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Srifuengfung G, Suppakitjanusant P, Chaisrimaneepan N. EBV-associated CNS infection in an immunocompetent adult: A case report and literature review. Clin Case Rep 2024; 12:e8568. [PMID: 38444918 PMCID: PMC10912102 DOI: 10.1002/ccr3.8568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 02/19/2024] [Accepted: 02/22/2024] [Indexed: 03/07/2024] Open
Abstract
EBV infections rarely cause CNS involvement. For young adult patients with suspected CNS infection, bacterial and other common viral infections should be excluded first and treated empirically until proven otherwise. Challenges in diagnosing EBV-associated CNS infection, emphasizing the role of CSF PCR in confirming the diagnosis.
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Affiliation(s)
- Gwyn Srifuengfung
- Department of NeurologyTexas Tech University Health Sciences CenterLubbockTexasUSA
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2
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Gomes D, André R, Oliveira C, Camões S, Silva CR, Mendes ML. Neurological Spectrum of Epstein-Barr Virus Infection: A Rare Clinical Case. Cureus 2024; 16:e53302. [PMID: 38435902 PMCID: PMC10906542 DOI: 10.7759/cureus.53302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2024] [Indexed: 03/05/2024] Open
Abstract
The Epstein-Barr virus (EBV) is a DNA virus that has been infecting humans since ancient times, capable of causing a wide range of pathologies and affecting approximately 90% of the population. A 61-year-old male with no significant medical history presented with a 5-day history of imbalance and difficulty walking. Neurological examination revealed specific findings, including absent reflexes, bilateral asynergy, and gait abnormalities. Contrasting with Guillain-Barré Syndrome, lumbar puncture suggested a central nervous system infection. Serological testing confirmed Epstein-Barr virus (EBV) positivity, and intravenous immunoglobulin led to significant improvement. Electromyogram results suggested inflammatory/ipnfectious polyradiculopathy. Repeat EBV serology, showing strongly positive IgG and negative IgM, confirmed the diagnosis of Polyradiculoneuropathy secondary to EBV. This case underscores the rare neurological complications of EBV and the importance of considering viral infections in such presentations.
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Affiliation(s)
- Dora Gomes
- Internal Medicine, Centro Hospitalar Tondela-Viseu, Viseu, PRT
| | - Rui André
- Neurology, Centro Hospitalar Tondela-Viseu, Viseu, PRT
| | | | - Sofia Camões
- Internal Medicine, Centro Hospitalar Tondela-Viseu, Viseu, PRT
| | | | - Miguel L Mendes
- Internal Medicine, Centro Hospitalar Tondela-Viseu, Viseu, PRT
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Pandey N, Chawala A, Kandhi S, Dhallu M, Chilimuri S. Epstein-Barr Virus Encephalitis Presenting As Acute Disseminated Encephalomyelitis: A Challenging Diagnostic Dilemma. Cureus 2023; 15:e48277. [PMID: 38058351 PMCID: PMC10695853 DOI: 10.7759/cureus.48277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2023] [Indexed: 12/08/2023] Open
Abstract
Epstein-Barr virus (EBV) is a common human herpesvirus associated with a wide range of clinical manifestations, primarily affecting the lymphoid system. However, central nervous system (CNS) involvement, although rare, can occur and present a diagnostic challenge, particularly in immunocompetent individuals. We present a case of a 28-year-old healthy female who initially presented with a flu-like illness, her symptoms rapidly progressed, leading to neurological deficits, and altered mental status. The patient's diagnostic workup, including a viral panel and various antibodies, failed to provide a conclusive diagnosis. However, lumbar puncture revealed significant abnormalities in cerebrospinal fluid (CSF), including elevated white blood cell count and elevated CSF protein. Neuroimaging studies demonstrated non-specific findings in subcortical white matter, pontomedullary junction, and extended spinal cord lesion. Tragically, the patient's condition rapidly worsened, with diffuse cerebral edema observed on repeat imaging, leading to the patient's demise even after conventional treatment. CSF analysis, performed at an apex lab, unexpectedly returned positive for EBV PCR, indicating a diagnosis of EBV encephalitis or EBV-associated acute disseminated encephalomyelitis (ADEM). This case highlights the challenges encountered in diagnosing EBV-associated CNS manifestations, especially in immunocompetent individuals, where these presentations are exceedingly rare. The atypical clinical course, negative initial laboratory investigations, and absence of specific radiological findings further complicated the diagnostic process. Early recognition and consideration of infectious etiologies, including EBV, in patients presenting with unexplained encephalitis or ADEM-like symptoms, are essential for timely intervention and optimal patient outcomes.
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Affiliation(s)
| | - Arpan Chawala
- Internal Medicine, BronxCare Health System, Bronx, USA
| | - Sameer Kandhi
- Internal Medicine, BronxCare Health System, Bronx, USA
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de Pádua Covas Lage LA, Araújo Soares V, Meneguin TD, Culler HF, Reichert CO, Jacomassi MD, Reis DGC, Zerbini MCN, de Oliveira Costa R, Rocha V, Pereira J. The role of whole-brain radiotherapy (WBRT) in primary central nervous system lymphoma: is it an alternative to ASCT for consolidation following HD-methotrexate based induction in low-income settings? Radiat Oncol 2022; 17:171. [PMID: 36273167 PMCID: PMC9588209 DOI: 10.1186/s13014-022-02142-y] [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: 07/28/2022] [Accepted: 10/06/2022] [Indexed: 11/10/2022] Open
Abstract
Background Primary central nervous system lymphoma (PCNSL) is a rare and aggressive malignancy. Although potentially curable, its prognosis remains dismal. Its treatment is based on high-doses of methotrexate (HD-MTX) and rituximab, followed by consolidation therapy with whole-brain radiotherapy (WBRT) or autologous stem cell transplantation (ASCT). Currently, there is no consensus about the best consolidation strategy, but better outcomes with ASCT are obtained with conditioning regimens based on thiotepa, a high-cost drug with restricted use in resource-constrained settings. Latin American data on clinical outcomes, prognostic factors, and therapeutic management in PCNSL are virtually unknown. Methods This is a retrospective, observational, and single-center study involving 47-Brazilian patients with PCNSL. We aim to assess outcomes, determine predictors of survival, and compare responses, as well as toxicities in patients consolidated with chemotherapy alone versus chemotherapy plus WBRT. Results The median age at diagnosis was 59 years (24–88 years), and 53.1% were male. LDH ≥ UVN occurred in 44.7%, ECOG ≥ 2 in 67.6%, and 34.1% had multifocal disease. Hemiparesis was the main clinical presentation, observed in 55.3%, 51.0% had intermediate-/high-risk IELSG prognostic score, and 57.6% had an ABC-like phenotype by IHC. With a median follow-up of 24.4 months, estimated 5-year OS and PFS were 45.5% and 36.4%, respectively. Among 40 patients treated with HD-MTX-based induction, estimated 2-year OS was 85.8% for those consolidated with WBRT plus HIDAC versus only 41.5% for those consolidated with HIDAC alone (p < 0.001). Hematologic and non-hematologic toxicities were not significant, and severe cognitive impairment occurred in only 6.3% (3/47) of cases, all of them treated with WBRT. Age < 60 years, Hb ≥ 120 g/L and WBRT consolidation were associated with increased OS, however, LDH ≥ UVN, hypoalbuminemia, ECOG ≥ 2, Karnofsky PS < 70 and intermediate-/high-risk Barcelona score were associated with decreased OS. Conclusion Combined consolidation therapy (CCT) based on WBRT plus HIDAC was associated with increased OS in PCNSL compared to isolated consolidation therapy (ICT) based on HIDAC alone. Here, severe late neurotoxicity was uncommon with this approach. These data suggest that WBRT may be an effective and safe alternative to ASCT for consolidation therapy in PCNSL, particularly in resource-constrained settings, where access to thiotepa for pre-ASCT conditioning is not universal.
