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Characterization and treatment of chronic active Epstein-Barr virus disease: A 28-year experience in the United States

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Chronic active EBV disease (CAEBV) is a lymphoproliferative disorder characterized by markedly elevated levels of antibody to EBV or EBV DNA in the blood and EBV RNA or protein in lymphocytes in tissues. We present our experience with CAEBV during the last 28 years, including the first 8 cases treated with hematopoietic stem cell transplantation in the United States. Most cases of CAEBV have been reported from Japan. Unlike CAEBV in Japan, where EBV is nearly always found in T or natural killer (NK) cells in tissues, EBV was usually detected in B cells in tissues from our patients. Most patients presented with lymphadenopathy and splenomegaly; fever, hepatitis, and pancytopenia were common. Most patients died of infection or progressive lymphoproliferation. Unlike cases reported from Japan, our patients often showed a progressive loss of B cells and hypogammaglobulinemia. Although patients with CAEBV from Japan have normal or increased numbers of NK cells, many of our patients had reduced NK-cell numbers. Although immunosuppressive agents, rituximab, autologous cytotoxic T cells, or cytotoxic chemotherapy often resulted in short-term remissions, they were not curative. Hematopoietic stem cell transplantation was often curative for CAEBV, even in patients with active lymphoproliferative disease that was unresponsive to chemotherapy. These studies are registered at http://www.clinicaltrials.gov as NCT00032513 for CAEBV, NCT00062868 and NCT00058812 for EBV-specific T-cell studies, and NCT00578539 for the hematopoietic stem cell transplantation protocol.
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doi:10.1182/blood-2010-11-316745
Prepublished online March 31, 2011;
2011 117: 5835-5849
Straus
El-Mallawany, Daniel Fowler, Claude Sportes, Michael R. Bishop, Wyndham Wilson and Stephen E.
Burbelo, Siu-Ping Turk, Rachael Fulton, Alan S. Wayne, Richard F. Little, Mitchell S. Cairo, Nader K.
Rooney, Stephen Gottschalk, Catherine M. Bollard, V. Koneti Rao, Adriana Marques, Peter D.
Jeffrey I. Cohen, Elaine S. Jaffe, Janet K. Dale, Stefania Pittaluga, Helen E. Heslop, Cliona M.
disease: a 28-year experience in the United States
Characterization and treatment of chronic active Epstein-Barr virus
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CLINICAL TRIALS AND OBSERVATIONS
Characterization and treatment of chronic active Epstein-Barr virus disease:
a 28-year experience in the United States
Jeffrey I. Cohen,1Elaine S. Jaffe,2Janet K. Dale,1Stefania Pittaluga,2Helen E. Heslop,3Cliona M. Rooney,3
Stephen Gottschalk,3Catherine M. Bollard,3V. Koneti Rao,1Adriana Marques,1Peter D. Burbelo,4Siu-Ping Turk,1
Rachael Fulton,1Alan S. Wayne,5Richard F. Little,6Mitchell S. Cairo,7Nader K. El-Mallawany,7Daniel Fowler,8
Claude Sportes,8Michael R. Bishop,8Wyndham Wilson,9and *Stephen E. Straus1
1Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD; 2Laboratory of Pathology,
National Cancer Institute, National Institutes of Health, Bethesda, MD; 3Center for Cell and Gene Therapy, Baylor College of Medicine, The Methodist Hospital
and Texas Children’s Hospital, Houston, TX; 4Laboratory of Sensory Biology, National Institute of Dental and Craniofacial Research, National Institutes of Health,
Bethesda, MD; 5Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD; 6HIV and AIDS
Malignancy Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD; 7Department of Pediatrics, Medicine,
Pathology and Cell Biology, NY-Presbyterian Morgan Stanley Children’s Hospital, Columbia University, New York, NY; 8Experimental Transplantation and
Immunology Branch, National Cancer Institute; and 9Metabolism Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
Chronic active EBV disease (CAEBV) is a
lymphoproliferative disorder character-
ized by markedly elevated levels of anti-
body to EBV or EBV DNA in the blood and
EBV RNA or protein in lymphocytes in
tissues. We present our experience with
CAEBV during the last 28 years, includ-
ing the first 8 cases treated with hemato-
poietic stem cell transplantation in the
United States. Most cases of CAEBV have
been reported from Japan. Unlike CAEBV
in Japan, where EBV is nearly always
found in T or natural killer (NK) cells in
tissues, EBV was usually detected in
B cells in tissues from our patients. Most
patients presented with lymphadenopa-
thy and splenomegaly; fever, hepatitis,
and pancytopenia were common. Most
patients died of infection or progressive
lymphoproliferation. Unlike cases re-
ported from Japan, our patients often
