Chronic high Epstein–Barr viral load carriage in pediatric small bowel transplant recipients

Lau AH, Soltys K, Sindhi RK, Bond G, Mazariegos GV, Green M. Chronic high Epstein–Barr viral load carriage in pediatric small bowel transplant recipients.
Pediatr Transplantation 2010: 14:549–553. © 2010 John Wiley & Sons A/S. Abstract: The development of EBV infection and PTLD is normally associated with a high EBV load in peripheral blood. Often, children undergoing primary or reactivation of EBV infection subsequent to ITx will have chronically elevated EBV loads. To better understand this phenomenon and its consequences, we retrospectively reviewed the records of children who underwent ITx (either isolated or part of multivisceral transplantation) at our center from 1992 to 2007, to identify chronic high EBV load carriers in this population. CHL state was defined as the presence of high load for >50% of samples for greater than or equal to six months following either asymptomatic infection or complete clinical resolution of EBV disease/PTLD. Thirty‐five CHL carriers were identified from our patient population. Pretransplant serologies were available on 34 of these patients: 17 were EBV negative and 17 seropositive; one had unknown EBV serostatus prior to transplant. Seven of the 17 seronegative patients developed their CHL carrier state at the time of their primary EBV infection. Thirteen of the 35 (37%) HLC patients developed EBV disease after meeting the definition of high‐load carrier states. EBV‐related diseases developing in CHL carriers included EBV adenitis (n = 1), EBV enteritis (n = 7), PTLD (n = 4), and EBV+ spindle cell tumor (n = 1). Disease was seen in 7/17 of the seronegative (one PTLD) and 6/17 of the seropositive patients (three PTLD). Thirteen of 35 patients (37%) resolved their CHL state without apparent sequelae while nine remain asymptomatic CHL carriers. Three children have had more than one episode of CHL. These data provide important information about the outcome of chronic EBV high‐load carriage in pediatric intestinal transplant recipients.     

Long‐term monitoring of Epstein–Barr virus DNA load and humoral parameter abnormalities in pediatric liver transplant recipients before development of malignancy

Gregorek H, Jankowska I, Dzier?anowska‐Fangrat K, Teisseyre J, Sawicka A, Kasztelewicz B, Paw?owska J. Long‐term monitoring of Epstein–Barr virus DNA load and humoral parameter abnormalities in pediatric liver transplant recipients before development of malignancy.
Pediatr Transplantation 2010: 14:629–635. © 2010 John Wiley & Sons A/S. Abstract: EBV loads and abnormalities of humoral responses were monitored in 51 pediatric liver transplant recipients as a proposed non‐invasive laboratory tool for early detection of changes preceding severe clinical complications. EBV DNA load, concentrations of IgM, IgG, IgA, and monoclonal proteins were determined in each blood sample. EBV DNA was detected in 70.6% of the children, dysgammaglobulinemia of one or more Ig isotype was present in 41.2% of them. MG detected in 43.1% of patients correlated with the presence of EBV DNA (p = 0.003) and was usually preceded by hypergammaglobulinemia. The median maximum EBV load was significantly higher in EBV DNA+/MG+ patients than in EBV DNA+/MG‐ patients (p = 0.04), although there was no correlation between current viral load and appearance of MG. Four of 15 EBV DNA‐negative patients developed MG, preceded by hypergammaglobulinemia in two. Minimization or cessation of immunosuppression in 42 patients, in whom abnormal biomarkers and/or clinical symptoms raised suspicion of disease progression, permitted complete resolution of abnormalities in all but one patient who developed B‐NHL and died. Simultaneous monitoring of protein profiles and EBV DNA load together with thorough physical evaluation of children after LTx is important for early implementation of suitable preemptive therapy.     