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Affiliation(s)
- Luís Alberto de Pádua Covas Lage
- Department of Hematology, Hemotherapy and Cell Therapy, Faculty of Medicine, University of São Paulo (FM-USP), São Paulo, Brazil. .,Laboratory of Medical Investigation in Pathogenesis and Directed Therapy in Onco-Immuno-Hematology (LIM-31), University of São Paulo (USP), Cerqueira César, Avenue Dr. Enéas de Carvalho Aguiar, 155 - Ambulatory building - 1st. Floor, Room 61, São Paulo (SP), 05403-000, Brazil.
| | - Vinícius Araújo Soares
- Department of Hematology, Hemotherapy and Cell Therapy, Faculty of Medicine, University of São Paulo (FM-USP), São Paulo, Brazil
| | - Thales Dalessandro Meneguin
- Department of Hematology, Hemotherapy and Cell Therapy, Faculty of Medicine, University of São Paulo (FM-USP), São Paulo, Brazil
| | - Hebert Fabrício Culler
- Department of Hematology, Hemotherapy and Cell Therapy, Faculty of Medicine, University of São Paulo (FM-USP), São Paulo, Brazil.,Laboratory of Medical Investigation in Pathogenesis and Directed Therapy in Onco-Immuno-Hematology (LIM-31), University of São Paulo (USP), Cerqueira César, Avenue Dr. Enéas de Carvalho Aguiar, 155 - Ambulatory building - 1st. Floor, Room 61, São Paulo (SP), 05403-000, Brazil
| | - Cadiele Oliana Reichert
- Department of Hematology, Hemotherapy and Cell Therapy, Faculty of Medicine, University of São Paulo (FM-USP), São Paulo, Brazil.,Laboratory of Medical Investigation in Pathogenesis and Directed Therapy in Onco-Immuno-Hematology (LIM-31), University of São Paulo (USP), Cerqueira César, Avenue Dr. Enéas de Carvalho Aguiar, 155 - Ambulatory building - 1st. Floor, Room 61, São Paulo (SP), 05403-000, Brazil
| | - Mayara D'Auria Jacomassi
- Department of Hematology, Hemotherapy and Cell Therapy, Faculty of Medicine, University of São Paulo (FM-USP), São Paulo, Brazil
| | - Diego Gomes Cândido Reis
- Department of Hematology, Hemotherapy and Cell Therapy, Faculty of Medicine, University of São Paulo (FM-USP), São Paulo, Brazil
| | | | - Renata de Oliveira Costa
- Department of Hematology and Hemotherapy, Faculty of Medical Sciences Santos (FCMS), Centro Universitário Lusíadas (Unilus), Santos, Brazil
| | - Vanderson Rocha
- Department of Hematology, Hemotherapy and Cell Therapy, Faculty of Medicine, University of São Paulo (FM-USP), São Paulo, Brazil.,Laboratory of Medical Investigation in Pathogenesis and Directed Therapy in Onco-Immuno-Hematology (LIM-31), University of São Paulo (USP), Cerqueira César, Avenue Dr. Enéas de Carvalho Aguiar, 155 - Ambulatory building - 1st. Floor, Room 61, São Paulo (SP), 05403-000, Brazil.,Fundação Pró-Sangue, Blood Bank of São Paulo, São Paulo, Brazil.,Churchill Hospital, Oxford University, Oxford, UK
| | - Juliana Pereira
- Department of Hematology, Hemotherapy and Cell Therapy, Faculty of Medicine, University of São Paulo (FM-USP), São Paulo, Brazil.,Laboratory of Medical Investigation in Pathogenesis and Directed Therapy in Onco-Immuno-Hematology (LIM-31), University of São Paulo (USP), Cerqueira César, Avenue Dr. Enéas de Carvalho Aguiar, 155 - Ambulatory building - 1st. Floor, Room 61, São Paulo (SP), 05403-000, Brazil.,Hospital Alemão Osvaldo Cruz, São Paulo, Brazil
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Abstract
After establishing latent infection, some viruses can be reactivated by the alteration of host immunological conditions. First, we reviewed viruses that can cause neuronal damage by reactivation. Then we focused on the herpes simplex virus (HSV). The reactivation leads to neuronal damages through two possible mechanisms; "reactivation of a latent herpes virus" by which viruses can cause direct virus neurotoxicity, and "post-infectious immune inflammatory response" by which a focal reactivation of HSV leads to an inflammatory reaction. The former is radiologically characterized by cortical lesions, the latter is characterized by subcortical white matter lesions. We experienced a female, who underwent the right posterior quadrantectomy and then developed recurrent herpes encephalitis caused by herpes simplex reactivation, which pathologically demonstrated inflammation in the white matter, suggesting a post-infectious immune inflammatory response. The patient was successfully treated with immunosuppressants. The reactivation of the HSV is extremely rare in Japan. Neurologists should recognize this condition because this disorder will increase as epilepsy surgery gains more popularity.
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Affiliation(s)
- Tomoyo Shimada
- Department of Neurology, Juntendo University School of Medicine
| | - Taiji Tsunemi
- Department of Neurology, Juntendo University School of Medicine
- Epilepsy Center, Juntendo University School of Medicine
| | - Yasushi Iimura
- Department of Neurosurgery, Juntendo University School of Medicine
- Epilepsy Center, Juntendo University School of Medicine
| | - Hidenori Sugano
- Department of Neurosurgery, Juntendo University School of Medicine
- Epilepsy Center, Juntendo University School of Medicine
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6
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Nakamura J, Yanagida M, Saito K, Kamata Y, Nagashima T, Iwamoto M, Sato T, Sato K. Epstein-Barr Virus Encephalitis in a Patient with Rheumatoid Arthritis. Mod Rheumatol Case Rep 2021; 6:160-162. [PMID: 34971371 DOI: 10.1093/mrcr/rxab045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 10/20/2021] [Accepted: 10/29/2021] [Indexed: 11/14/2022]
Abstract
A 53-year-old woman with a 6-year history of rheumatoid arthritis (RA) presented with pharyngeal pain, fever, and altered mental status. The patient had been treated with methotrexate (MTX) 12 mg/week, baricitinib 4 mg/day, and tacrolimus 2 mg/day. Magnetic resonance imaging of the brain revealed diffuse high-intensity lesions in the cerebral white matter, basal ganglia, brainstem, and right cerebellar hemisphere. She was diagnosed with Epstein-Barr virus (EBV) encephalitis due to elevated levels of EBV-DNA in the cerebrospinal fluid and serum. Although MTX-associated lymphoproliferative disorders are well-known complications in patients with RA, EBV encephalitis requires careful attention for such patients undergoing treatment with multiple potent immunosuppressants.
