Umbilical cord blood transplantation in adults with advanced hodgkin's disease: high incidence of post-transplant lymphoproliferative disease.

We report the outcome of 30 consecutive patients with Hodgkin disease (HD) who underwent single-unit UCBT. Most (90%) patients had failed previous autologous hematopoietic stem cell transplantation. The conditioning regimens were based on combinations of thiotepa, busulfan, cyclophosphamide or fludarabine, and antithymocyte globulin. The cumulative incidence (CI) of myeloid engraftment was 90% [95% confidence interval (C.I.), 74-98%] with a median of 18 d (range, 10-48). CI of acute graft-versus-host disease (GvHD) grades II-IV was 30% (95% C.I., 17-44%), while the incidence of chronic GVHD was 42% (95% C.I., 23-77%). The non-relapse mortality (NRM) at 100 d and 4 yr was 30% (95% C.I., 13-46%) and 47% (95% C.I., 29-65%), respectively. EBV-related post-transplant lymphoproliferative disease (EBV-PTLD) accounted for more than one-third of transplant-related death, with an estimate incidence of 26% (95% C.I., 9-44). The incidence of relapse at 4 yr was 25% (95% C.I., 9-42%). Four-year event-free survival (EFS) and overall survival (OS) were 28% and 30%, respectively. Despite a high NRM and an unexpected high incidence of EBV-PTLD, UCBT in heavily pretreated HD patients is an option for patients lacking a suitable adult donor, provided the disease is not in refractory relapse.

Clinical and virological characteristics of 15 patients with chronic active Epstein-Barr virus infection treated with hematopoietic stem cell transplantation.

BACKGROUND: Chronic active Epstein-Barr virus (EBV) infection is characterized by recurrent infectious mononucleosis-like symptoms, and infected patients have high viral loads in their peripheral blood. Standard therapy for the disease has not yet been established. Recently, hematopoietic stem cell transplantation (HSCT) has been introduced and has the potential to become a standard treatment, although guidelines for HSCT to treat chronic active EBV infection have not yet been proposed. METHODS: Fifteen patients were retrospectively analyzed, both clinically and virologically, to investigate the factors associated with prognosis of chronic active EBV infection treated with HSCT. RESULTS: After HSCT, 7 patients died after survival periods that ranged from 1 to 16 months (mean duration of survival after HSCT, 5 months). Three patients were considered to have died of transplantation-related complications. The duration between infection onset and diagnosis was significantly longer in patients who died than in those who survived. Five of the 7 patients who died experienced > or =3 life-threatening complications. The plasma concentrations of interferon-gamma, interleukin-10, thrombomodulin, and soluble E-selectin did not differ significantly between the groups of patients. With regard to sequence variations in the EBV latent membrane protein 1 gene, no specific patterns were found in the patients who died. Importantly, the plasma EBV load at diagnosis was significantly higher in patients who died than in living patients. Moreover, plasma viral load was shown to be an important factor to monitor during follow-up for patients after HSCT. CONCLUSIONS: The number of life-threatening complications and plasma viral load are indicative of the stage of disease progression and may be useful factors for predicting the outcome of HSCT.

Systemic type Epstein-Barr virus-related lymphoproliferative diseases in children and young adults: challenges for pediatric hemato-oncologists and infectious disease specialists.

Involvement of Epstein-Barr virus (EBV) has long been known in the development of various tumor-forming proliferating diseases, such as nasopharyngeal carcinoma in adults. However, in children and young adults more attention should be focused on systemic, severe type EBV-related diseases, such as fatal infectious mononucleosis, hemophagocytic syndrome, or chronic active EBV infection (CAEBV). These disorders show the typical clinical features of hemophagocytic lymphohistiocytosis (HLH). Although viral infectious diseases are mostly taken care of by infectious disease specialists, pediatric hemato-oncologists need to intervene in the treatment of this kind of disease because of their clonal and neoplastic disease characteristics and of their hematologically problematic, rapid, and life-threatening clinical courses.

Increasing incidence of severe Epstein-Barr virus-related infectious mononucleosis: surveillance study.

Older patients are more susceptible to severe Epstein-Barr virus (EBV)-related infectious mononucleosis (IM). This condition may increase in industrialized countries where primary EBV infection occurs later in life. Between 1990 and 2004, 38 patients were admitted to our department with EBV-related IM. Two patients died. The annual incidence increased significantly (r = 0.623; P = 0.013).

[Fatal course of acute appendicitis associated with infectious mononucleosis]. / Een fataal verlopende combinatie van appendicitis acuta en mononucleosis infectiosa.