Epstein-Barr viremia levels after pediatric liver transplantation as measured by real-time polymerase chain reaction

Abstract: Effective immunosuppression has improved the results following liver transplantation, but also increased the risk for opportunistic infections. Epstein–Barr virus (EBV) infection in transplant patients can cause various symptoms including the life‐threatening premalignant condition, post‐transplantation lymphoproliferative disorder (PTLD). Serum specimens from 24 consecutive children (mean 7.6 specimens/patient), who had undergone liver transplantation in Göteborg from January 1995 to May 2002, were analyzed retrospectively for EBV DNA by real‐time TaqMan^® polymerase chain reaction (PCR). The results were related to clinical picture, immunosuppression, graft rejection and infections with other agents. Eleven patients (46%) developed primary EBV infection at a mean time of 4.8 months after transplantation, and six (25%) reactivated EBV infection at a mean of 4.0 months after transplantation. Four of the 11 patients with primary infection had symptomatic EBV infection: two had PTLD and two hepatitis. One patient in the group with reactivated infection developed PTLD. EBV DNA levels were significantly higher in the group with primary symptomatic infection compared with the patients with primary asymptomatic infection (mean 65 500 copies/mL; range 14 200–194 300 vs. 3700 copies/mL; range 100–9780). In patients with symptomatic infection EBV DNA levels did not differ between PTLD and hepatitis patients. The data suggest that quantitative analysis of EBV DNA in serum by real‐time PCR is useful for identification of EBV‐related disease.     

Diagnosis of infectious mononucleosis caused by Epstein–Barr virus in infants

Background: The diagnosis of infectious mononucleosis (IM) is usually on serologic tests. The responses of anti‐Epstein–Barr virus (anti‐EBV) antibodies are weak in infants. The authors encountered some IM infants in whom anti‐EBV antibodies were undetectable during early stage, although EBV genome was found in their blood. The aim of the present study was therefore to clarify the frequency of anti‐EBV‐antibody negative IM cases. Methods: The EBV serostatus of 104 IM children diagnosed on Sumaya criteria was retrospectively studied. The EBV genome in peripheral blood mononuclear cells was measured. Results: The anti‐viral capsid antigen‐IgM (anti‐VCA‐IgM)‐positive rate in the acute phase was only 25% in infants but 80% in patients ≥4 years of age. Twenty percent of the infants were negative for all anti‐EBV antibodies and required repeated serologic tests. For infants, the significant rise in anti‐VCA‐IgG was the most sensitive marker. Three seronegative infants with IM symptoms, with circulating EBV genome during acute phase, were eventually considered as having IM on anti‐VCA‐IgG seroconversion thereafter. Conclusions: To diagnose IM in infants the serologic test alone in the acute phase is not sensitive enough. It is proposed that the EBV genome be evaluated in peripheral blood mononuclear cells when infants presenting with IM symptoms are negative for anti‐EBV antibodies during the acute phase.     

Exploring beyond viral load testing for EBV lymphoproliferation: Role of serum IL‐6 and IgE assays as adjunctive tests

Barton M, Wasfy S, Hébert D, Dipchand A, Fecteau A, Grant D, Ng V, Solomon M, Chan M, Read S, Stephens D, Tellier R, Allen UD and the EBV and Associated Viruses Collaborative Research Group. Exploring beyond viral load testing for EBV lymphoproliferation: Role of serum IL‐6 and IgE assays as adjunctive tests.
Pediatr Transplantation 2010: 14: 852–858. © 2010 John Wiley & Sons A/S. Abstract: We examined serum IL‐6 and IgE assays as adjuncts to VL monitoring for PTLD. Paediatric solid organ transplant recipients were followed with VL monitoring. VL, IL‐6, and IgE assays were compared between PTLD cases and non‐cases at <3, 3–6 and >6 months after transplantation. Median IL‐6 levels in PTLD cases were 15.5 (2.0–87.1) and 23.3 (2.1–276) pg/mL compared with 3.25 (0.92–114) and 3.5 (0.75–199.25) pg/mL in non‐cases at 3–6 and >6 months, respectively (p = 0.006 and p = 0.005). At >6 months, IL‐6 levels correlated with VL and PTLD occurrence (Spearman’s coefficients = 0.40; p = 0.001 and 0.32; p = 0.003) in univariate analyses. No benefit was derived from performance of IgE levels. The sensitivity and specificity of high VL as a test of PTLD were 76.3% and 92.5%, while the negative predictive value and PPV of VL were 94.9% and 68.4%, respectively. Combining elevated IL‐6 with high VL increased the PPV and specificity to 80% and 96.2%, respectively, and improved the receiver operating characteristic curve. Serum IL‐6 levels can improve the clinician’s ability to identify PTLD, among patients with elevated EBV viral loads.     

