Tuberculin anergy and infectious mononucleosis

Virus-associated apoptosis of blood neutrophils as a risk factor for invasive meningococcal disease

Aims

To quantify a range of haematological indicators of viral infection (leucocyte apoptosis, cytopenia of normal lymphocytes, reactive lymphocyte increase, neutropenia) in patients with recent onset invasive meningococcal disease (IMD), with a view to test the association of viral infection with IMD and identify possible haematological risk factors for its development.

Subjects and methods

88 patients with recent onset IMD, classified on clinical severity as fatal (n=14), septic shock survived (n=26) and no shock (n=48), and 50 healthy controls were studied. Blood film microscopy and leucocyte counts were used to quantify the virus-associated indicators. Cocci-containing neutrophils were also quantified.

Results

All viral parameters were significantly more frequent or higher in patients than controls, with leucocyte apoptosis found only in the patients. A significant gradient in accord with clinical severity was found for neutrophil and lymphocyte apoptosis, neutropenia and cocci-containing neutrophils. Crucially, apoptotic neutrophils did not contain cocci, and cocci-containing neutrophils were not apoptotic.

Conclusions

The correlation between magnitude of neutrophil apoptosis and severity of IMD suggests a cause–effect relationship. We propose that neutrophil apoptosis is more likely a facilitator rather than an effect of IMD for these reasons: (1) apoptotic neutrophils did not contain cocci and cocci-containing neutrophils were not apoptotic, (2) leucocyte apoptosis is a recognised viral effect and (3) Neisseria meningitidis is incapable of producing a Panton–Valentine type leucocidin. The lymphocyte apoptosis which accompanies neutrophil death may contribute to risk by impairing the generation of microbicidal antibody. Leucocyte apoptosis is a morphological expression of viral immunosuppression and, we suggest, is a likely contributor to a range of viral effects.

Clinical outcome of patients infected with hepatitis C virus infection on survival after primary liver transplantation under tacrolimus

The outcome of hepatitis C virus (HCV) infection on patient and graft survival after orthotopic liver transplantation (OLT) has been controversial. An earlier experience with a higher dose of tacrolimus (>/=0.1 mg/kg/d intravenously and >/=0.2 mg/kg/d orally) was associated with a worse clinical outcome in patients infected with HCV. The clinical outcome of 183 liver transplant recipients with end-stage liver disease (ESLD) secondary to HCV infection (HCV group) was compared with a contemporary cohort of 556 patients with HCV infection who underwent transplantation for nonviral, nonmalignant ESLD (control group). All patients were prospectively screened for anti-HCV antibodies and HCV RNA by reverse-transcriptase polymerase chain reaction. All OLT patients were receiving low-dose tacrolimus immunosuppression. Cumulative patient survival rates for the HCV group were 80% after 1 year and 75% after 3 years compared with rates of 84% and 78%, respectively, in the control group (P = .452). Primary graft survival rates at the same time intervals for the HCV group and the control group were 72% and 77.5% at 1 year and 67% and 72% at 3 years, respectively (P = .144). The incidence of re-transplantation (re-OLT) in the HCV group and the control group was 12.6% and 10.4%, respectively (P = .42). Chronic HCV infection as an indication for OLT with a lower dose of tacrolimus immunosuppression (</=0.05 mg/kg/d intravenously and </=0.1 mg/kg/d orally) is associated with a similar patient and graft survival as those without HCV infection.

The relationship between fatigue, psychological and immunological variables in acute infectious illness

OBJECTIVE

The aim of this paper is to explore the longitudinal relationships between physical and psychological symptoms and immunological factors following acute infective illnesses.

METHOD

Preliminary data from a prospective investigation of patients with serologically proven acute infectious illnesses due to Epstein-Barr virus (EBV), Ross River virus (RRV) or Q fever are reported. Patients were assessed within 4 weeks of onset of symptoms and then reviewed 2 and 4 weeks later. Physical illness data were collected at interview. Psychological and somatic symptom profiles were assessed by standardised self-report questionnaires. Cell-mediated immune (CMI) function was assessed by measurement of delayed-type hypersensitivity (DTH) skin responses.