The case history is presented of a 10-year-old boy with a fatal combination of acute appendicitis and infectious mononucleosis, in the literature a particularly rare combination. The boy died of a perforative peritonitis. His appendicitis appeared not to be a complication of the infectious mononucleosis.

Fatal infectious mononucleosis in a family.

Two male siblings, one aged five and a half months (SB), and the other aged six months (VB), with fatal infectious mononucleosis phenotype of the X-linked lymphoproliferative syndrome, which resulted in the death of both infants, are presented. Both patients had been healthy, one until the age of five and a half months, and the other until the age of six months. Then, they developed a maculopapular rash, hepatosplenomegaly and lymphadenopathy. In one sibling, the serum IgG level was low, the IgM and IgA levels were high, and the proportion of E-rosette forming cells (E-RFC) and in vitro proliferative response to PHA were normal. In the other sibling, however, the serum IgG level was normal, the IgM and IgA levels were high and the stimulation index for proliferative response to PHA was reduced due to increased spontaneous blastogenesis. Anti-EBV antibodies were negative in both siblings, except for the IgM anti-VCA in V.B. A lymph node specimen could be studied in one infant and was found to be positive for the EBV genome. Postmortem histopathological findings included the absence of cortico-medullary differentiation and identifiable Hassal's corpuscles in the thymus and depletion of T-dependent regions of lymph nodes and spleen in V.B. Atypical mononuclear cell infiltration was detected in the portal areas of the postmortem liver biopsy in S.B.

Epstein-Barr virus--associated lymphoproliferative lesions.

From this review of the natural history of EBV infection in humans, it is clear that the virus has evolved to a symbiotic state with humans. Once individuals are infected, EBV establishes a permanent infection that is maintained at a low level by replication of the virus in the oropharyngeal region with subsequent seeding of circulating B-lymphocytes. Individuals with normal immune systems are able to control the pronounced proliferative potential of EBV-infected cells and thus prevent the emergence of lymphoproliferations. Disease states result when the immune system is altered by other infections, developmental conditions, immunosuppressive agents, or debilitating circumstances such as cancer or starvation. In some cases, localized lymphoproliferations resembling large-cell non-Hodgkin's lymphomas can result that are monoclonal by immunoglobulin gene rearrangement studies. Remarkably, many of the localized masses will regress if the immunosuppressive agents or condition can be ameliorated in these individuals. In patients with hereditary immune deficiencies, these localized masses can progress to a fatal disease without further cytogenetic events. Burkitt's lymphoma, which is associated with EBV infection, appears to result when EBV-driven lymphoproliferations undergo cytogenetic translocations involving predominantly chromosome 8. Most of the conditions that are associated with EBV can be diagnosed by accurate application of EBV-serology, examination of peripheral blood films, a careful history and physical examination, and, in some cases, more sophisticated techniques such as the establishment of lymphoblastoid cell lines, EBNA staining, DNA probes, and pedigree analysis.

Fatal infectious mononucleosis and virus-associated hemophagocytic syndrome.

A detailed clinicopathologic analysis of 52 cases of fatal infectious mononucleosis was performed. Fever, rash, generalized lymphadenopathy, hepatosplenomegaly, and blood cytopenias were the characteristic findings. Epstein-Barr virus infection was documented in 44 of the 52 patients. A triphasic process evolved in the blood and bone marrow of 43 patients. Early, the leukocyte count was elevated due to numerous atypical lymphoid cells, and the marrow was hyperplastic. Later, severe pancytopenia developed, and the marrow showed extensive infiltration by lymphoid cells with cellular necrosis and histiocytic hemophagocytosis. Terminally, the marrow showed massive necrosis with severe cellular depletion and marked histiocytic hemophagocytosis. The median survival time of the patients was six weeks. Opportunistic infections and/or acute hemorrhage were the major causes of death. We conclude that bone marrow damage secondary to an Epstein-Barr virus-associated hemophagocytic syndrome plays a major role in the death of patients with infectious mononucleosis.

Effect of acyclovir and phosphonoformate on cytomegalovirus infection in guinea pigs.