Demonstration of type II latency in T lymphocytes of Epstein–Barr Virus‐associated hemophagocytic lymphohistiocytosis

Epstein–Barr virus (EBV) is the most common infectious cause of non‐genetic hemophagocytic lymphohistiocytosis (HLH). To investigate EBV‐infected lymphocytes and immune dysfunction in EBV‐associated HLH, blood samples from a 6‐year‐old boy were longitudinally analyzed using molecular techniques. EBV‐positive lymphocytes were detected as CD5⁺, CD8⁺, and/or HLA DR⁺ lymphocytes on Day 25 of the disease, mostly disappearing thereafter. CD8⁺ cells specific for lytic antigen BRLF1 were detected, but cells specific for latent antigens EBNA3 and LMP2 were not. EBV genes EBNA1, LMP1, LMP2, EBER1, BARTs were detected, suggesting a latency type II gene expression pattern in this case. Pediatr Blood Cancer 2013;60:326–328. © 2012 Wiley Periodicals, Inc.     

The impact of monitoring Epstein–Barr virus PCR in paediatric bone marrow transplant patients: Can it successfully predict outcome and guide intervention?

BACKGROUND: Epstein-Barr virus (EBV) associated lymphoproliferative disease is a complication of haemopoietic stem cell transplantation (HSCT). In certain groups (unrelated and mismatched donor transplants, T-cell depleted) the risk may be as high as 25% with significant morbidity and mortality. Strategies to predict the impending development of this disorder and allow early intervention have therefore assumed importance. We routinely screen the peripheral blood of all recipients of allogeneic HSCT to detect EBV DNA by quantitative polymerase chain reaction (PCR) technology and report here how this correlates with clinical disease and management. PROCEDURE: Data on 28 successive patients who underwent HSCT at our institution were reviewed. The relationship between EBV reactivation demonstrated by quantitative PCR and development of post transplant lymphoproliferative disease (PTLD) was determined. RESULTS: EBV reactivation occurred in 68% of patients, however only 7% developed clinical PTLD. Patients with high level reactivation (n = 9) had more frequent episodes of reactivation and all patients who progressed to overt PTLD were found in this group. In contrast none of those patients with low level reactivation (n = 10) or persistently negative results (n = 9) showed any signs of clinical disease. Anti-CD20 monoclonal antibody (Rituximab) therapy was instigated in both cases of proven PTLD and three cases of high level reactivation with successful outcomes. Response to treatment was associated with a prompt decline in viral copy number. CONCLUSIONS: Our results indicate that EBV reactivation is a common occurrence in the paediatric allogeneic transplant setting and that only a proportion of patients will progress to PTLD. Frequent monitoring may help to predict those at highest risk and guide intervention.     

Spontaneous resolution of Epstein–Barr virus‐associated hemophagocytic lymphohistiocytosis

Secondary hemophagocytic lymphohistiocytosis (sHLH) is a reactive, proliferative disorder of the immune system resulting in lymphohistiocytic proliferation, hemophagocytosis, and cytokine dysregulation. The most common infectious trigger in sHLH is Epstein–Barr virus (EBV‐HLH). Current treatment protocols for EBV‐HLH have a cure rate of approximately 75%; however, there are significant toxicities associated with these therapies. We present two patients with EBV‐HLH who experienced spontaneous resolution of their disease prior to the initiation of therapy, suggesting there may be a subgroup of patients with EBV‐HLH who do well with conservative management and can avoid potentially toxic therapies. Pediatr Blood Cancer. 2010;55:754–756. © 2010 Wiley‐Liss, Inc.     

