Epstein-Barr virus and the elderly host

Skin Aging, Cellular Senescence and Natural Polyphenols

The skin, being the barrier organ of the body, is constitutively exposed to various stimuli impacting its morphology and function. Senescent cells have been found to accumulate with age and may contribute to age-related skin changes and pathologies. Natural polyphenols exert many health benefits, including ameliorative effects on skin aging. By affecting molecular pathways of senescence, polyphenols are able to prevent or delay the senescence formation and, consequently, avoid or ameliorate aging and age-associated pathologies of the skin. This review aims to provide an overview of the current state of knowledge in skin aging and cellular senescence, and to summarize the recent in vitro studies related to the anti-senescent mechanisms of natural polyphenols carried out on keratinocytes, melanocytes and fibroblasts. Aged skin in the context of the COVID-19 pandemic will be also discussed.

Morphologic Spectrum of Lymphadenopathy in Adult-onset Immunodeficiency (Anti-interferon-γ Autoantibodies)

Adult-onset immunodeficiency syndrome (AOIS) caused by anti-interferon-γ autoantibodies is an emerging disease. Affected patients present typically with systemic lymphadenopathy, fatigue, and fever. We studied 36 biopsy specimens, 31 lymph nodes, and 5 extranodal sites, of AOIS confirmed by serum autoantibody or QuantiFERON-TB Gold In-Tube assay. We describe the morphologic features and the results of ancillary studies, including special stains, immunohistochemistry, and molecular testing. The overall median age of these patients was 60.5 years (range, 41 to 83 y) with a male-to-female ratio of 20:16. All biopsy specimens showed nontuberculous mycobacterial infection, and most cases showed the following histologic features: capsular thickening with intranodal sclerosing fibrosis, irregularly distributed ill-formed granulomas or histiocytic aggregates with neutrophilic infiltration, interfollicular expansion by a polymorphic infiltrate with some Hodgkin-like cells that commonly effaces most of the nodal architecture and proliferation of high endothelial venules. In situ hybridization analysis for Epstein-Barr virus-encoded RNA showed scattered (<1%) to relatively more common (4% to 5%) positive cells in 29 of 30 (97%) tested specimens, reflecting immune dysregulation due to an interferon-γ defect. In the 31 lymph node specimens, 23 (74%) cases showed increased immunoglobulin G4-positive plasma cells (4 to 145/HPF; mean, 49.7/HPF) with focal areas of sclerosis reminiscent of immunoglobulin G4-related lymphadenopathy, 4 (13%) cases resembled, in part, nodular sclerosis Hodgkin lymphoma, and 9 (29%) cases mimicked T-cell lymphoma. Among 33 patients with available clinical follow-up, 20 (61%) showed persistent or refractory disease despite antimycobacterial therapy, and 1 patient died of the disease. We conclude that the presence of ill-defined granulomas, clusters of neutrophils adjacent to the histiocytic aggregates, and some Epstein-Barr virus-positive cells are features highly suggestive of AOIS. A high index of clinical suspicion and awareness of the morphologic features and differential diagnosis of AOIS are helpful for establishing the diagnosis.

Persistent infections, immune-senescence and Alzheimer's disease

Alzheimer's disease (AD) is a progressive neurodegenerative disorder and the most common cause of dementia. Classical hallmarks of AD such as amyloid deposition and neurofibrillary tangles do not completely explain AD pathogenesis. Recent investigations proposed Aβ peptide as an anti-microbial factor. Our previous works suggested that the concomitant presence of single nucleotide polymorphisms (SNPs) from AD genetic studies might impair antiviral defenses and increase the individual susceptibility to herpes virus infection. Viruses of herpes family by inducing frequent cycles of reactivation and latency constantly challenge the immune response and drive the accumulation of memory T cells. However, the immune system is not able to completely eradicate these viruses. The continuous antigen stimulation activates chronic inflammatory responses that may progressively induce neurodegenerative mechanisms in genetically susceptible elderly. The aim of this paper is to suggest new perspectives in clinical pathogenesis of AD with potential prevention and new medical treatment of the age associated cognitive decline.

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.

A longer stay for the kissing disease: epidemiology of bacterial tonsillitis and infectious mononucleosis over a 20-year period

Introduction:

Anecdotally, infectious mononucleosis is considered a more severe infection than bacterial tonsillitis, requiring a longer hospital stay. However, there is little in the literature comparing the epidemiology of the two conditions. This study aimed to compare the epidemiology of bacterial tonsillitis and infectious mononucleosis, in particular any differences in the length of in-patient stay.

Methodology:

The hospital in-patient enquiry system was used to analyse patients admitted with bacterial tonsillitis and infectious mononucleosis between 1990 and 2009 inclusive.

Results:

There was a total of 3435 cases over the 20 years: 3064 with bacterial tonsillitis and 371 with infectious mononucleosis. The mean length of stay was 3.22 days for bacterial tonsillitis and 4.37 days for infectious mononucleosis. The median length of stay for each condition was compared using the Mann–Whitney U non-parametric test, and a significant difference detected (p < 0.001).