Adult Hartley guinea pigs infected with guinea pig cytomegalovirus (CMV) develop a mononucleosis syndrome with a brief viremia, splenomegaly, lymphadenopathy, and peripheral lymphocytosis with circulating atypical lymphocytes. The present study used this experimental model to evaluate in vivo the therapeutic efficacy of acyclovir (ACV) and phosphonoformate (PFA) during CMV infection. Guinea pigs were treated with ACV or PFA from day 3 to day 7 postinoculation. The course of the mononucleosis syndrome and the spread of virus in various tissues were similar in drug- and sham-treated infected guinea pigs. Infected animals treated with ACV or PFA developed disseminated CMV disease with severe interstitial pneumonia, whereas sham-treated infected and drug-treated noninfected animals did not. In addition, mortality rates in infected animals treated with ACV were significantly higher than those in sham-treated animals. Furthermore, the normal lymphoproliferative response to CMV infection appeared to be reduced in ACV-treated as compared to sham-treated animals, with fewer peripheral lymphocytes, less lymphoid tissue in the spleen and lymph nodes, and less mononuclear inflammation around the inclusion-containing cells of the liver and salivary gland. These results show that ACV and PFA are not useful in the treatment of CMV infection in guinea pigs but instead may have harmful effects.

Immunopathology of the X-linked lymphoproliferative syndrome.

The immunopathogenesis of 25 kindreds affecting 100 males with the X-linked lymphoproliferative syndrome (XLP) is being studied comprehensively by our registry and laboratory group. XLP is a combined variable immune deficiency with Epstein-Barr virus (EBV) induced phenotypes of: (1) fatal infectious mononucleosis (IM), (2) chronic IM progressive to malignant lymphoma, (3) acute IM progressive to acquired agammaglobulinemia or (4) malignant lymphoma. Cytogenetic studies of peripheral blood lymphocytes from 15 surviving males and 21 carrier females reveal random karyotype errors in several kindreds. Often polyclonal Ig or selective IgM increases and lymphocytosis with plasmacytoid forms typifies the IM phenotypes. Weakly reactive EBV-specific antibodies are found and anti-EB nuclear antigen is lacking. Antibodies to EBV are paradoxically elevated in female carriers. Initially all lymphoid tissues show immunoblastic proliferation with plasma cell differentiation and focal to extensive necrosis. Thymus gland and other lymphoid organs become depleted in T cell regions and Hassall's corpuscles may become destroyed. Multinucleated giant cells may be seen destroying the corpuscles or calcified corpuscles are found. The lymphoid infiltrates and lesions resemble graft-versus-host response in the fatal IM phenotype. Extensive necrosis in lymph nodes and deficient Ig secretion of B-cells characterize acquired agammaglobulinemia phenotypes. The malignant lymphomas span the spectrum of B cell differentiation with most being immunoblastic sarcomas. One case probably was monoclonal thus far, others are being studied. EBV DNA hybridization of tissues from 7 patients with fatal IM revealed 1 to 20 EBV genome equivalents per cell. The patients lacked appropriate EBV antibody responses. Our studies of XLP support the hypothesis that immune deficiency the EBV permits chronic and fatal lymphoproliferative diseases in XLP following EBV infections. Owing to this knowledge, rational bases for prevention by genetic counseling and by providing high titer gammaglobulin and antiviral therapy is being attempted.

[Epstein-Barr virus infections in pregnancy. The serological profile of active infections in pregnant women. Their possible relationship with perinatal mortality (author's transl)]. / Les infections à virus Epstein-Barr (EBV) au cours de la grossesse. Profil sérologique des infections actives chez la femme enceinte. Ses relations possibles avec la pathologie périnatale.

A significant number of cases of deaths and of perinatal misfortunes are still of unknown origin. The role of pathological infection is probably important in these cases and particularly those in the Torch group of viruses, and among these, as has been shown by epidemiological and virological tests, the Epstein-Barr virus (E.B.V.). The authors have undertaken a prospective study based on serology, looking for E.B.V. antibodies in pregnancy. 1,164 women were studied and 74 of these had perinatal abnormalities. There is a significant relationship between active E.B.V. infection and mishaps in pregnancy.

Infectious mononucleosis: histopathologic aspects.

The main histopathologic features of infectious mononucleosis are described. In the lymph nodes, the principal change is the appearance of numerous large pyroninophilic cells (immunoblasts), initially expanding the paracortical zone but later extending throughout the node. Similar, large lymphoid cells appear as infiltrates in many other organs and tissues. Cells morphologically similar to Sternberg-Reed cells may be found in the lymph nodes of patients with infectious mononucleosis and other conditions apart from Hodgkin's disease. The diagnostic importance of considering not only the Sternberg-Reed cells but their milieu is stressed. A possible relationship between infectious mononucleosis and lymphoreticular malignancy is suggested by a number of observations, but a definite etiologic link is yet to be established.