RESULTS

Thirty patients who had been assessed and followed over the 4-week period (including 17 patients with EBV, five with RRV and eight with Q fever) were included in this analysis. During the acute phase, profound fatigue and malaise were the most common symptoms. Classical depressive and anxiety symptoms were not prominent. Initially, 46% of cases had no DTH skin response (i.e. cutaneous anergy) indicative of impaired cellular immunity. Over the 4-week period, there was a marked improvement in both somatic and psychological symptoms, although fatigue remained a prominent feature in 63% of subjects. The reduction in reported fatigue was correlated with improvement in the DTH skin response (p = 0.001) and with improvement in General Health Questionnaire (GHQ) scores (p < 0.01).

CONCLUSIONS

Acute infectious illnesses are accompanied by a range of nonspecific somatic and psychological symptoms, particularly fatigue and malaise rather than anxiety and depression. Although improvement in several symptoms occurs rapidly, fatigue commonly remains a prominent complaint at 4 weeks. Resolution of fatigue is associated with improvement in cell-mediated immunity.

Activation of a varicella-zoster virus-specific IgA response during acute Epstein-Barr virus infection

The influence of an acute Epstein-Barr virus (EBV) infection on the serological parameters of persistent varicella-zoster virus (VZV) and herpes simplex virus (HSV) was studied. Sera from 161 patients with infectious mononucleosis caused by EBV and 178 age-matched controls were tested for HSV- and VZV-specific IgA. 98.7 percent of VZV-IgG-positive controls were negative for VZV-IgA, pointing to the stringent control of latent VZV in healthy individuals. During acute EBV infection, 33.8% of VZV-IgG-positive infectious mononucleosis patients produced VZV-specific IgA. This result may be explained either by reactivation of VZV due to transient suppression of cellular immune functions during acute EBV infection or by polyclonal stimulation caused by EBV. Due to the high incidence of HSV-IgA in healthy HSV-IgG-positive individuals, only a marginal effect of acute EBV infection on the appearance of HSV-specific IgA was found.

Cell-mediated immunity in patients with chronic fatigue syndrome, healthy control subjects and patients with major depression

The chronic fatigue syndrome (CFS) is characterized by severe persistent fatigue and neuropsychiatric symptoms. It has been proposed that the abnormalities in cell-mediated immunity which have been documented in patients with CFS may be attributable to a clinical depression, prevalent in patients with this disorder. Cell-mediated immune status was evaluated in patients with carefully defined CFS and compared with that of matched subjects with major depression (non-melancholic, non-psychotic) as well as healthy control subjects. Patients with CFS demonstrated impaired lymphocyte responses to phytohaemagglutinin (PHA) stimulation, and reduced or absent delayed-type hypersensitivity (DTH) skin responses when compared either with subjects with major depression or with healthy control subjects (P less than 0.05 for each analysis). Although depression is common in patients with CFS, the disturbances of cell-mediated immunity in this disorder differ in prevalence and magnitude from those associated with major depression. These observations strengthen the likelihood of a direct relationship between abnormal cell-mediated immunity and the etiology of CFS.

Suppression of interleukin-2 production and activity by factor(s) released by peripheral blood mononuclear cells during papillomavirus infections

Supernatant fluids from cultured peripheral blood mononuclear cells (PBMC) obtained from patients with extensive papillomavirus infections such as condyloma acuminatum (CA) and epidermodysplasia verruciformis (EV) depressed the proliferative responses of T cells to phytohemagglutinin-P (PHA-P) and the production of interleukin-2 (IL-2) from those preparations. Fluids from the same cultures also inhibited the mitogenic activity of IL-2 on CTLL-2 cells as IL-2-dependent target cells. These soluble suppressor factors (SSF) from PBMC were present in significantly higher concentrations in fluids from cultured PBMC from patients in comparison to healthy controls. A soluble suppressor factor was characterized also from cultured rabbit PBMC after the rabbits had been infected with Shope papillomaviruses. This suppressor factor likewise inhibited IL-2 production and IL-2 activity.

Infectious mononucleosis complicated by necrotizing epiglottitis, dysphagia, and pneumonia

Although infectious mononucleosis is usually a benign illness, life-threatening complications may occur. We describe a 17-year-old pregnant girl who developed necrotizing epiglottitis and dysphagia progressing to aspiration pneumonia and respiratory failure. The factors predisposing to this life-threatening complication are discussed.