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Affiliation(s)
- Jun Nakamura
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Mai Yanagida
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Keisuke Saito
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Yasuyuki Kamata
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Takao Nagashima
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Masahiro Iwamoto
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Takeo Sato
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Kojiro Sato
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Tochigi, Japan
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7
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Wang Y, Yang J, Wen Y. Lessons from Epstein-Barr virus DNA detection in cerebrospinal fluid as a diagnostic tool for EBV-induced central nervous system dysfunction among HIV-positive patients. Biomed Pharmacother 2021; 145:112392. [PMID: 34781140 DOI: 10.1016/j.biopha.2021.112392] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 10/21/2021] [Accepted: 11/02/2021] [Indexed: 12/24/2022] Open
Abstract
Polymerase chain reaction (PCR) analysis of Epstein-Barr virus (EBV) DNA in cerebrospinal fluid (CSF) remains vital for evaluating active EBV infection involving the central nervous system (CNS). CSF EBV DNA was often found in conjunction with other microbial infection affecting the CNS among patients infected with human immunodeficiency virus (HIV). Sometimes CSF EBV DNA is detectable in patients without neurological symptoms. This review focused on the clinical and laboratory features of CNS EBV infection among patients with HIV, and discussed various types of EBV-associated CNS infections, and predominant neoplasms involving CNS such as primary central nervous system lymphoma (PCNSL), CNS-non-Hodgkin's lymphoma, smooth muscle tumors and leiomyosarcomas, EBV encephalitis or myelitis, EBV meningitis and EBV coinfection with other causative agents were also included. Furthermore, the metagenomic next-generation sequencing technique with high sensitivity for the detection of pathogenic coinfection in the CSF were also reviewed. We concluded that CSF EBV-DNA detection with high sensitivity and specificity could be a useful diagnostic tool for CNS lymphoma among HIV patients; however, it is still unknown for other CNS diseases. We further summarized and conclude that positive CSF EBV-DNA detection combined with specific brain focal lesions could be a minimally invasive method to diagnose PCNSL. The occurrence of positive CSF EBV-DNA was influenced by PCR detection limit, PCR methods, immunocompromised status, the possible influence of anti-herpetic therapy and anti-HIV therapy, and the size and location of a tumor mass. Uniform PCR methods as vital diagnostic tools and optimal EBV-DNA load threshold need to be established.
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Affiliation(s)
- Yanli Wang
- Department of Infectious Diseases, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Jun Yang
- Neurology Department, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Ying Wen
- Department of Infectious Diseases, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China.
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8
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Wang Y, Dong Q, Chen YD, Hu WL, Zhao L. Intracranial Epstein-Barr virus infection appearing as an unusual case of meningitis in an immunocompetent woman: a case report. J Int Med Res 2020; 48:300060520903215. [PMID: 32046554 PMCID: PMC7111016 DOI: 10.1177/0300060520903215] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Yue Wang
- Department of Neurology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Qian Dong
- Department of Neurology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yu-Dan Chen
- Department of Neurology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Wen-Li Hu
- Department of Neurology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Li Zhao
- Department of Neurobiology and Center of Stroke, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China
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9
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Guess KE, Harada Y, Hill A, Ferry J, Veerapandiyan A. A Toddler With Bilateral Facial Weakness. Clin Pediatr (Phila) 2020; 59:529-531. [PMID: 31948285 DOI: 10.1177/0009922819901007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Katherine E Guess
- Arkansas Children's Hospital, Little Rock, AR, USA
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Yohei Harada
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Aubrey Hill
- Arkansas Children's Hospital, Little Rock, AR, USA
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jennifer Ferry
- Arkansas Children's Hospital, Little Rock, AR, USA
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Aravindhan Veerapandiyan
- Arkansas Children's Hospital, Little Rock, AR, USA
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
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10
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Abstract
PURPOSE OF REVIEW This article reviews the spectrum of neurologic disease associated with human herpesvirus infections. RECENT FINDINGS As more patients are becoming therapeutically immunosuppressed, human herpesvirus infections are increasingly common. Historically, infections with human herpesviruses were described as temporal lobe encephalitis caused by herpes simplex virus type 1 or type 2. More recently, however, additional pathogens, such as varicella-zoster virus, Epstein-Barr virus, cytomegalovirus, and human herpesvirus 6 have been identified to cause serious neurologic infections. As literature emerges, clinical presentations of herpesvirus infections have taken on many new forms, becoming heterogeneous and involving nearly every location along the neuraxis. Advanced diagnostic methods are now available for each specific pathogen in the herpesvirus family. As data emerge on viral resistance to conventional therapies, newer antiviral medications must be considered. SUMMARY Infections from the herpesvirus family can have devastating neurologic outcomes without prompt and appropriate treatment. Clinical recognition of symptoms and appropriate advanced testing are necessary to correctly identify the infectious etiology. Knowledge of secondary neurologic complications of disease is equally important to prevent additional morbidity and mortality. This article discusses infections of the central and peripheral nervous systems caused by herpes simplex virus type 1 and type 2, varicella-zoster virus, Epstein-Barr virus, cytomegalovirus, and human herpesvirus 6. The pathophysiology, epidemiology, clinical presentations of disease, diagnostic investigations, imaging characteristics, and treatment for each infectious etiology are discussed in detail.
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11
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Valencia-Sanchez C, Steenerson KK, Kelemen K, Orenstein R, Kusne S, Grill MF. Post-transplant primary central nervous system lymphoma after Epstein-Barr virus cerebellitis. J Neurovirol 2019; 25:280-283. [PMID: 30607891 DOI: 10.1007/s13365-018-0711-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 10/03/2018] [Accepted: 12/03/2018] [Indexed: 10/27/2022]
Abstract
Post-transplantation lymphoproliferative disorder (PTLD) is a complication of solid organ and hematopoietic stem cell transplantation. Cases with isolated central nervous system (CNS) disease are rare. Epstein-Barr virus (EBV) plays a causative role. We present a patient with EBV cerebellitis documented 5 months prior to development of primary CNS PTLD (PCNS-PTLD). This case report demonstrates progression from EBV CNS infection to lymphoproliferative disorder, highlighting the importance of serial clinical and imaging monitoring in transplant patients post-EBV CNS infection. PCNS-PTLD should always be considered in the differential diagnosis for transplant patients presenting with CNS symptoms, even in cases with no evidence of EBV viremia. Earlier diagnosis and appropriate treatment could result in improved outcomes.
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Affiliation(s)
| | - Kristen K Steenerson
- Otology & Neurotology Division, Stanford Ear Institute, 2452 Watson Ct Ste 1500, Palo Alto, CA, 94303, USA
| | - Katalin Kelemen
- Division of Laboratory Medicine and Pathology, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA
| | - Robert Orenstein
- Division of Infectious Diseases, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA
| | - Shimon Kusne
- Division of Infectious Diseases, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA
| | - Marie F Grill
- Division of Neurology, Mayo Clinic Arizona, 13400 East Shea Boulevard, Scottsdale, AZ, 85259, USA
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12
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Poorthuis MHF, Battjes S, Dorigo-Zetsma JW, de Kruijk JR. Primary Epstein-Barr virus infection in immunocompetent patients with acute transverse myelitis and a combination of polyradiculitis and anterior horn syndrome as neurological manifestations. BMJ Case Rep 2018; 2018:bcr-2018-225333. [PMID: 30158264 PMCID: PMC6119397 DOI: 10.1136/bcr-2018-225333] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2018] [Indexed: 11/04/2022] Open
Abstract
Neurological manifestations of a primary Epstein-Barr virus (EBV) infection are rare. We describe a case with acute transverse myelitis and another case with a combination of polyradiculitis and anterior horn syndrome as manifestations of a primary EBV infection.The first case is a 50-year-old immunocompetent male diagnosed with acute transverse myelitis, 2 weeks after he was clinically diagnosed with infectious mononucleosis. The second case is an 18-year-old immunocompetent male diagnosed with a combination of polyradiculitis and anterior horn syndrome while he had infectious mononucleosis. The first patient was treated with methylprednisolone. After 1 year, he was able to stop performing clean intermittent self-catheterisation. The second patient completely recovered within 6 weeks without treatment.Primary EBV infection should be considered in immunocompetent patients presenting with acute transverse myelitis and a combination of polyradiculitis and anterior horn syndrome. Antiviral treatment and steroids are controversial, and the prognosis of neurological sequelae is largely unknown.
