Long-term remission in a child with refractory EBV(+) hydroa vacciniforme-like T-cell lymphoma through sequential matched EBV(+)-related allogeneic hematopoietic SCT followed by donor-derived EBV-specific cytotoxic T-lymphocyte immunotherapy

Case report: Cellular therapy for hydroa vacciniforme-like lymphoproliferative disorder in pediatric common variable immunodeficiency with chronic active Epstein-Barr virus infection

Hydroa vacciniforme-like lymphoproliferative disorder (HV-LPD) is a cutaneous form of chronic active Epstein-Barrvirus (EBV) infection, which can develop into the extremely rare systemic lymphoma. Patients with Inborn errors of immunity (IEI), such as common variable immunodeficiency (CVID), are at higher risk of developing a severe course of infections especially viral and malignancies than the general population. The aim of the study was to present complex diagnostic and therapeutic management of HV-LPD. The clinical diagnosis was confirmed at the histological and molecular level with next generation sequencing. HV-LPD was diagnosed in a patient with CVID and chronic active Epstein–Barr virus (CAEBV) infection. The patient was refractory to CHOP chemotherapy and immunosuppressive treatment in combination with antiviral drugs (prednisone, bortezomib, gancyclovir). The third-party donor EBV-specific cytotoxic T cells (EBV-CTL, tabelecleucel) were used, which stabilised the disease course. Finally, matched unrelated donor hematopoietic cell transplantation (MUD-HCT) was performed followed by another cycle of EBV-CTL.

Hydroa vacciniforme-like lymphoproliferative disorder: A clinicopathological, immunohistochemical, and prognostic study of 24 cases in China

Hydroa vacciniforme‐like lymphoproliferative disorder (HV‐LPD) is a rare cutaneous disease associated with Epstein–Barr virus infection. We retrospectively analyzed the clinical presentation, histopathological characteristics, and prognostic study of HV‐LPD in 24 Chinese patients. All patients presented with recurrent papulovesicular and necrotic eruptions on the face, neck, and extremities, with 11 showing systemic symptoms. Twenty patients were diagnosed with HV‐LPD in childhood (age < 18 years) and four in adulthood (age ≥ 18 years). The median age at diagnosis was 8.5 years old (range, 2–50). Histopathology revealed variably dense lymphocyte infiltration throughout the dermis. All cases were strongly positive for CD3 and Epstein–Barr encoding region based on in situ hybridization. Of 18 cases with a T‐cell phenotype, 15 harbored monoclonal rearrangements in T‐cell receptor (TCR) genes. Four cases with a natural killer cell phenotype carried polyclonal rearrangements in TCR genes. Among 24 patients, eight (33.3%) received chemotherapy, two (8.3%) allogeneic hematopoietic stem cell transplantation, and both are currently alive without disease. The median follow‐up period was 24 months (range, 7–120) and 23 patients were available: 15 (62.5%) were alive, and eight (33.3%) had died. Fourteen cases had a relapse of disease and three developed lymphoma within 24 months of diagnosis. The mean survival time of childhood‐onset patients was longer than that of adult‐onset patients (36.4 vs. 20.8 months). In summary, the wide clinical course and representative presentation of cases in our center reflect the pedigree characteristics of HV‐LPD. Allogeneic hematopoietic stem cell transplantation should be a preferred choice for relapse and refractory patients due to the poor effect of chemotherapy. Adult‐onset and high serum EBV DNA loads may indicate an increased risk of aggressive disease in patients with HV‐LPD.

Hydroa Vacciniforme-like Lymphoproliferative disorder in an adult invades the liver and bone marrow with clear pathological evidence: a case report and literature review

Background

Hydroa Vacciniforme-like Lymphoproliferative Disorder (HV-LPD) is the name given to a group of Epstein-Barr virus (EBV)-associated diseases. It resembles hydroa vacciniforme (HV), the rarest form of photosensitivity, and is a T-cell disorder associated with an Epstein-Barr virus infection. The majority of diagnosed cases occur in East Asia and South America. It is rare in the United States and Europe. Multiple studies have revealed the clinical manifestation of an enlarged liver, but no gold standard such as pathology has yet supported this as a clinical sign of HV-LPD.