showed a progressive loss of B cells and
hypogammaglobulinemia. Although pa-
tients with CAEBV from Japan have nor-
mal or increased numbers of NK cells,
many of our patients had reduced NK-cell
numbers. Although immunosuppressive
agents, rituximab, autologous cytotoxic
T cells, or cytotoxic chemotherapy often
resulted in short-term remissions, they
were not curative. Hematopoietic stem
cell transplantation was often curative for
CAEBV, even in patients with active lym-
phoproliferative disease that was unre-
sponsive to chemotherapy. These studies
are registered at http://www.clinicaltrials-
.gov as NCT00032513 for CAEBV,
NCT00062868 and NCT00058812 for EBV-
specific T-cell studies, and NCT00578539
for the hematopoietic stem cell transplan-
tation protocol. (Blood. 2011;117(22):
5835-5849)
Introduction
Approximately 95% of adults are infected with EBV. Although
most infections occur during childhood and are asymptomatic,
infection in adolescents or young adults often results in infectious
mononucleosis. Mononucleosis often presents with fever, pharyngi-
tis, lymphadenopathy, and splenomegaly. Most patients have an
uncomplicated course; however, some develop complications,
including upper airway obstruction, rupture of the spleen, neuro-
logic disease, severe hematologic cytopenias, or hepatitis. In most
cases these symptoms resolve without sequelae.
Rare persons infected with EBV develop a life-threatening
condition termed chronic active EBV disease (CAEBV).1-4 Most
cases of CAEBV have been reported from Japan. These patients
often have some of the complications found in otherwise-healthy
patients with acute EBV infection, but unlike healthy patients,
these complications persist and progress. These patients have
markedly elevated levels of EBV DNA in the blood and viral RNA
and proteins in tissues. Most patients present with fever, hepatic
dysfunction, splenomegaly, lymphadenopathy, and thrombocytope-
nia.2Other features that appear in 10% of patients include
hepatomegaly, anemia, hypersensitivity to mosquito bites, rash, oral
ulcers, hemophagocytic syndrome, coronary artery aneurysms, liver
failure, lymphoma, and interstitial pneumonia. Less common features
include uveitis, CNS disease, intestinal perforation, and myocarditis.5
Although EBV is present in the B cells of healthy persons
infected with EBV, in most cases of CAEBV reported in Asians or
Native Americans, EBV has been detected in T or natural killer
(NK) cells.2,6 The virus was present in the B cells of lesions from
rare patients with CAEBV in Japan5and in the United States.7
Some patients had defective cytotoxic T-cell (CTLs)8,9 or NK-cell10
activity against EBV-infected cells. Recently, we reported one
patient with mutations in both alleles of his perforin gene that
impaired maturation of the protein and reduced killing by T cells.11
At an international workshop,4participants concluded that CAEBV
should be classified as a B, T, or NK cell in origin, and although the
authors of one study compared T- and NK-cell disease,5no reports
have compared T- and B-cell disease.
Therapy for CAEBV, in the absence of hematopoietic stem
cell transplantation (HSCT), is often unsatisfactory and at best
Submitted November 9, 2010; accepted March 9, 2011. Prepublished online as
Blood First Edition paper, March 31, 2011; DOI 10.1182/blood-2010-11-
316745.
*Deceased.
The online version of this article contains a data supplement.
The publication costs of this article were defrayed in part by page charge
payment. Therefore, and solely to indicate this fact, this article is hereby
marked ‘‘advertisement’’ in accordance with 18 USC section 1734.
5835BLOOD, 2 JUNE 2011 VOLUME 117, NUMBER 22
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transiently delays the progression of disease. Antiviral therapy and
immunomodulatory agents usually are ineffective. Corticosteroids
or other immunosuppressive agents often reduce symptoms, but
over time patients become refractory to therapy, develop progres-
sive immunodeficiency, and usually succumb to opportunistic
infections or lymphoproliferative disease. Cytotoxic chemotherapy
and autologous EBV specific CTLs are usually unsuccessful. In
contrast, allogeneic HSCT has been successful in several cases
reported from Japan.12-14
We report our experience with 19 patients with CAEBV. Sixteen
consecutive patients were followed at the National Institutes of
Health (NIH) Clinical Center during the past 28 years, and
3 patients were seen at Baylor College of Medicine. We describe
the features of CAEBV in the United States that differ from those
cases reported in Japan and report that the only effective therapy in
our patients with CAEBV is allogeneic HSCT.