The changing face of post‐transplant lymphoproliferative disease in the era of molecular EBV monitoring

Kerkar N, Morotti RA, Madan RP, Shneider B, Herold BC, Dugan C, Miloh T, Karabicak I, Strauchen JA, Emre S. The changing face of post‐transplant lymphoproliferative disease in the era of molecular EBV monitoring.
Pediatr Transplantation 2010: 14:504–511. © 2010 John Wiley & Sons A/S. Abstract: Pediatric PTLD is often associated with primary EBV infection and immunosuppression. The aim was to retrospectively review the spectrum of histologically documented PTLD for two time intervals differentiated by changes in use of molecular EBV monitoring. Eleven of 146 patients (7.5%) in 2001–2005 (Era A) and 10 of 92 (10.9%) in 1993–1997 (Era B) were diagnosed with PTLD. The median age at liver transplantation (0.8 and 0.9 yr, respectively) and the median duration between liver transplant and diagnosis of PTLD (0.6 and 0.7 yr, respectively) were similar in both eras. However, patients in Era A presented with significantly less advanced histological disease compared to patients in Era B (p = 0.03). Specifically, nine patients (82%) in Era A had Pl hyperplasia/polymorphic PTLD, whereas in Era B, six had advanced histological disease (five monomorphic and one unclassified). Three transplant recipients in Era B died secondary to PTLD, whereas there were no PTLD‐related deaths in Era A (p = 0.03). Heightened awareness of risk for PTLD, alterations in baseline immunosuppression regimens, implementation of molecular EBV monitoring, pre‐emptive reduction in immunosuppression and improved therapeutic options may have all contributed to a milder PTLD phenotype and improved clinical outcomes.     

Correlation of rabbit antithymocyte globulin serum levels and clinical outcomes in children who received hematopoietic stem cell transplantation from an alternative donor

We analyzed the correlation between rabbit ATG (rATG) serum levels and clinical outcomes in 37 children who received rATG at a total dose of 10 or 15 mg/kg during HSCT conditioning from an alternative donor. Fourteen patients had advanced malignant diseases, 13 had severe AA, and 10 had inherited disorders. Complete engraftment was achieved in all patients, and no rejection occurred. The cumulative incidence of grades II–IV acute GVHD and extensive chronic GVHD was 27% (95% CI, 12.5–39.6%) and 8.1% (95% CI, 0–23.1%), respectively. Multivariate analysis identified lower rATG levels at week 4 as an independent risk factor in the development of grades II–IV acute GVHD (p = 0.037). Serious infections were not observed in any patient following HSCT. No correlation was found between EBV reactivation and rATG levels at week 2 and week 4 after HSCT. Furthermore, no correlation was found between relapse and rATG levels two and four wk post‐transplantation. The probability of five‐yr OS among patients was 70.3% (95% CI, 59.8–79.2%). Our results suggest that targeted rATG administration may protect patients from severe acute GVHD without increasing the risk of EBV reactivation or relapse.     

Monoclonal gammopathy of undetermined significance in pediatric kidney transplant: A possible role of Epstein‐Barr virus

MG is a common event of hematologic malignancies. There are many papers regarding kidney transplantation patients with MGUS in adults, while data in pediatrics are scarce. The etiology and clinical significance of MGUS are unclear both in adults and children. Immunosuppressive drugs, graft antigenicity, and viral infection could play a possible role. The viruses most frequently implicated seem to be EBV or CMV in particular, but their role has to be defined better. However, many investigators have emphasized an impaired balance between an adequate immune response and reactivation of viral infection.     

Cytokine profiles in children with primary Epstein–Barr virus infection

Primary Epstein–Barr virus (EBV) infection causes infectious mononucleosis and hemophagocytic lymphohistiocytosis (HLH) in children, where EBV infects B and CD8⁺ T cells, respectively. We measured pro‐inflammatory and anti‐inflammatory cytokines in both diseases. Significantly higher concentrations of various mediators, including interferon‐γ, neopterin, interleukin (IL)‐6, IL‐10, IL‐18, and heme oxygenase‐1, were observed in EBV‐HLH. Because of their similarity to the profile of familial HLH, this profile was likely a consequence of HLH, but not ectopic infection. TNF‐α levels were elevated in both diseases. Elevation of those mediators may contribute to the disease pathogenesis of EBV‐HLH by activating and inhibiting host immune responses. Pediatr Blood Cancer 2013; 60: E46–E48. © 2013 Wiley Periodicals, Inc.     