Case presentation

Here, we report a case of a 34-year-old Asian female with definite liver invasion. The patient had complained of a recurring facial rash for many years. The patient was admitted to the hospital because of an enlarged liver. After hospitalization, she was given an EB virus nucleic acid test. The EB virus nucleic acid test was positive, and pathological examination suggested that HV-LPD had invaded the skin, bone marrow, and liver. After being given antiviral treatment, the patient’s symptoms were mitigated.

Conclusions

Our case confirms the liver damage was caused by HV-LPD and the effectiveness of antiviral treatment.

Clinicopathological categorization of hydroa vacciniforme-like lymphoproliferative disorder: an analysis of prognostic implications and treatment based on 19 cases

Background

Hydroa vacciniforme-like lymphoproliferative disorder (HV-LPD) is a cutaneous form of chronic active Epstein-Barr virus (EBV) infection, which occurs mainly in children in Latin America and Asia. It can progress to systemic lymphoma. However, prognostic factors and treatment remain unclear.

Methods

This retrospective study reviewed the clinical, morphologic, immunophenotypical features, and clinical treatment of 19 patients with HV-LPD.

Results

All 19 patients had skin lesions in the face, extremities, or areas unexposed to the sun, including edema, blistering, ulceration, and scarring. The course was slowly progressive and relapsing. Histopathology showed an atypical lymphocytic infiltrate in the dermis and/or subcutaneous tissue. The lesions had a cytotoxic T/NK-cell immunophenotype. Among 19 patients, 7 (37%) exhibited CD4+ T cells, 5 (26%) exhibited CD8+ T cells, and 7 (37%) exhibited CD56+ cells. Of 12 cases with a T-cell phenotype, molecular analyses demonstrated that 7 had monoclonal rearrangements in the T-cell receptor genes. Three cases had an NK-cell phenotype and had polyclonal rearrangements in the TCR genes. All cases were associated with EBV infections. Among 19 patients, 9 (47.4%) received chemotherapy. Only one patient received allogeneic transplantation and EBV-specific cytotoxic T lymphocyte treatment after chemotherapy. That patient was the only one alive without disease at the latest follow up. Nine patients died of systemic lymphoma with disease progression, indicating irreversible process.

Conclusions

This study confirmed that HV-LPD is a broad-spectrum EBV+ lymphoproliferative disorder. It progressed to EBV+ systemic T/NK lymphoma, although some patients had a more indolent, chronic course. Cytopenia, elevated lactate dehydrogenase, destructive-multiorgan involvement, and older age were poor prognostic factors. Only allogeneic transplantation was curative.

Hydroa Vacciniforme-Like Lymphoma with Systemic Symptoms: Two Case Reports

Two Chinese children presented with relapsing papules, vesicles, ulcers on the face and limbs with systemic symptoms being caused by mosquito bite. Lesion biopsy revealed atypical lymphocyte in the dermis and subcutis. Immunohistochemistry identified cells as positive for CD3, CD45RO, TIA-1 and EBER. Taken together, both the patients were diagnosed with hydroa vacciniforme-like lymphoma. Two patients showed significant improvement in clinical symptoms after being treated with acyclovir, low dose predisone and IFN-α.

Hydroa vacciniforme-like cutaneous T-cell lymphoma in a child: A case report

RATIONALE

Hydroa vacciniforme (HV)-like T-cell lymphoma is a rare malignancy in childhood associated with Epstein-Barr virus infection.

PATIENT CONCERNS

A 6-year old girl presented with complaint of 3-year history of recurrent skin lesions, 3 months of fever accompanied by cough for 8 days.

DIAGNOSES

Skin biopsy revealed a HV-like lymphoma presentation and positive signals of EBER were detected by in situ hybridization. TCR-γ gene monoclonal rearrangement was present. A HV-like cutaneous T-cell lymphoma was diagnosed.

INTERVENTIONS

The girl was treated with cyclosporine and CHOP.

OUTCOMES

The girl's condition had been stable for 6 months.

LESSONS

Our case highlights the necessity for taking the HV-like lymphoma as a differential diagnosis especially when a patient manifests as recurrent skin lesions accompanied by systemic involvement.

