Primary immunodeficiency diseases and Epstein-Barr virus-induced lymphoproliferative disorders

Fatal lymphoproliferative disorder in a child with Schimke immuno-osseous dysplasia

Schimke immuno-osseous dysplasia (SIOD) is a rare autosomal recessive disorder characterized by spondyloepiphyseal dysplasia, nephrotic syndrome, and cell-mediated immunodeficiency. Mutations in the SMARCAL1 gene (SW1/SNF2-related, matrix-associated, actin-dependent regulator of chromatin, subfamily a-like1) cause SIOD. We report a patient with SIOD and SMARCAL1 mutations, who presented with fever of unknown origin secondary to B-cell lymphoma. To our knowledge, this is the first report of an SIOD patient with a primary lymphoproliferative disorder (LPD).

Herpesviruses: emerging nosocomial pathogens?

BACKGROUND

Herpesviruses are ubiquitous pathogens that are known to cause infection in humans and animals. It is likely that more than 90% of adults have been infected by one or more herpesviruses. As hospitalized patients become increasingly immunosuppressed by virtue of illness or therapies, it is increasingly likely that human herpesvirus infection will become manifest in the hospital. Whether these manifestations represent manifestations of reactivated latent disease or true nosocomial infections is an open question.

METHODS

Review of the pertinent English-language literature.

RESULTS

There are eight known herpesviruses that cause disease in humans. Herpesviruses are double-stranded DNA viruses. The prototypical structure consists of an inner DNA core that is encased within a nucleocapsid that is icosahedral in configuration and consists of capsomere subunits. Herpesvirus infection generally occurs when virus is transmitted in oral secretions from an infected to a naive host. Clinical reactivation syndromes can occur in transplant patients, cancer chemotherapy patients, and patients with acquired immunodeficiency syndrome. Life-threatening infections are most closely associated with human herpesvirus-5 (cytomegalovirus), whereas the relationships between human herpesvirus-7 and clinical disease are largely undefined.

CONCLUSION

Clinical expressions of herpesvirus in surgical patients are not nosocomial infections, but are in the vast majority of cases the reactivation of latent infection. Reactivation disease can be lethal to the immunosuppressed host.

Biological aspects of Epstein-Barr virus (EBV)-infected lymphocytes in chronic active EBV infection and associated malignancies

Most primary Epstein-Barr virus (EBV) infections are clinically inapparent, but occasionally EBV infection can cause acute infectious mononucleosis. EBV has been linked to a variety of hematologic and non-hematologic malignancies. Chronic active EBV (CAEBV) infection designates a recently identified EBV-associated syndrome characterized by a variety of serious hematological disorders, including malignant lymphoma. EBV was found to infect circulating T- and/or NK-cells in patients with CAEBV infection. These EBV-infected T- and/or NK-cells express EBNA-1, LMP-1, and LMP-2A, a type II form of EBV latency, which is also observed in nasopharyngeal carcinoma (NPC), Hodgkin's disease (HD), and peripheral T-cell lymphoma. CAEBV infections may thus represent a subset of EBV-associated T- and/or NK-cell lymphoproliferative disorders.

Epstein-Barr virus in patients with immunodeficiency disorders

The Epstein-Barr virus (EBV), one of eight known human herpesviruses, causes a wide spectrum of diseases under certain conditions. In particular, in the setting of immunodeficiency, which includes primary or secondary/acquired immunodeficiencies, they have been increasingly reported. The major clinical phenotype is the EBV genome-positive lymphoproliferative disorder, which ranges from benign lymphoproliferation to malignant lymphoma with cytogenetic alterations. Severe or fatal infectious mononucleosis may develop in some patients with immunodeficiencies such as X-linked lymphoproliferative disease.