Epstein-Barr virus (EBV) antigen-specific leukocyte migration inhibition (LMI) in infectious mononucleosis (IM). I. Kinetics and response to a membrane protein on EBV-transformed cells

Cell-mediated immune response of mononucleosis (IM) patients to Epstein-Barr virus (EBV)-determined antigens was measured by the leukocyte migration inhibition (LMI) assay. Patients in the acute phase of the disease failed to respond to partially purified nuclear antigen, EBNA, or to cell extracts that contained EBNA as the predominant EBV antigen. They showed a strong specific response to cell extracts enriched in early antigen (EA) and virus capsid antigen (VCA). The LMI response to EBNA appeared in convalescence in parallel with EBNA-specific antibodies, slightly later in children than in adults. Membrane fractions of EBV-carrying, virus nonproducer Raji cells induced an EBV-specific LMI at approximately the same time. A bacterial fusion protein containing the hydrophilic part of the virus-coded membrane antigen of latently EBV-infected cells also induced an EBV-specific response that parallelled the LMI reaction elicited by the Raji membrane fraction. This is in line with our previous finding (D. Sulitzeanu et al., J. Virol. 58, 230, 1986) that this fusion protein shares an epitope with Raji cell membranes.

Transient immune deficiency in patients with acute Epstein-Barr virus infection

To study the effect of primary Epstein-Barr virus (EBV) infection on antigen-specific antibody production, we immunized 17 college students who had developed acute infectious mononucleosis with the T-cell dependent neoantigen bacteriophage phi X174. During the early phase of infectious mononucleosis, the proportion of peripheral blood lymphocytes displaying Ia and T8 (CD8) phenotypes was increased and the T helper/suppressor (T4/T8) ratio was decreased (less than 1). These abnormalities disappeared during the convalescent phase. Correlating with EBV-induced changes in T lymphocytes, we demonstrated depressed humoral immune responses to bacteriophage phi X174 both in vivo and in vitro. In vitro coculture experiments indicated that the Ia+ suppressor T cells could inhibit antibody production and isotype switch. Removal of T8+ lymphocytes from patient T cells normalized in vitro antibody synthesis. In addition, impaired B-cell function was shown to be in part responsible for deficient antibody production. These studies demonstrate that infection with EBV affects both B and T lymphocytes and causes a broad-based transient immune deficiency in patients with uncomplicated infectious mononucleosis.

Isoprinosine abolishes the blocking factor-mediated inhibition of lymphocyte responses to Epstein-Barr virus antigens and phytohemagglutinin

Acute infectious mononucleosis (IM) is accompanied by measurable abnormalities of immune function, including a transient immunosuppression. The sera of patients with acute IM contain an IgG blocking factor which binds to T-lymphocytes and decreases their responses to antigens and mitogens. The experiments reported herein indicate that isoprinosine, an immunopotentiating agent, can reverse this inhibition of T cells by IM-associated IgG blocking factor. Isoprinosine may be a useful tool in understanding the interactions between blocking factors and lymphocytes; moreover, isoprinosine may be of value in patients with abnormal clinical responses to Epstein-Barr virus (EBV) such as chronic IM or persistent active EBV infections.

Virus infections in immunocompromised patients: their importance and their management

Opportunistic viral infections were investigated in 156 adult patients admitted over one year to a medical oncology service: 35% of the total group and 65% of those with acute leukaemia experienced viral infections, 79% of which were with viruses of the herpes group. Surprisingly few enteric viruses were recovered. Reactivation of herpes simplex virus in the brains of these immunosuppressed patients was suggested by the demonstration by nucleic acid hybridization of herpes simplex virus DNA sequences in neurones and endothelial cells in patients with evidence of past infection with virus. Acyclovir was effective in therapy and prophylaxis. Twenty-three strains from 7 patients were tested for sensitivity to this antiviral: in 3 instances clinical resistance was observed but the strains were fully sensitive in vitro, as were all other strains tested.