Facial manifestations of Epstein–Barr virus‐related lymphoproliferative disease in childhood acute lymphoblastic leukemia in remission: Two atypical presentations

Epstein–Barr virus‐related lymphoproliferative disease (EBV‐LPD) rarely occurs in patients with acute lymphoblastic leukemia (ALL), who have not received hematopoietic transplantation. We describe EBV‐LPD manifesting as facial lesions in two children with ALL in remission. One patient was a 16‐year‐old male with T‐cell ALL with an EBV‐positive angiocentric polymorphous lip lesion presenting as right‐sided facial swelling. The other patient was a 12‐year‐old male with B‐cell ALL with an EBV‐positive polymorphous lymphoplasmacytic infiltrate presenting as bilateral dacryoadenitis. Neither patient had known primary immunodeficiencies. Both cases improved with immunosuppressant de‐escalation. These cases suggest that immunosuppression induced by maintenance chemotherapy is sufficient to promote EBV‐LPD.     

Gene expression using microarrays in transplant recipients at risk of EBV lymphoproliferation after organ transplantation: Preliminary proof‐of‐concept

Abstract: We hypothesized that aspects of the virus–host interaction could be measured to help predict progression to EBV–PTLD. We examined the spectrum of host genes differentially expressed and any relevant clustering in children at risk of EBV lymphoproliferation after organ transplantation. We compared the genes expressed among patients with different levels of viral loads. Gene expression was measured by microarray analysis of RNA from CD19+ B lymphocytes using the Human Genome U133 Plus 2.0 GeneChip. Among 27 samples from 26 transplant recipients, the viral load categories were: low or undetectable loads (LU), n = 14; high or intermediate loads (HI), n = 13. There were seven healthy EBV‐seropositive (P) and ‐seronegative controls (N). Median time of post‐transplantation was 0.5 yr (range 0.1–3.8). We identified 24–54 differentially expressed genes in each of four comparisons of HI vs. P, LU vs. P, HI vs. LU, and P vs. N. We identified patterns of 563 gene expressions, creating five clusters aligned with levels of viral load. PTLD occurred in four of five clusters. In summary, we demonstrated varying degrees of alignment between levels of VL and gene clusters. Analyses for differential expression of genes showed genes that could be implicated in the pathogenesis of EBV–PTLD.     

Concomitant Presentation of Hemophagocytic Lymphohistiocytosis and Posttransplant Lymphoproliferative Disease‐Like Lymphoma in a Mildly Immunosuppressed Leukemia Patient: An Unusual Association

We describe a 4‐year‐old female with pre‐B‐cell acute lymphoblastic leukemia on maintenance chemotherapy, who developed hemophagocytic lymphohistiocytosis (HLH) secondary to Epstein–Barr virus (EBV) infection, complicated by an aggressive lymphoproliferative disorder. Although there was no history of bone marrow transplant or underlying immunodeficiency, EBV triggered a post‐transplant lymphoproliferative disease (PTLD)‐like lymphoma. Multiple regimens of chemotherapy failed to induce remission and patient developed multiorgan failure. The association of HLH with EBV‐related PTLD‐like lymphoproliferative disorder is rare. We present this case to highlight this unusual association so that this highly fatal disease can be recognized and promptly addressed.     

Epstein-Barr virus associated aplastic anaemia and hepatitis

Abstract We report a Chinese girl with Epstein-Barr virus (EBV) associated aplastic anaemia and hepatitis. Epstein-Barr virus genome was demonstrated in her bone marrow cells and EBV-specific serology suggested reactivation of EBV infection. She was initially treated with anti-thymocyte globulin (ATG) and methylprednisolone but with no haematologic response, and liver function continued to deteriorate. She was then treated with acyclovir. Her aplastic anaemia improved and hepatitis resolved, and there was eradication of EBV genome from her bone marrow cells.     