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13
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Koeller KK, Shih RY. Viral and Prion Infections of the Central Nervous System: Radiologic-Pathologic Correlation: From the Radiologic Pathology Archives. Radiographics 2017; 37:199-233. [PMID: 28076019 DOI: 10.1148/rg.2017160149] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Viral infections of the central nervous system (CNS) range in clinical severity, with the most severe proving fatal within a matter of days. Some of the more than 100 different viruses known to affect the brain and spinal cord are neurotropic with a predilection for producing CNS infection. The host response to viral infection of the CNS is responsible for the pathophysiology and imaging findings seen in affected patients. Viral CNS infections can take the form of meningitis, encephalitis, encephalomyelitis, or, when involving the spinal cord and nerve roots, encephalomyeloradiculitis. In 1982, an infectious particle termed a prion that lacked nucleic acid and therefore was not a virus was reported to produce the fatal neurodegenerative disease Creutzfeldt-Jakob disease and related disorders. These prion diseases produce characteristic neuroimaging findings that are distinct from those seen in most viral infections. The clinical and imaging findings associated with viral CNS infection are often nonspecific, with microbiologic analysis of cerebrospinal fluid the most useful single test allowing for diagnosis of a specific viral infection. This review details the spectrum of viral CNS infections and uses case material from the archives of the American Institute for Radiologic Pathology, with a focus on the specific clinical characteristics and magnetic resonance imaging features seen in these infections. Where possible, the imaging features that allow distinction of these infections from other CNS inflammatory conditions are highlighted.
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Affiliation(s)
- Kelly K Koeller
- From the Department of Neuroradiology, American Institute for Radiologic Pathology, Silver Spring, Md (K.K.K., R.Y.S.); Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (K.K.K.); Uniformed Services University of the Health Sciences, Bethesda, Md (R.Y.S.); and Department of Radiology, Walter Reed National Military Medical Center, Bethesda, Md (R.Y.S.)
| | - Robert Y Shih
- From the Department of Neuroradiology, American Institute for Radiologic Pathology, Silver Spring, Md (K.K.K., R.Y.S.); Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (K.K.K.); Uniformed Services University of the Health Sciences, Bethesda, Md (R.Y.S.); and Department of Radiology, Walter Reed National Military Medical Center, Bethesda, Md (R.Y.S.)
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14
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Paralysie faciale bilatérale au cours d’une infection à virus d’Epstein–Barr. Arch Pediatr 2017; 24:564-567. [DOI: 10.1016/j.arcped.2017.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 11/21/2016] [Accepted: 03/20/2017] [Indexed: 11/18/2022]
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15
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Kazamel M, Klein CJ, Benarroch EE, Patnaik MM, Tracy JA. Subacute demyelinating polyradiculoneuropathy complicating Epstein-Barr virus infection in GATA2 haploinsufficiency. Muscle Nerve 2017; 57:150-156. [PMID: 28093780 DOI: 10.1002/mus.25581] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2017] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Autosomal dominant haploinsufficiency of GATA2 causes monocytopenia and natural killer cell lymphopenia, resulting in predisposition to mycobacterial, fungal, and viral infections. METHODS Herein we report on the clinical, serologic, electrophysiologic, and pathologic evaluations of a 29-year-old woman with GATA2 haploinsufficiency and active Epstein-Barr virus (EBV) infection complicated by subacute painful neuropathy. RESULTS Nerve conduction and electromyography studies showed predominantly demyelinating sensorimotor polyradiculoneuropathy. Lumbar spine MRI showed thickening and enhancement of the cauda equina nerve roots. Serum and cerebrospinal fluid anti-IgG and IgM EBV capsid and nucleic acid antibodies were positive. Sural nerve biopsy showed microvasculitis and an increased frequency of fibers with segmental demyelination. Intravenous immunoglobulin and steroids improved the patient's neuropathy. CONCLUSION GATA2 mutation-related immunodeficiency may predispose to EBV-associated subacute demyelinating polyradiculoneuropathy by both viral susceptibility and immune dysregulation. In patients who present in this manner, immunodeficiency syndromes should be considered when lymphomatous infiltration is excluded. Immunotherapy can be helpful. Muscle Nerve 57: 150-156, 2018.
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Affiliation(s)
- Mohamed Kazamel
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, 55905, USA
| | - Christopher J Klein
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, 55905, USA
| | - Eduardo E Benarroch
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, 55905, USA
| | - Mrinal M Patnaik
- Department of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jennifer A Tracy
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, 55905, USA
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Kano K, Katayama T, Takeguchi S, Asanome A, Takahashi K, Saito T, Sawada J, Saito M, Anei R, Kamada K, Miyokawa N, Nishihara H, Hasebe N. Biopsy-proven case of Epstein-Barr virus (EBV)-associated vasculitis of the central nervous system. Neuropathology 2016; 37:259-264. [PMID: 28004435 DOI: 10.1111/neup.12356] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 10/20/2016] [Accepted: 10/21/2016] [Indexed: 01/29/2023]
Abstract
A 75-year-old woman was admitted to our hospital with rapidly deteriorating consciousness disturbance. She had a 7-year history of rheumatoid arthritis (RA), which had been treated with methotrexate (MTX) and prednisolone. Brain T2-weighted MRI showed diffuse high-intensity lesions in the cerebral subcortical and deep white matter, bilateral basal ganglia and thalamus. A cerebrospinal fluid examination revealed elevated protein levels and positive Epstein-Barr virus (EBV) DNA. Human immunodeficiency virus was negative. Brain biopsy showed perivascular lymphocytic infiltration in the parenchyma and meninx with EBV-encoded small RNA (EBER). Since this case did not fulfill the criteria for chronic active EBV infection (CAEBV), she was diagnosed with Epstein-Barr virus (EBV)-associated vasculitis of the central nervous system. High-dose methylprednisolone, acyclovir, ganciclovir and foscarnet were not effective. Although EBV is a causative agent of infectious mononucleosis (IM), lymphomas and nasopharyngeal carcinomas, vasculitic pathology of the central nervous system with EBV reactivation in the elderly is rare. Immunosuppressive drugs such as steroids and MTX are widely used to treat autoimmune disorders, but may exacerbate the reactivation of EBV. This is the first case of biopsy-proven EBV-positive/HIV-negative vasculitis during the treatment of RA with MTX and steroids. This case indicates that EBV-associated vasculitis needs to be considered as a differential diagnosis of CNS vasculitis.