Epstein-Barr virus-specific T cells for the management of Epstein-Barr virus lymphomas

Epstein-Barr virus (EBV), a human herpes virus, is associated with a variety of malignancies. In vitro, it is able to transform B cells, which will grow as lymphoblastoid cell lines in the absence of T cells. Patients with a variety of immunodeficiency diseases are subject to the development of B-cell lymphomas that express viral antigens on their cell surface. Development of EBV-associated B-cell lymphomas is seen in solid organ transplant and bone marrow transplant recipients receiving immunosuppressive therapy. Transfer of mature T cells from EBV-immune marrow donors has been demonstrated to be effective in controlling these EBV-associated B-cell tumors. Recently the demonstration that EBV transcripts are found in other lymphomas (including Hodgkin disease cells) has led to the suggestion that transfer of EBV-specific T cells may also be effective in managing these tumors. Current research involves optimizing methods to expand cells that recognize the EBV antigens expressed in the lymphoma cells.

Fatal lymphoproliferative disease as a complication of Evans syndrome

A 9-month-old boy had bruising and petechiae. Investigation revealed a Coombs-positive hemolytic anemia and immune-mediated thrombocytopenia. The infant was treated with intravenous immunoglobulin and steroids. The infant eventually had recurrent fevers, hepatosplenomegaly, pulmonary nodules, and parenchymal central nervous system (CNS) lesions develop. Results of a lung biopsy revealed a polyclonal lymphoproliferative disease. Polymerase chain reaction analysis showed the presence of the Epstein-Barr (EB) viral genome in the lung nodules. The infant died from progressive lung disease 6 months after the initial symptoms of Evans syndrome. Lymphoproliferative disease is known to occur in a variety of settings after immunosuppression, especially in solid organ transplant recipients. We report a case of polyclonal lymphocyte proliferation in a patient with Evans syndrome.

Haematological associations of Epstein-Barr virus infection

Epstein-Barr virus (EBV) is one of eight human herpesviruses and is ubiquitous. Primary infection with EBV in childhood is generally silent, but often causes overt diseases such as infectious mononucleosis (IM) and lymphoproliferative disorders (LPD). The latter occurs in immunologically compromised individuals. Historically, EBV has been thought to be aetiologically linked to human malignancies such as EBV genome-positive Burkitt's lymphoma (BL) and nasopharyngeal carcinoma (NPC). Furthermore, studies using recent developments in molecular and immunological diagnostic approaches have suggested that this virus has a causative role in a spectrum of human diseases of previously unknown pathogenesis, including chronic active EBV infection syndrome (CAEBV), EBV-related haemophagocytic lymphohistiocytosis (HLH), and certain disorders such as EBV genome-positive T-cell lymphoma, natural killer (NK) cell leukaemia/lymphoma, Hodgkin's disease (HD) and gastric carcinoma. This chapter reviews recent progress regarding EBV-associated diseases.

Epstein-Barr virus (EBV) hypersensitivity of peripheral B lymphocytes in patients with EBV genome-positive Burkitt's lymphoma

Peripheral blood mononuclear cells (PBMC) from four Japanese patients with Epstein-Barr virus (EBV) genome-positive Burkitt's lymphoma (BL) during remission were exposed to the B95-8 strain of EBV. Maximum concentrations of the EBV-determined nuclear antigen (EBNA) before cellular DNA synthesis were similar to those of healthy counterparts. Subsequently, EBV-immortalised cell lines were established. These immortalised lymphoblastoid cells were treated with 12-O-tetradecanoylphorbol-13-acetate (TPA) and superinfected with the P3HR-1 strain of EBV. EBV early antigens (EA) and viral capsid antigen (VCA) were expressed in approximately 3-10 fold higher concentrations by these lymphoblastoid cells than by those from patients with other types of malignant neoplasia including EBV genome-negative BL and from healthy counterparts. Moderate to extremely high IgG antibody titres to EBV VCA as well as IgG antibodies to EA were demonstrated in these patients during the study. These results suggest that defective underlying cellular mechanisms for regulating the replication of EBV may be present in patients with EBV genome-positive BL.