Virologic, immunologic, and clinical observations on a patient during the incubation, acute, and convalescent phases of infectious mononucleosis

One patient with infectious mononucleosis (IM) was studied from the probable time of Epstein-Barr virus (EBV) infection (38 days before the onset of clinically overt disease), during the incubation and acute phases, until 6 months after clinical remission. Analysis of spontaneous outgrowth of EBV-carrying lymphoblastoid cells, by limiting dilution on feeder layer cultures, showed that virus containing B lymphocytes are already present early during the incubation period. Also low interferon serum levels were detected early after infection, and only before the onset of clinical disease. All other studied clinical laboratory and virus-associated variables were within normal range during the incubation phase, but changed to a pattern characteristic of IM in parallel to the clinical symptoms. During the acute disease EBV-associated nuclear antigen (EBNA)-positive cells could be directly detected among the lymphocytes, and antibodies to EBV antigens appeared. Lymphocytes stained by monoclonal antibodies, detecting Ia-like determinants (activated cells) and suppressor cells, increased dramatically, in parallel to a strong increase of functional suppressor cell activity, measured by inhibition of blastogenesis and PWM-induced immunoglobulin production. During the acute phase there was also a decrease of spontaneous cytotoxicity against the NK-sensitive cell line K562, while cytotoxicity (spontaneous) against an autologous EBV-positive lymphoblastoid cell line (LCL) was detected only during this phase. These reactions correlated to the presence of blasts, and the autologous reaction was exerted mainly by Fc-receptor-negative cells. Lymphokine production in response to EBV antigens was also initiated during the acute phase. During the convalescence period the serological and cellular immune parameters adjusted to the pattern of a normal EBV-seropositive person.

Infectious mononucleosis fifty years after the discovery of the Paul-Bunnell test

The Paul-Bunnell test, now 50 years old, is still of fundamental importance in the diagnosis of infectious mononucleosis, even though various immunologic methods have been developed in clinical practice to identify constituents of the Epstein-Barr virus (EBV). The demonstration of sheep red cell agglutinins in infectious mononucleosis (Paul-Bunnell) was in fact the first observation of the presence of heterophil antibodies in this viral disease which was later shown to evoke a polyclonal antibody response to a wide spectrum of autoantigens as well. The selective tropism of EBV for B lymphocytes and the reactivity of T lymphocytes to these infected B lymphocytes are the pathophysiological elements characteristic of infectious mononucleosis, and are the reason for this massive antibody response.

Relationship of in vitro immune responses to Epstein-Barr herpesvirus and severity of infectious mononucleosis

Immune responses to Epstein-Barr herpesvirus (EBV) and EBV-related antigens were studied serially in 18 patients with heterophil antibody-positive infectious mononucleosis and in 18 control subjects. Enhanced cellular immune responses to EBV particles and to EBV intracellular soluble antigens were found in the patients at convalescence, suggesting that the development of specific cellular immune responses was associated with apparent control of the virus infection. In addition, a correlation between severity of disease and specific cellular immune response was found. Patients with severe clinical signs were found to have a more active cellular immune response to EBV intracellular soluble antigens early in the infection compared with patients with mild disease. This suggests that an increased immune reactivity to intracellular antigens during the early part of the illness is related to the severity of clinical manifestations in infectious mononucleosis. Serum antibody to viral capsid antigen and early antigen was not related to the severity of clinical disease.

Immunosuppression and alterations of T-lymphocyte subpopulations after rubella vaccination

Lymphocyte stimulation tests and determinations of T-lymphocyte subpopulations were undertaken in 11 subjects before and after rubella vaccination and in 11 controls. The lymphocyte stimulation response to phytohemagglutinin was suppressed 7 to 10 days after vaccination. The proportion of T lymphocytes with receptors for the Fc part of immunoglobulin G increased after vaccination, whereas there was no significant change in the proportion of T lymphocytes with immunoglobulin M-Fc receptors.