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Affiliation(s)
- Kohei Kano
- Division of Neurology, First Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Takayuki Katayama
- Division of Neurology, First Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Shiori Takeguchi
- Division of Neurology, First Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Asuka Asanome
- Division of Neurology, First Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Kae Takahashi
- Division of Neurology, First Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Tsukasa Saito
- Division of Neurology, First Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Jun Sawada
- Division of Neurology, First Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Masato Saito
- Department of Neurosurgery, Asahikawa Medical University, Asahikawa, Japan
| | - Ryogo Anei
- Department of Neurosurgery, Asahikawa Medical University, Asahikawa, Japan
| | - Kyousuke Kamada
- Department of Neurosurgery, Asahikawa Medical University, Asahikawa, Japan
| | - Naoyuki Miyokawa
- Department of Clinical Pathology, Asahikawa Medical University, Asahikawa, Japan
| | - Hiroshi Nishihara
- Department of Translational Pathology, Hokkaido University School of Medicine, Sapporo, Japan
| | - Naoyuki Hasebe
- Division of Neurology, First Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan
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Shen Y, Tu J, Liu H, Dai T, Wu W. Epstein-Barr virus infection involving bilateral middle cerebellar peduncles in an old woman: a case report. Neurol Sci 2015; 37:479-81. [DOI: 10.1007/s10072-015-2431-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 11/26/2015] [Indexed: 11/27/2022]
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18
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Epstein-barr virus encephalitis in infancy. W INDIAN MED J 2014; 63:206-7. [PMID: 25303265 DOI: 10.7727/wimj.2014.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 02/13/2014] [Indexed: 11/18/2022]
Abstract
Epstein-Barr virus (EBV) infection causes a wide spectrum of illness in humans including subclinical infection, infectious mononucleosis, and is associated with some malignancies. This report presents the clinical findings of an unusual case of EBV encephalitis in a 10-month old infant who presented with a febrile infection and seizures. The clinical manifestations, serologic study and a dynamic change of EBV DNA in cerebrospinal fluid with spontaneous recovery confirmed the diagnosis of EBV infection of the nervous system.
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20
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Mahan M, Karl M, Gordon S. Neuroimaging of viral infections of the central nervous system. HANDBOOK OF CLINICAL NEUROLOGY 2014; 123:149-73. [PMID: 25015484 DOI: 10.1016/b978-0-444-53488-0.00006-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Mathur Mahan
- Department of Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Muchantef Karl
- Department of Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Sze Gordon
- Department of Radiology, Yale University School of Medicine, New Haven, CT, USA.
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Abstract
Invasion of the central nervous system (CNS) by viral agents typically produces a meningoencephalitis in which either meningitis or encephalitis may predominate. Viruses may also infect cranial or spinal blood vessels to produce ischemic injury. Viral and other infections may also elicit a host immune response which is cross-reactive with components of the neural tissue, resulting in encephalomyelitis, transverse myelitis, injury to peripheral nerves, or optic neuritis. This chapter discusses the pathogenesis of CNS viral infections and reviews clinical features of these disorders, major agents responsible in immunocompromised and immunocompetent individuals, and treatment. Prion diseases and postinfectious viral CNS syndromes including postinfectious encephalomyelitis, acute hemorrhagic leukoencephalitis, cerebellar ataxia, and transverse myelitis are also discussed.
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Hottenrott T, Rauer S, Bäuerle J. Primary Epstein-Barr virus infection with polyradiculitis: a case report. BMC Neurol 2013; 13:96. [PMID: 23879452 PMCID: PMC3724718 DOI: 10.1186/1471-2377-13-96] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2013] [Accepted: 07/23/2013] [Indexed: 12/03/2022] Open
Abstract
Background Nervous system complications of primary Epstein-Barr virus (EBV) infection in adults are rare, but may occur with encephalitis, meningitis, myelitis, cranial and peripheral neuropathies, or radiculitis. Case presentation We describe an immune competent adult with a primary EBV infection complicated by lumbosacral polyradiculitis with pure radicular pain. Prior to the onset of radicular pain the 35-year-old woman had been suffering from infectious mononucleosis misdiagnosed for streptococcal tonsillitis. The diagnosis of primary EBV infection associated polyradiculitis was proven by serology and PCR in serum and CSF. Under initially started empiric therapy with intravenous acyclovir and analgesics the patient completely recovered within a few days. Conclusion This case report highlights that EBV should be taken into consideration in the diagnostic work up of radicular pain syndromes, even in immune competent adults. There is no approved causal therapy for EBV infections. In accordance with our case, observations based on a few patients with EBV and nervous system involvement suggest, that acyclovir treatment might be associated a with better course. However, prospective randomized controlled trials addressing the question of the effectiveness of acyclovir in patients with primary EBV infection and neurological complications are lacking.
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Affiliation(s)
- Tilmann Hottenrott
- Department of Neurology, University Hospital Freiburg, Breisacher Str. 64, 79106 Freiburg, Germany
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24
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Abstract
BACKGROUND Antiganglioside antibodies are found in various neurological disorders that constitute a continuum from peripheral neuropathy to encephalitis. However, nystagmus has rarely been described in patients with ataxia associated with antiganglioside antibodies. METHODS From January 2008 to July 2009, we identified 3 patients with acute ataxia and nystagmus in 2 University Hospitals of Korea, who were found to have anti-GD1b, anti-GM1, or anti-GQ1b antibodies. RESULTS In addition to acute ataxia, all 3 patients showed various combinations of nystagmus, which included central positional nystagmus (n = 3), vertical nystagmus (n = 1), and periodic alternating nystagmus (n = 1). The spontaneous and positional nystagmus were mostly detectable only with the elimination of fixation and magnification of the eyes using video goggles. Two patients also exhibited gaze-evoked nystagmus that was noticeable without the aid of video goggles. Patients had serum IgG antibodies to GD1b, GM1, or GQ1b. Cerebrospinal fluid examination, nerve conduction studies, and brain MRI were normal. In all patients, the symptoms and signs resolved over 3-12 months. CONCLUSIONS Various forms of nystagmus with acute ataxia may be a sole or predominant manifestation of disorders related to antiganglioside antibodies. The nystagmus indicates a central pathology involving the cerebellum or brainstem in this antibody-associated disorder. Antiganglioside antibodies should be measured in patients with nystagmus and acute ataxia of undetermined etiology.
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Carra-Dallière C, Mernes R, Juntas-Morales R. [Isolated palsy of the hypoglossal nerve complicating infectious mononucleosis]. Rev Neurol (Paris) 2011; 167:635-7. [PMID: 21513962 DOI: 10.1016/j.neurol.2010.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Revised: 11/11/2010] [Accepted: 11/22/2010] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Neurological complications of infectious mononucleosis are rare. Various disorders have been described: meningitis, encephalitis, peripheral neuropathy. Isolated cranial nerve palsy has rarely been reported. OBSERVATION A 16-year-old man was admitted for isolated and unilateral hypoglossal nerve palsy, four weeks after infectious mononucleosis. Cerebral MRI, cerebrospinal fluid study and electromyography were normal. IgM anti-VCA were positive. Two months later, without treatment, the tongue had almost fully recovered. CONCLUSION To the best of our knowledge, only seven cases of isolated palsy of the hypoglossal nerve complicating infectious mononucleosis have been previously reported.
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Affiliation(s)
- C Carra-Dallière
- Service de neurologie, hôpital Gui-de-Chauliac, CHU de Montpellier, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France.