Conclusion:

Patients with infectious mononucleosis have a significantly longer stay in hospital than those with bacterial tonsillitis.

Anorectal Epstein-Barr virus infection mimicking Hodgkin lymphoma in an immunocompetent man

Anorectal Hodgkin lymphoma (HL) is rare, mainly described in human immunodeficiency virus (HIV) patients with exceptional cases reported in immunocompetents. We report the case of a middle age HIV male, presenting with intestinal occlusion. Rectosigmoidoscopy showed multiple anorectal nodular and ulceronecrotic masses. The biopsy specimens revealed a diffuse polymorphous inflammatory infiltrate in the lamina propria, associated with CD30, CD20, CD3, CD15, and ALK1 scattered large Hodgkin and/or Reed Sternberg -like cells stained by LMP1 antibody and EBER. A diagnosis of EBV-associated atypical lymphoproliferative disease mimicking HL was made. These lesions remained stable for 2 years without treatment then disappeared leaving a mucosal scar. A later control biopsy showed a condylomatous lesion, without lymphoid lesion, suggesting a sexually acquired infection. Eight years later, the complete resolution of the lesion without any treatment is a strong argument against a malignant lymphoid process and raises doubts as to the reality of isolated anorectal HL in immunocompetent participants.

Viral Infections

Although influenza remains indisputably the most significant viral pathogen in adults, other viruses such as respiratory syncytial virus, parainfluenza viruses, and human metapneumovirus are now recognized as significant pathogens in older populations.

Oseltamivir and zanamivir are antiviral agents that are effective for the treatment and prophylaxis of influenza A and B. For treatment and for optimal effect, therapy should be initiated within 48 h of symptom onset.

Infection with hepatitis viruses may be more severe in older adults with more fulminate disease as observed with acute hepatitis A and a more rapid progression to cirrhosis with hepatitis C.

Outbreaks of viral gastroenteritis are common in long-term care facilities, and infection may lead to death due to dehydration and oliguria.

The incidence of herpes zoster increases with advancing age and carries with it a significant risk of post herpetic neuralgia. The use of antiviral medications and corticosteroids may reduce the incidence and severity of chronic pain.

Community-acquired viral pneumonia

Advanced age often is associated with functional and immunologic decline and chronic cardiopulmonary diseases that predispose to pneumonia when viral infection occurs. Influenza virus remains the primary viral pathogen in the elderly, although the impact of the other respiratory viruses remains to be defined. The clinical syndromes associated with respiratory viruses frequently are indistinguishable from one another or bacterial pathogens; often, viral illness in older adults exacerbates underlying conditions, complicating diagnosis. Antiviral therapy is available for influenza A and B; specific viral diagnosis, particularly with the use of rapid antigen detection, may be useful for clinical management. Treatment for other viruses primarily is supportive.

Acute Epstein-Barr virus infection in two elderly individuals

Most individuals acquire Epstein-Barr virus (EBV) infection in young age. Because of uncommon presentation and misdiagnosis, clinical manifestations are less well described in older age. We present two cases of elderly patients with predominant symptoms attributed to cold agglutinin haemolytic anaemia due to acute EBV infection without fever, lymphadenopathy, pharyngitis or splenomegaly. We conclude that misleading clinical manifestations are frequent in older individuals and may lead to inappropriate diagnostic invasive procedures.

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.

Analysis of Epstein-Barr virus (EBV) receptor CD21 on peripheral B lymphocytes of long-term EBV- adults

Primary infections with EBV are rarely observed after the age of 20. Some individuals even remain seronegative all their lives. Previously, a lack of EBV receptors on B cells of persistently EBV- adults was described as a reason for long-term EBV-seronegativity. The present study examined the CD21 receptor status of 20 repeatedly EBV- healthy adults and 32 EBV+ volunteers by means of flow cytometry. CD21 molecules on the surface of CD19+ B cells were quantified using anti-IgG-coated microbeads. The percentage of CD19+/CD21+ B lymphocytes was slightly lower in the peripheral blood of EBV- donors, but the CD21 antibody binding capacity on CD19+ B cells showed no significant differences between EBV- and EBV+ adults. In vitro studies showed an equally good EBV transformability of peripheral B lymphocytes of EBV- and EBV+ donors. Since HLA-DR was recently described as a co-receptor for EBV infection of B cells, we also determined HLA-DRB1 alleles in the EBV- group. We found a significant negative association of EBV-seronegativity with HLA-DR13 in comparison with 111 healthy blood donors. In summary, a biologically significant lack of the EBV receptor CD21 on peripheral B lymphocytes of persistently EBV- adults was excluded as a reason for long-term EBV-seronegativity.