Leukocyte migration inhibition with Epstein-Barr virus negative and positive cell extracts

Leukocyte migration inhibition of seronegative and seropositive healthy children and that of patients with infectious mononucleosis was studied in the presence of EBV-negative and -positive cell extracts. Seronegative children showed no alteration of the leukocyte migration in the presence of the extracts. EBV-positive cell extracts caused significant migration inhibition in the group of seropositive healthy children and of IM patients. The effect was specific, since the EBV-negative cell extract had no inhibitory effect. In the acute phase of infectious mononucleosis a depressed response was observed, while after recovery the same migration inhibition could be detected. The possible cause of the depressed cell-mediated immune response in the acute phase of the disease is discussed.

Cytomegalovirus granulomatous hepatitis

Three patients with granulomatous hepatitis due to cytomegalovirus are described. They are compared to the three previously described patients with this disease, and their clinical and serologic characteristics are discussed. Similarities and differences between infectious mononucleosis (Epstein-Barr virus) and cytomegalovirus infections are adduced. That cytomegalovirus may be a cause of granulomatous hepatitis in the adult is stressed.

Antibodies to smooth muscle and other tissue components in infectious mononucleosis

Antibodies to tissue components were studied by the indirect immunofluorescent method in 24 patients with infectious mononucleosis (IM). Smooth-muscle antibodies (SMA) were found in 70.8% of the patients, and in only one (3.8%) of 26 controls. SMA in patients were of the IgG (54.2%), the IgA (12.5%) and the IgM (41.6%) class. IgM-SMA occurred in the early phase of the disease, while IgG-SMA were found both early and late in its course. It was not possible to demonstrate that the development of SMA was due to liver involvement. Antinuclear antibodies, parietal-cell antibodies and antibodies to the cytoplasm of renal tubular cells were not detected significantly more often in patients than in controls. The serum concentrations of IgG, IgA and IgM were elevated in the acute phase of IM, and it was found that the Ig values were higher in patients with SMA than in those without.

Tuberculin anergy in patients with Mycoplasma pneumoniae infection

Skin testing for delayed hypersensitivity to tuberculin was performed in 36 patients with pneumonia associated with Mycoplasma pneumoniae infection. 22 of these patients had a negative tuberculin reaction when first tested. The tuberculin reaction was negative in 13 out of 16 cases tested during the first 2 weeks after onset of illness, in 6 out of 11 cases tested 15-28 days after onset of illness and in 3 out of 9 cases tested 29-45 days after clinical onset. In 19 patients with a negative tuberculin test in the early phase after onset of illness the test was repeated several weeks or months later. 16 of these cases had a positive tuberculin reaction at the later time period. Two of these cases showed prolonged tuberculin anergy for more than 5 months.

Infectious mononucleosis: model for self-limiting lymphoproliferation

Evidence for the extensive lymphoproliferation which characterises infectious mononucleosis (I.M.) is summarised, and some of the mechanisms which are though to control lymphoproliferative activity in this disease are discussed. The main host responses which appear to limit lymphoproliferation in I.M. include the development of humoral antibodies against the Epstein-Barr (E.B.) virus-associated membrane antigen (present on the E.B. viral envelope and on E.B.-virus-infected cells) and cellular immune responses directed against E.B.-virus-containing lymphocytes. Recent evidence is reviewed which indicates that E.B. virus preferentially infects B lymphocytes and that these E.B.-virus-containing cells, which are altered antigenically, evoke a massive response in the host T cells which do not carry E.B. virus; in the presence of E.B.-virus-infected B cells, T cells are transformed and become cytotoxic for B cells. Some of the general implications of the predominant T-cell response in I.M. are discussed with particular relation to autoantibody formation and antigenic competition. The possible role of the distinctive heterophil antigens and antibodies in determining the self-limiting course of I.M. is briefly considered. The general status of I.M. as a self-limiting, albeit intense, lymphoproliferative disease is appraised and the tenuous relationship between I.M. and irreversible lymphoproliferative states is discussed.

Antibodies to Epstein-Barr and other viruses in children with acute lymphoblastic leukaemia

Sixty-eight children with acute lymphoblastic leukaemia were tested for antibodies to Epstein-Barr (EB) virus and to other viruses. The antibody response to the test viruses in these children was unremarkable, with the exception of EB virus, where the presence of complement-fixing antibodies in children tested during the first month of their illness suggested that a higher proportion had previous experience with this virus than was the case in control children. The implications of this observation with regard to leukaemogenesis are discussed.