Methods
Entry criteria
CAEBV was defined as (1) a severe progressive illness of 6 months’
duration usually with fever, lymphadenopathy, and splenomegaly that either
began as a primary EBV infection or was associated with markedly elevated
antibody titers to EBV viral capsid antigen (VCA 1:5120) or early
antigen (1:640), or markedly elevated EBV DNA in the blood;
(2) infiltration of tissues (eg, lymph nodes, lungs, liver, CNS, bone marrow,
eye, skin) with lymphocytes; (3) elevated EBV DNA, RNA, or proteins in
affected tissues; and (4) the absence of any other immunosuppressive
condition.2,15 Our definition is similar to that used in most Japanese
studies,2but we also required evidence of lymphocytic infiltration (and
EBV) in the tissues to ensure that the organ disease was attributable to
EBV-infected lymphocytes. This research was approved by Institutional
Review Boards at NIH and at Baylor College of Medicine, and all patients
or guardians provided written informed consent in accordance with the
Declaration of Helsinki. Patient 3,11 patient 10,6and patient 1516 were
reported previously.
Pathology
All cases of CAEBV from the NIH Clinical Center from 1982 until the
present (patients 1-8, 10-16) and an additional 4 patients from Baylor
College of Medicine in Houston who underwent HSCT (patients 9, 17-19)
were reviewed at the Hematopathology Section of the National Cancer
Institute at the NIH. Immunohistochemistry was performed on formalin-
fixed, paraffin-embedded tissue sections as described previously.6
In situ hybridization for EBV-encoded RNA-1 (EBER1) was performed
on fixed paraffin-embedded sections as previously described with the use of
an EBER1 riboprobe.6Double staining for EBER1 and CD20 or CD3 was
performed with in situ hybridization and then immunohistochemistry. In
selected cases, the distribution of EBER1 positivity in T cells versus B cells
was inferred by comparison of sequential sections, on the basis of the
observed distribution of cells positive for EBER, CD3, and CD20.
Molecular studies were performed by extracting genomic DNA from
paraffin-embedded sections. Clonal rearrangements of the IgH genes and
the TCR chain genes were investigated by the use of appropriate primers
and PCR as described previously.6
EBV viral DNA loads
EBV DNA was quantified from peripheral blood lymphocytes of patients
8-11 by the use of serial dilutions of DNA and PCR as described
previously.17 EBV DNA was quantified from PBMCs in patients 12-16 by
real-time PCR as described previously.18 EBV DNA was measured in
patients 17-19 by isolating DNA from PBMCs with an anion exchange
column followed by real-time PCR as described previously.19
Serum cytokines and EBV-specific antibodies
Serum cytokines (IL-1, IL-2, IL-4, IL-5, IL-6, IL-7, IL-8, IL-10,
IL-12p70, IL-13, IFN, GM-CSF, and TNF-) were measured by the use of
the Multiplex MAP high sensitivity human cytokine panel (Millipore),
following the manufacturer’s instructions. To account for the multiple
cytokine tests that were performed, only Pvalues .01 were considered
significant.
To measure EBV-specific antibody responses, fusion proteins were
constructed in which EBV genes were fused to the Renilla luciferase gene
plasmid vectors pREN3S or pREN2 (see supplemental data, available on
the Blood Web site; see the Supplemental Materials link at the top of the
online article). Antibodies were measured against latency (EBNA-1,
LMP2A), immediate-early (BZLF1), early (BALF1, BHRF1, BMRF1,
SM), and late (BCRF1, p18 capsid protein, p23 capsid, protein, gp25,
gp350, and gp42) viral proteins. Cos1 cells were transfected with plasmids
containing EBV-luciferase fusion proteins and activity of lysates was
determined by measuring light units (LU) with a luminometer.20 Plasma
was diluted 1:10 and 10 L was added to 1 107LU of transfected Cos1
cell extract, immunoprecipitations were performed with addition of protein
A/G beads, and LU were determined by a plate luminometer. A cutoff
threshold limit was derived from the mean value plus 2 SD of background
LU. Controls for cytokine and antibody measurements were persons with
chronic inflammatory disorders and with chronic fatigue syndrome on
protocols approved by the Institutional Review Board at NIH.
Results
Clinical characteristics and pathology of patients with CAEBV
Nineteen patients with CAEBV were evaluated—16 patients at the
NIH Clinical Center and 3 at Baylor College of Medicine (Table 1).