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Kittan N, Beier F, Kurz K, Niller H, Egger L, Jilg W, Andreesen R, Holler E, Hildebrandt G. Isolated cerebral manifestation of Epstein-Barr virus-associated post-transplant lymphoproliferative disorder after allogeneic hematopoietic stem cell transplantation: a case of clinical and diagnostic challenges. Transpl Infect Dis 2011; 13:524-30. [DOI: 10.1111/j.1399-3062.2011.00621.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Khalil M, Enzinger C, Wallner-Blazek M, Scarpatetti M, Barth A, Horn S, Reiter G. Epstein-Barr virus encephalitis presenting with a tumor-like lesion in an immunosuppressed transplant recipient. J Neurovirol 2010; 14:574-8. [PMID: 18991070 DOI: 10.1080/13550280802345715] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Epstein-Barr virus (EBV) associated central nervous system (CNS) infection is a rare disease. We report an atypical manifestation of EBV encephalitis initially presenting with a tumor-like lesion of the optic tract in an immunocompromised patient 8 years after a combined kidney and pancreas transplantation had been performed. Polymerase chain reaction (PCR) in the cerebrospinal fluid (CSF) and antibody testing confirmed the diagnosis of EBV encephalitis, most likely as a consequence of a reactivated persistent EBV infection. After cessation of the immunosuppressive therapy and induction of treatment with ganciclovir, clinical and magnetic resonance imaging (MRI) findings rapidly improved.
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Affiliation(s)
- Michael Khalil
- Department of Neurology, Medical University Graz, Graz, Austria. Medical University Graz, Graz, Austria
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28
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Vaglio A, Manenti L, Mancini C, Chierici E, Cobelli R, Bacci F, Palmisano A, Buzio C, Bignardi L, Maggiore U. EBV-associated leukoencephalopathy with late onset of central nervous system lymphoma in a kidney transplant recipient. Am J Transplant 2010; 10:947-951. [PMID: 20420644 DOI: 10.1111/j.1600-6143.2009.02999.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Central nervous system (CNS) lymphoma is a rare posttransplant lymphoproliferative disorder (PTLD), which usually has a poor outcome. To date, no specific conditions predisposing to this complication have been identified. We here describe the case of a renal transplant patient who was initially diagnosed as having Epstein-Barr virus (EBV)-associated leukoencephalopathy and ultimately developed EBV-positive CNS lymphoma. The patient was a young lady who, 2 years after transplantation, presented with focal neurological and electroencephalographic abnormalities and diffuse white matter lesions on brain magnetic resonance imaging. EBV-DNA was detected in the cerebrospinal fluid (CSF) by polymerase chain reaction. After acyclovir therapy and immunosuppressive drug tapering, the symptoms and electroencephalographic abnormalities subsided, and EBV-DNA disappeared from the CSF. Ten years later, a bulky cerebral mass was found. After excision, a diagnosis of EBV-positive, Hodgkin-like monomorphic B-cell PTLD was made. This case illustrates the potential pathophysiological relationships between EBV infection, leukoencephalopathy and CNS lymphoma; although a long time elapsed from the initial neurological illness to CNS lymphoma, a link between these two conditions cannot be excluded. Therefore, a careful long-term follow-up of EBV-related encephalopathy is advisable.
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Affiliation(s)
- A Vaglio
- Department of Clinical Medicine, Nephrology and Health Sciences, University of Parma, Parma, Italy
| | - L Manenti
- Division of Nephrology, Arcispedale S. Maria Nuova, Reggio Emilia, Italy
| | - C Mancini
- Department of Pathology and Laboratory Medicine, Section of Pathology, University of Parma, Italy
| | - E Chierici
- Division of Neurology, Vaio Hospital, Fidenza, Italy
| | - R Cobelli
- Department of Radiology, University of Parma, Parma, Italy
| | - F Bacci
- Institute of Hematology and Clinical Oncology 'L. and A. Seràgnoli', S.Orsola-Malpighi Hospital, Bologna, Italy
| | - A Palmisano
- Department of Clinical Medicine, Nephrology and Health Sciences, University of Parma, Parma, Italy
| | - C Buzio
- Department of Clinical Medicine, Nephrology and Health Sciences, University of Parma, Parma, Italy
| | - L Bignardi
- Department of Clinical Medicine, Nephrology and Health Sciences, University of Parma, Parma, Italy
| | - U Maggiore
- Department of Clinical Medicine, Nephrology and Health Sciences, University of Parma, Parma, Italy
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Fatal Epstein-Barr virus encephalitis in a 12-year-old child: an underappreciated neurological complication? Nat Rev Neurol 2009; 5:171-4. [PMID: 19262593 DOI: 10.1038/ncpneuro1043] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2008] [Accepted: 01/07/2009] [Indexed: 11/08/2022]
Abstract
BACKGROUND A 12-year-old boy presented to a community hospital with fever, malaise and fatigue. A polymerase chain reaction test of the cerebrospinal fluid was positive for Epstein-Barr virus. Despite intensive care treatment and antiviral drugs, the patient died 1 month after his initial presentation. INVESTIGATIONS Physical examination, polymerase chain reaction analysis of the cerebrospinal fluid, brain MRI, immunohistochemistry and molecular biological investigations of postmortem brain samples. DIAGNOSIS Epstein-Barr Virus encephalitis. MANAGEMENT Aciclovir, intensive care treatment with intubation, sedation, antiepileptic drugs.
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30
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Grillo E, da Silva RJM, Barbato Filho JH. Epstein-Barr virus acute encephalomyelitis in a 13-year-old boy. Eur J Paediatr Neurol 2008; 12:417-20. [PMID: 18054506 DOI: 10.1016/j.ejpn.2007.10.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2007] [Revised: 10/10/2007] [Accepted: 10/30/2007] [Indexed: 11/15/2022]
Abstract
The association of acute myelopathy and encephalopathy is reported in a 13-year-old boy. Signs and symptoms of infectious mononucleosis, presence of heterophile antibodies, anticapsid antibodies and Epstein-Barr virus DNA detected in cerebrospinal fluid, disclosed a primary or reactivated infection by Epstein-Barr virus. Outcome was rapid and benign with complete clinical recovery in 1 month, after pulse therapy with methylprednisolone. Epstein-Barr virus is a known agent related to acute disseminated encephalomyelitis, by immune mediated mechanisms. However, in this case, cortical involvement in magnetic resonance imaging, short time between infectious mononucleosis and central nervous system manifestations, and the presence of viral DNA in cerebrospinal fluid, raised the possibility of a direct action of the virus in central nervous system. Acute myelopathy associated to Epstein-Barr virus encephalitis has been rarely reported in children.
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Affiliation(s)
- Eugênio Grillo
- Department of Neurology, Joana de Gusmão Children's Hospital, Florianópolis, SC, Brazil
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31
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Bulakbasi N, Kocaoglu M. Central nervous system infections of herpesvirus family. Neuroimaging Clin N Am 2008; 18:53-84; viii. [PMID: 18319155 DOI: 10.1016/j.nic.2007.12.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Herpesviruses are one of the most common groups of pathogens causing central nervous system infections in humans. They mostly cause encephalitis, meningitis, or myelitis in immunocompetent and immunocompromised patients. Children, adults, and the elderly can all be affected. Although contrast-enhanced CT is more widely used for diagnosis, contrast-enhanced MR imaging combined with diffusion-weighted imaging is superior to CT in the detection of early changes and the real extent of the disease, and in assessing prognosis and monitoring response to antiviral treatment. More sophisticated techniques, such as MR spectroscopy and perfusion imaging, can aid in the differential diagnosis of herpesvirus infections from other tumoral, demyelinating, and ischemic processes.