Hydroa vacciniforme-like lymphoma: a case report from India

We report a 14-year-old Indian boy who presented with a history of weight loss, fever, facial edema, and a relapsing papulovesicular eruption on the face and limbs for 1 year. Histopathology of the skin showed dense lymphoid infiltrate from dermis to subcutaneous fat. Immunohistochemistry of this lymphoid infiltrate was CD3, CD8, CD56, CD57, Granzyme B, TIA, and Epstein Barr virus LMP1. The histopathology and immunohistochemistry were consistent with the diagnosis of hydroa vacciniforme-like T-cell lymphoma. The child responded remarkably to oral steroids but relapsed on tapering doses. CHOP (Cyclophosphamide, Adriamycin, Vincristine, and Prednisolone) chemotherapy was initiated in view of systemic involvement to which he showed some response, however, the disease relapsed again. He then had a rapidly progressive disease and ultimately succumbed to his illness. This is the first case of hydroa vacciniforme-like T-cell lymphoma being reported from this subcontinent.

Systemic lymphoma arising from hydroa vacciniforme-like lymphoma: report of two cases with review of literature

Hydroa vacciniforme-like lymphoma (HVLL) is an extremely rare lymphoma described in children that occurs mainly in Asia and Latin American countries. It is an Epstein-Barr virus (EBV)-positive lymphoproliferative disease (LPD) characterized by a monoclonal proliferation of T or NK cells. In this study, we report the clinical and pathological features of two Chinese patients with HVLL showed T-cell phenotype expressing CD4. The two patients generally presented with similar clinical histories of waxing and waning ulcerative blistering lesions for ten years or more until progression to systemic lymphoma. One patient died two months after progression and another is alive with disease. In the two cases, persistence infection of EBV may be attributed to the disease progression, and systemic lymphoma arising from HVLL behaves in an aggressive fashion and is predisposing to chemotherapeutic agent resistance.

Advances in the treatment of metastatic melanoma: adoptive T-cell therapy

Metastatic melanoma is notoriously resistant to chemotherapy and radiotherapy regimens. The prospect for newly diagnosed metastatic melanoma patients is grim, with a median survival of less than 1 year. Currently, the only therapies resulting in long-term disease-free intervals, high-dose interleukin-2 (IL-2) and more recently anti-CTLA-4, work through activation of the immune system. However, with both therapies the response rate is low. Advances in our knowledge of how the immune system interacts with cancer have led to a number of strategies to manipulate anti-tumor immune responses through immunotherapy. This review will focus on one avenue of immunotherapy using the transfer of T cells referred to as "adoptive cell therapy" (ACT), which involves the ex vivo expansion of autologous tumor-specific T cells to large numbers that are ultimately transferred back to the patient to boost anti-tumor immunity. This approach has been shown to be effective in the treatment of virally induced cancers, as well as metastatic melanoma. Recent successes with ACT hold promise and further emphasize the tremendous potential benefit of harnessing the immune system in the fight against cancer.

Characterization and treatment of chronic active Epstein-Barr virus disease: a 28-year experience in the United States

Chronic active EBV disease (CAEBV) is a lymphoproliferative disorder characterized by markedly elevated levels of antibody to EBV or EBV DNA in the blood and EBV RNA or protein in lymphocytes in tissues. We present our experience with CAEBV during the last 28 years, including the first 8 cases treated with hematopoietic stem cell transplantation in the United States. Most cases of CAEBV have been reported from Japan. Unlike CAEBV in Japan, where EBV is nearly always found in T or natural killer (NK) cells in tissues, EBV was usually detected in B cells in tissues from our patients. Most patients presented with lymphadenopathy and splenomegaly; fever, hepatitis, and pancytopenia were common. Most patients died of infection or progressive lymphoproliferation. Unlike cases reported from Japan, our patients often showed a progressive loss of B cells and hypogammaglobulinemia. Although patients with CAEBV from Japan have normal or increased numbers of NK cells, many of our patients had reduced NK-cell numbers. Although immunosuppressive agents, rituximab, autologous cytotoxic T cells, or cytotoxic chemotherapy often resulted in short-term remissions, they were not curative. Hematopoietic stem cell transplantation was often curative for CAEBV, even in patients with active lymphoproliferative disease that was unresponsive to chemotherapy. These studies are registered at http://www.clinicaltrials.gov as NCT00032513 for CAEBV, NCT00062868 and NCT00058812 for EBV-specific T-cell studies, and NCT00578539 for the hematopoietic stem cell transplantation protocol.