Sex difference in the serostatus of adults to the Epstein-Barr virus

A total of 1047 adults, aged between 18 and 90 years, including blood donors and surgical patients of the Medical University of Lübeck in Germany, were screened for IgG antibodies to the Epstein-Barr Virus, either by standard indirect immunofluorescence or by a novel enzyme-linked immunosorbent assay (Enzygnost Anti-EBV/IgG, Behring, Marburg, Germany). There was a significant sex difference in the serostatus to the Epstein-Barr virus in adults. Male adults were more likely than females (p < 1%) to be EBV-seronegative. The same trend was seen in both a group of 713 blood donors and 334 surgical patients and when different test methods were used. However, this sex difference was not shown in the sera of 86 pediatric patients of the Medical University of Lübeck tested by indirect immunofluorescence for IgG antibodies to the Epstein-Barr virus. Furthermore, titers of IgG antibodies to Epstein-Barr virus specific antigens of female adults, obtained by the enzyme-linked immunosorbent assay (Enzygnost Anti-EBV/IgG), had significantly higher median values than male adults (p < 5%).

Fever of unknown origin in elderly patients

OBJECTIVE

To describe the spectrum of diseases that may give rise to fever of unknown origin in elderly patients and to delineate the diagnostic approach in these patients.

DESIGN

Subgroup analysis of a prospectively collected case series followed more than 2 years.

SETTING

General Internal Medicine Service based at University hospital, Leuven, Belgium.

PATIENTS

Forty-seven consecutive patients, older than 65 years, meeting the classic criteria of fever of unknown origin.

MEASUREMENTS

The final diagnosis established and the clinical value of diagnostic procedures.

RESULTS

Infections, tumors and multisystem diseases (encompassing rheumatic diseases, connective tissue disorders, vasculitis including temporal arteritis, polymyalgia rheumatica, and sarcoidosis) were found in 12 (25%), six (12%) and 15 patients (31%), respectively. Drug-related fever was the cause in three patients (6%), miscellaneous conditions were found in five patients (10%), and six patients (12%) remained undiagnosed. Microbiologic investigations were diagnostic in eight cases (16%), serologic tests yielded one diagnosis, immunologic investigations had a diagnostic value in four cases, standard X-rays yielded a diagnostic contribution in 10 cases, ultrasonography and computed tomography were diagnostic in 11 cases, Gallium scintigraphy had a diagnostic contribution in 17 cases, and biopsies yielded the final diagnosis in 18 cases.

CONCLUSIONS

Multisystem diseases emerged as the most frequent cause of fever of unknown origin in the elderly, and temporal arteritis was the most frequent specific diagnosis. Infections, particularly tuberculosis, remain an important group. The percentage of tumors was higher in our elderly patients than in the younger ones but still clearly lower than in other recent series of FUO in adults. The number of undiagnosed cases was significantly lower in elderly patients than in younger individuals (P < or = 0.01). The investigation of elderly patients with FUO should encompass routine temporal artery biopsy and extensive search for tuberculosis if the classic tests such as blood count, chemistry, urinalysis, cultures, chest X-rays, and abdominal ultrasonography do not yield any clue. Gallium scintigraphy should be considered as the next step and not as a last-resort procedure.

Primary cerebral lymphoma: a study of 47 cases probed for Epstein-Barr virus genome

AIMS

To determine the prevalence of Epstein-Barr virus genome in primary cerebral lymphomas occurring in the absence of immune suppression.

METHODS

Forty eight consecutive patients with lymphomas restricted to the central nervous system were identified, all of whom had had neurosurgical biopsies performed at the National Hospitals for Neurology and Neurosurgery, London. Only five patients had some form of underlying immune deficiency; 43 were apparently normal. The tumours were studied with immunohistochemical markers and by in situ hybridisation, using a biotinylated probe to the internal repeat region of Epstein-Barr virus.

RESULTS

All the lymphomas were B cell in origin. Tumours from the five immunosuppressed patients all showed hybridisation, as did two of the "spontaneous" tumours.

CONCLUSIONS

This is the largest series of cerebral lymphomas so far probed for Epstein-Barr virus genome: as more are examined, it is suggested that a small proportion of the tumours from immunocompetent patients will also contain the virus.

Viruses and the blood

Haematological syndromes attributed to viruses demonstrate geographical variations in incidence and great dependence on host factors. Severe haematological disease is the exception rather than the rule in dengue virus infection, and probably depends at least in part on the host immune response to the virus. The increased incidence of hepatitis-associated aplasia in east Asia may reflect distribution of an infectious agent, an environmental toxin, or genetic predisposition, but probably represents some combination of these factors. Agents with apparently universal distribution, such as parvovirus B19 and Epstein-Barr virus, are associated with bone marrow failure only in a very narrow range of hosts. These examples teach us that viral causes cannot automatically be excluded from the differential diagnosis of syndromes whose occurrence is rare or apparently sporadic. Further investigation of these syndromes should include more detailed characterization of host factors, particularly immunological characteristics, and possible infectious and toxic cofactors which are associated with morbidity.

Intrafamilial transmission of symptomatic Epstein-Barr virus infection among six adult members of one family

The contagiousness of Epstein-Barr virus (EBV) is low, and transmission of the disease from infected persons within a family or to other contacts is rare. We report of 6 adult members of 1 family who over a period of 6 months showed symptoms and laboratory findings compatible with acute EBV infection. Four patients examined for EBV specific antibodies had serology typical of primary EBV infection. Three of the 6 patients--1 of them serologically confirmed--were 60 years old or more, an age in which acute EBV infection is very rare.