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Affiliation(s)
- Nail Bulakbasi
- Department of Radiology, Gulhane Military Medical Academy and School of Medicine, Etlik, Ankara 06018, Turkey.
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32
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An JY, Yoon B, Kim JS, Song IU, Lee KS, Kim YI. Guillain-Barré syndrome with optic neuritis and a focal lesion in the central white matter following Epstein-Barr virus infection. Intern Med 2008; 47:1539-42. [PMID: 18758131 DOI: 10.2169/internalmedicine.47.1224] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We report a case of Guillain-Barré syndrome (GBS) accompanied by optic neuritis and a central white matter lesion subsequent to Epstein-Barr virus (EBV) infection. A 49-year-old man presented with visual disturbance and hemiparesis one week after developing cold-like symptoms. T2- and diffusion-weighted brain MRI showed a high-signal intensity lesion in the left internal capsule. The patient's visual acuity improved during steroid pulse therapy, but his hemiparesis progressed to quadriparesis. Nerve conduction studies showed demyelination predominant in the distal nerve terminals, consistent with GBS. Serological testing suggested EBV reinfection. Our findings indicate that EBV-related central and peripheral demyelination can occur simultaneously and can be successfully treated with a combination of corticosteroids and immunoglobulin.
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Affiliation(s)
- Jae Young An
- Department of Neurology, College of Medicine, The Catholic University of Korea
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33
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Erben Y, Gonzalez Hofmann C, Steinmetz H, Ziemann U. [Isolated neuritis of the oculomotor nerve in infectious mononucleosis]. DER NERVENARZT 2007; 79:462-4. [PMID: 18058080 DOI: 10.1007/s00115-007-2385-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
A 19-year-old immune-competent patient developed right-sided headache and, subsequently, subacute diplopia. On clinical examination he had incomplete right oculomotor palsy. Cranial MRI showed pathologic contrast enhancement of the right oculomotor nerve at its exit point from the mesencephalon, and the CSF displayed slight pleocytosis. The following relevant differential diagnoses were not supported by additional examinations: neurosarcoidosis, Lyme neuroborreliosis, neurosyphilis, tuberculous meningitis, viral meningitis (HIV, VZV, CMV), CNS lymphoma, vasculitis associated with rheumatic disease, Tolosa-Hunt syndrome, and diabetic neuropathy. However, on the basis of blood lymphocytosis, positive heterophile antibody test (Paul-Bunnell test), the presence of IgM antibodies against Epstein-Barr virus capsid antigen, and elevated transaminases, infectious mononucleosis was diagnosed. Isolated neuritis of the oculomotor nerve is a rare parainfectious manifestation of infectious mononucleosis.
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Affiliation(s)
- Y Erben
- Klinik für Neurologie, Johann-Wolfgang-Goethe-Universität, Schleusenweg 2-16, 60528, Franfurt am Main, Deutschland
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Phowthongkum P, Phantumchinda K, Jutivorakool K, Suankratay C. Basal ganglia and brainstem encephalitis, optic neuritis, and radiculomyelitis in Epstein–Barr virus infection. J Infect 2007; 54:e141-4. [PMID: 17055062 DOI: 10.1016/j.jinf.2006.09.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2006] [Revised: 08/19/2006] [Accepted: 09/09/2006] [Indexed: 11/21/2022]
Abstract
The neurologic complications of Epstein-Barr virus (EBV) infection are rare. We describe a healthy adult with acute EBV meningoencephalomyeloradiculitis. The clinical manifestations, a serologic study, and a dynamic change of EBV DNA in the cerebrospinal fluid with spontaneous recovery confirmed the diagnosis of EBV infection of the nervous system. In addition, we provide other clinical clues for suspicion of EBV infection in patients with encephalitis. These include bilateral basal ganglia and brainstem lesions on magnetic resonance imaging, optic neuritis, or involvement of all levels of the nervous system.
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Affiliation(s)
- Prasit Phowthongkum
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine, Phrama IV, Chulalongkorn University, Bangkok 10330, Thailand
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35
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Diedler J, Rieger S, Koch A, Parthé-Peterhans S, Schwaninger M. Bilateral facial palsy: Epstein–Barr virus, not Lyme disease. Eur J Neurol 2006; 13:1029-30. [PMID: 16930373 DOI: 10.1111/j.1468-1331.2006.01434.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Bilateral facial palsy is frequently linked with lyme disease. We report a patient with bilateral facial palsy due to Epstein-Barr virus infection but with Borrelia burgdorferi IgM in serum caused by polyclonal B-lymphocyte stimulation.
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Affiliation(s)
- J Diedler
- Department of Neurology, Institute of Hygiene, University of Heidelberg, Germany.
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36
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Kleinschmidt-DeMasters BK, Gilden DH. The expanding spectrum of herpesvirus infections of the nervous system. Brain Pathol 2006; 11:440-51. [PMID: 11556690 PMCID: PMC8098551 DOI: 10.1111/j.1750-3639.2001.tb00413.x] [Citation(s) in RCA: 121] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Herpesviruses cause various acute, subacute, and chronic disorders of the central (CNS) and peripheral (PNS) nervous systems in adults and children. Both immunocompetent and immunocompromised individuals may be affected. Zoster (shingles), a result of reactivation of varicella zoster virus (VZV), is the most frequent neurologic complication. Other neurological complications include encephalitis produced by type I herpes simplex virus (HSV-1), and less frequently HSV-2, as well as by VZV and cytomegalovirus (CMV). Acute meningitis is seen with VZV and HSV-2, and benign recurrent meningitis with HSV-2. Combinations of meningitis/ encephalitis and myelitis/radiculitis are associated with Epstein Barr Virus (EBV); myelitis with VZV, CMV, EBV, and HSV-2; and ventriculitis/encephalitis with VZV and CMV. Brainstem encephalitis due to HSV and VZV, and polymyeloradiculitis due to CMV are well documented. HHV-6 produces childhood exanthem subitum (roseola) and febrile convulsions. Immunocompetent and immunocompromised hosts manifest different incidences and patterns of herpesvirus infections. For example, stroke due to VZV-mediated large vessel disease (herpes zoster ophthalmicus) occurs predominantly in immunocompetent hosts, while small vessel disease (leukoencephalitis) and ventriculitis develop almost exclusively in immunocompromised patients. EBV-associated primary CNS lymphomas also are restricted to immunosuppressed individuals. Recent large CSF PCR studies have shown that VZV, EBV, and CMV more frequently produce meningitis, encephalitis, or encephalopathy in immunocompetent hosts than was formerly realized. We review herpesvirus infections of the nervous system and illustrate the expanding spectrum of disease by including examples of a 75-year-old male on steroid treatment for chronic lung disease with fatal HSV-2 meningitis and an 81-year-old male with myasthenia gravis, long-term azathioprine use, and an EBV-associated primary CNS lymphoma.