Delta Virus and Childhood Leukemia

We studied 145 children with acute lymphocytic leukemia (ALL) in remission who had been off chemotherapy for at least 2 years, to assess the prevalence of hepatitis delta virus (HDV) infection, and to determine whether HD V infection was associated with more severe chronic liver disease. The prevalence of chronic HBV infection was 41.5% (60/145). The prevalence of HDV infection among these patients with chronic HBV infection was 50% (30/60). Eighty-five patients were HBsAg-negative. There was evidence that HDV-infected children had more severe chronic liver disease than did HBsAg-positive, anti-HDV-negative patients: (1) their serum ALT levels were significantly more likely to be elevated at long-term follow-up (27/30 vs. 10/26, p = 0.0001); (2) their mean ALT levels were significantly higher 3 years after the cessation of chemotherapy (128 vs. 84 IU/L, p = 0.001); and (3) they were more likely to have either chronic acute hepatitis or cirrhosis when liver biopsy was done (18/23 vs. 6/18, p = 0.0038). Children who were HBsAg-negative had the lowest alanine aminotransferase (ALT) levels and were least likely to have chronic active hepatitis or cirrhosis (3/31).

We conclude that infection with HDV in children with ALL is associated with serious chronic liver disease. In long-term survivors, HDV infection is a major cause of morbidity and an adverse prognostic factor in terms of leukemia-free survival.     

The prevalence of GB virus C/hepatitis G virus RNA among healthy and HCV-infected Catalan children

GB virus C (GBV-C) is a blood-borne flavivirus. The prevalence of GBV-C viremia among healthy adults is 0.5% to 4% and, to date, no disease has been definitely associated with GBV-C infection. We conducted a cross-sectional study to evaluate GBV-C viremia prevalence in a group of 327 healthy children with normal alanine amino transferase (ALT) levels (Group A) and elevated ALT levels (Group B) of unknown origin, and among 38 pediatric patients with mother-to-child-transmitted hepatitis C virus (HCV) infection (Group C). No statistically significant differences were observed between prevalences in Groups A and B (2.2% vs 6.7%, p = 0.06). None of the children in Groups A or B who tested positive for GBV-C RNA showed any clinical symptoms. The prevalence of GBV-C viremia in Group A was lower than for patients in Group C (2.2% vs 13.2%, p = 0.007); no differences were observed in HCV infection characteristics between those patients who were co-infected with GBV-C and those who were not. In conclusion, while GBV-C viremia is more frequent among HCV-infected pediatric patients, it is neither associated with liver disease nor has any influence on HCV-related chronic hepatitis.     

The prevalence of atopy in children with antibodies against hepatitis A virus and hepatitis B virus

To investigate the relationship between atopy and hepatitis A virus (HAV) and hepatitis B virus (HBV) infections, we studied 42 children who had had HAV infection (Group I), 28 children who had had HBV infection (Group II), and 31 children who were seronegative for both HAV and HBV infection (Control group). Serological tests for HAV and HBV infections (anti-HAV IgG, HBsAg, anti-HBc IgG) and allergic skin tests and specific IgE investigations for the detection of atopy were carried out. In this study, there was no significant divergence in the socio-demographic characteristics among the three groups. The rates of specific IgE positivity in children in the HAV seropositive group (11.9%) and in children in the HBV seropositive group (17.8%) were lower than in the control group (35.4%) (p = 0.03 and p = 0.22, respectively). Also, the number of children with respiratory allergic diseases (allergic rhinitis and/or asthma) both in the HAV seropositive group and in the HBV seropositive group were significantly lower than in the control group (p < 0.05). When atopy in all of the groups was evaluated, the prevalence of atopy was found to be more widespread in HAV seronegative children (Adjusted OR, 9.2; 95% CI, 1.7-48.2) and HBV seronegative children (Adjusted OR, 5.9; 95% CI, 1.1-31.8) than in HAV and HBV seropositive children, after adjustment for age, number of older siblings and education of the father. In conclusion, in this study, the prevalence of atopy in children who had had HAV or HBV infection was found to be low, and this situation was considered to be related to the relationship of HAV and HBV infections to poor hygiene and to the fact that these infections occur at early ages in Turkey.