplasmosis-associated HLH among adults is a lethal disease of highly immunocompromised patients, especially patients with HIV/AIDS. Clinical features such as splenomegaly, elevated ferritin, and cytopenias should prompt evaluation for HLH in this population. Further data are needed to define the role of immunosuppression, IVIG, and highly active antiretroviral therapy in treating this condition.
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Shi X, Sims MD, Hanna MM, Xie M, Gulick PG, Zheng YH, Basson MD, Zhang P. Neutropenia during HIV infection: adverse consequences and remedies. Int Rev Immunol 2014; 33:511-36. [PMID: 24654626 DOI: 10.3109/08830185.2014.893301] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Neutropenia frequently occurs in patients with Human immunodeficiency virus (HIV) infection. Causes for neutropenia during HIV infection are multifactoral, including the viral toxicity to hematopoietic tissue, the use of myelotoxic agents for treatment, complication with secondary infections and malignancies, as well as the patient's association with confounding factors which impair myelopoiesis. An increased prevalence and severity of neutropenia is commonly seen in advanced stages of HIV disease. Decline of neutrophil phagocytic defense in combination with the failure of adaptive immunity renders the host highly susceptible to developing fatal secondary infections. Neutropenia and myelosuppression also restrict the use of many antimicrobial agents for treatment of infections caused by HIV and opportunistic pathogens. In recent years, HIV infection has increasingly become a chronic disease because of progress in antiretroviral therapy (ART). Prevention and treatment of severe neutropenia becomes critical for improving the survival of HIV-infected patients.
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Pinto-Patarroyo GP, Rytting ME, Vierling JM, Suarez-Almazor ME. Haemophagocytic lymphohistiocytosis presenting as liver failure following Epstein-Barr and prior hepatitis A infections. BMJ Case Rep 2013; 2013:bcr-2013-008979. [PMID: 23943807 DOI: 10.1136/bcr-2013-008979] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is associated with high mortality even after prompt diagnosis. We present a young man with HLH triggered by two common viral diseases, infectious mononucleosis and hepatitis A. This patient presented with fever, rapidly progressive liver failure, anasarca and cholestasis, followed by anaemia and neutropenia. His carbohydrate antigen 19-9 reached over 9000 U/mL. Initial bone marrow and liver biopsies did not show histological features of malignancy or HLH. The patient was finally diagnosed and treated almost 1 year after the initial symptoms started, and had an excellent response with etoposide and dexamethasone. This case is unusual because it was triggered following mononucleosis in a patient with positive total antibodies against hepatitis A, with rapidly developing liver failure, and also because the patient's response was excellent despite the delay in treatment. It underscores the importance of suspecting HLH when severe systemic illness develops after a viral infection, even in the absence of clear histological features.
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