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MESH Headings
- Adolescent
- Adult
- Aged
- Child
- Child, Preschool
- Cytomegalovirus/genetics
- Cytomegalovirus/immunology
- Cytomegalovirus/pathogenicity
- Female
- Herpesviridae Infections/classification
- Herpesviridae Infections/pathology
- Herpesviridae Infections/physiopathology
- Herpesvirus 1, Human/genetics
- Herpesvirus 1, Human/immunology
- Herpesvirus 1, Human/pathogenicity
- Herpesvirus 2, Human/genetics
- Herpesvirus 2, Human/immunology
- Herpesvirus 2, Human/pathogenicity
- Herpesvirus 3, Human/genetics
- Herpesvirus 3, Human/immunology
- Herpesvirus 3, Human/pathogenicity
- Herpesvirus 4, Human/genetics
- Herpesvirus 4, Human/immunology
- Herpesvirus 4, Human/pathogenicity
- Herpesvirus 6, Human/genetics
- Herpesvirus 6, Human/immunology
- Herpesvirus 6, Human/pathogenicity
- Humans
- Infant
- Infant, Newborn
- Male
- Middle Aged
- Nervous System/pathology
- Nervous System/physiopathology
- Nervous System/virology
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Roselli F, Russo I, Fraddosio A, Aniello MS, De Mari M, Lamberti P, Livrea P, Defazio G. Reversible Parkinsonian syndrome associated with anti-neuronal antibodies in acute EBV encephalitis: a case report. Parkinsonism Relat Disord 2006; 12:257-60. [PMID: 16459123 DOI: 10.1016/j.parkreldis.2005.11.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2005] [Revised: 09/20/2005] [Accepted: 11/07/2005] [Indexed: 11/25/2022]
Abstract
We report a case of subacute-onset isolated parkinsonian syndrome in a 16 years old patient. Epstein-Barr infection was diagnosed according to serologic evidences. Parkinson-like syndrome completely recovered after 60 days. Autoantibodies reacting against a 130 Kda antigens expressed in human neuroblastoma cell line were detected. Pathogenesis and differential diagnosis are briefly discussed. EBV testing could be worthwhile in juvenile, acute-onset, parkinsonism.
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Affiliation(s)
- Francesco Roselli
- Department of Neurologic and Psychiatric Sciences-University of Bari, p.za Giulio Cesare, 2 70124 Bari (BA), Italy.
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Takahashi K, Kunishige M, Shinohara M, Kubo K, Inoue H, Yoshino H, Asano A, Honda S, Matsumoto T, Mitsui T. Guillain-Barré syndrome and hemophagocytic lymphohistiocytosis in a patient with severe chronic active Epstein-Barr virus infection syndrome. Clin Neurol Neurosurg 2004; 108:80-3. [PMID: 16311154 DOI: 10.1016/j.clineuro.2004.11.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2004] [Revised: 10/06/2004] [Accepted: 11/09/2004] [Indexed: 11/20/2022]
Abstract
Epstein-Barr virus (EBV) infection causes a wide range of neurologic and hematologic manifestations. We report a 72-year-old Japanese male patient with severe chronic active EBV infection syndrome (SCAEBV) who presented with Guillain-Barré syndrome (GBS) and developed hemophagocytic lymphohistiocytosis (HLH) several months after the onset of GBS. He showed acute onset of distal muscle weakness, ophthalmoplegia and bulbar palsy. Results of nerve conduction study revealed acute motor-sensory axonal neuropathy (AMSAN). His serum was positive for anti-LM1 IgG and anti-GM1b IgM. Titers of antibodies to EBV-related antigens indicated chronic reactivated EBV infection. Treatment with IVIg resolved the acute ophthalmoplegia, but there was no notable improvement in the AMSAN and bulbar palsy despite repeated. Finally, he developed refractory HLH resulting in a fatal outcome. In the present patient, it seems that SCAEBV was associated with the development of GBS and fatal HLH via parainfectious autoimmunity and direct infectious immune mechanisms, respectively.
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Affiliation(s)
- Koji Takahashi
- Department of Internal Medicine, Anan Kyoei Hospital, Hanoura-cho, Naka-gun, Tokushima, Japan
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Lima M, Teixeira MDA, Queirós ML, Santos AH, Gonçalves C, Correia J, Farinha F, Mendonça F, Soares JMN, Almeida J, Orfão A, Justiça B. Immunophenotype and TCR-Vbeta repertoire of peripheral blood T-cells in acute infectious mononucleosis. Blood Cells Mol Dis 2003; 30:1-12. [PMID: 12667982 DOI: 10.1016/s1079-9796(03)00014-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Although a number of studies on the phenotypic changes that occur after T-cell activation have already been published, the specific immunophenotypic features of T-lymphocytes and the frequency at which TCR-variable region (TCR-V) restricted T-cell expansions occur "in vivo" during acute viral infection still remains to be established. We report on the immunophenotype and TCR-V repertoire of peripheral blood T-cells from 28 patients with acute infectious mononucleosis. Immunophenotypic studies were performed by flow cytometry using direct immunofluorescence techniques and stain-and-then-lyse sample preparation protocols with three- and four-colour combinations of monoclonal antibodies directed against a large panel of T- and NK-cell associated markers, activation- and adhesion-related molecules and TCR-Vbeta, -Vgamma and -Vdelta families. Nearly all patients (27/28) showed a massive expansion of CD8(+)/TCRalphabeta(+) T cells, the majority (>90%) of which displayed an immunophenotype compatible with T-cell activation: CD2(+high), CD7(+low), CD11a(+high), CD38(+high), HLA-DR(+high), CD28(+/-low), CD45RO(+high), CD45RA(-/+low), CD11b(-/+low), CD11c(+/-low), CD16(-), CD56(-), CD57(-), CD62L(-), CD94(-), CD158a(-), CD161(-), NKB1(-). Additionally, the levels of both CD3 and CD5 were slightly decreased compared to those found in normal individuals. Late-activation antigens, such as CD57, were found in small proportions of CD8(+)/TCRalphabeta(+) T-cells. Increased numbers of CD4(+)/TCRalphabeta(+) T-cells, TCRgammadelta(+) T-cells and NK-cells were also noticed in 17, 16 and 13 of the 28 cases studied, respectively. Evidence for activation of CD4(+)/TCRalphabeta(+) and TCRgammadelta(+) T-cells relied on changes similar to those described for CD8(+)/TCRalphabeta(+) although less pronounced, except for higher levels of both CD5 and CD28 in the absence of reactivity for CD11c on CD4(+)/TCRalphabeta(+) T-cells and higher levels of CD161 and CD94 on TCRgammadelta(+) T-cells. Small expansions of one or more TCR-Vbeta families accounting for 12 +/- 7% of either the CD8(+)/TCRalphabeta(+) or the CD4(+)/TCRalphabeta(+) T-cell compartment were found in 12 of 14 patients studied, whereas the distribution of the TCR-Vgamma and -Vdelta repertoires tested in 2 of the individuals with expanded TCRgammadelta(+) T-cells was similar to that observed in control individuals. The results presented here provide evidence for an extensive T-cell activation during acute viral infection and establish the immunophenotype patterns associated with this condition.
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MESH Headings
- Acute Disease
- Adolescent
- Adult
- Blood Cell Count
- Child
- Female
- Flow Cytometry
- Humans
- Immunophenotyping
- Infectious Mononucleosis/blood
- Infectious Mononucleosis/immunology
- Infectious Mononucleosis/pathology
- Lymphocyte Activation/immunology
- Lymphocyte Subsets/immunology
- Male
- Middle Aged
- Receptors, Antigen, T-Cell, alpha-beta/analysis
- Receptors, Antigen, T-Cell, alpha-beta/immunology
- Receptors, Antigen, T-Cell, gamma-delta/analysis
- Receptors, Antigen, T-Cell, gamma-delta/immunology
- T-Lymphocytes/immunology
- T-Lymphocytes/pathology
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Affiliation(s)
- Margarida Lima
- Service of Clinical Haematology, Hospital Santo António, Porto, Portugal.
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