Sixty-eight percent were men, and 32% were women. Twelve
(63%) were white, 3 (16%) were Asian, 3 (16%) were Hispanic,
and 1 (5%) was African American. None of the patients had family
histories suggestive of similar disease. The mean age at the onset of
disease was 19 years (range, 4-51 years). Eleven had B-cell
CAEBV, 3 T-cell CAEBV, 1 had NK-cell CAEBV, and 4 were
undetermined. Of the patients with B-cell CAEBV, 4 patients
(patients 3, 6, 9, and 11) had a prominent reactive T-cell infiltrate in
biopsy sections and fewer numbers of EBERand CD20
lymphocytes demonstrating a similar distribution in sequential
sections. Many of the patients with EBV in B cells had virus in both
CD20and CD20B cells on their initial biopsy, and the
frequency of CD20B cells increased after rituximab therapy (eg,
patient 16, Figure 1); the latter would not be sensitive to rituximab.
Patients with T-cell CAEBV were younger at presentation
(mean age, 7 years) than those with B-cell disease (mean age,
23 years). Of the 11 patients followed at NIH for at least 5 years
who did not undergo HSCT, only one is alive and she has B-cell
lymphoproliferative disease resembling posttransplantation lym-
phoproliferative disease (PTLD). The mean time to death after
onset of disease was 6.2 years; this finding was similar in those
with T-cell CAEBV and those with B-cell disease. Death was most
often because of uncontrolled lymphoproliferative disease or
opportunistic infection.
The most common signs and symptoms were lymphadenopathy
in 79% of patients, splenomegaly in 68%, fever in 47%, hepatitis in
47%, hypogammaglobulinemia in 44%, pancytopenia in 42%,
hematophagocytosis in 32%, hepatomegaly in 32%, interstitial
pneumonitis in 26%, central nervous system disease in 21%, and
peripheral neuropathy in 21% (Table 2). The most frequent organs
involved with EBVlymphocytes were lymph nodes in 63% of
patients, BM in 37%, liver in 26%, spleen in 21%, lung in 21%, and
5836 COHEN et al BLOOD, 2 JUNE 2011 VOLUME 117, NUMBER 22
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Table 1. Outcome of patients with chronic active EBV disease
Patient Race/sex Age at onset, y Age at death, y Outcome
Unknown whether B-, T-, or
NK-cell disease
1 WM 28 38 Died, LPD, MDS/acute myelomonocytic leukemia
2 WM 13 30 Died, infection
4 AF 11 14 Died, LPD, pneumonia
5 WM 22 23 Died, LPD, pulmonary thrombosis
B-cell disease
3 WM 9 17 Died, progressive disease, disseminated candidiasis
6 WM 18 24 Died, progressive disease, Aspergillus pneumonia, brain abscess
7 BF 13 17 Died, B-cell lymphoma
8 WM 29 36 Died, cirrhosis (alcohol-related)
9 WM 17 Alive (37 y) Alive 11 years after BMT, EBV negative
11 WF 20 31 Died, progressive disease
12 WM 51 Alive (64 y) Alive 6 years after HSCT, EBV positive, mild GVHD, infections
13 WM 44 45 Died, central pontine myelinolysis after HSCT, residual B-cell lymphoma
14 AF 22 Alive (30 y) Alive with B-cell LPD, 1 year after autologous EBV CTLs (LCL-specific and
LMP1/2- specific cells)
16 WM 29 31 Died, residual B-cell lymphoma after HSCT 3
17 HF 5 Alive (16 y) Alive 6 years after HSCT, EBV negative
T-cell disease
10 WF 9 15 Died, T-cell lymphoma
15 HM 8 Alive (15 y) Alive 2 years after HSCT
18 AM 4 9 Died, 4 years after HSCT, T-cell lymphoma
NK-cell disease
19 HM 7 Alive (14 y) Alive 2 years after HSCT in complete remission
A indicates Asian; B, black; BMT, bone marrow transplant; CTLs, cytotoxic T lymphocytes; F, female; H, Hispanic; HSCT, hematopoietic stem cell transplant; LCL,
lymphoblastoid cell line (EBV-transformed B-cell line); LMP, latent membrane protein; LPD, lymphoproliferative disease; M, male; MDS, myelodysplastic syndrome; and W, white.
Figure 1. EBV RNA in both CD20and CD20B cells
in a lymph node from patient 16. (A) Lymph node biopsy
shows polymorphic B-cell lymphoma. (B) In situ hybridiza-
tion shows that the tumor cells are positive for EBER. Few
cells express the CD20 B-cell marker (C), whereas many
cells express the CD3 T-cell (D), CD79 B-cell (E), and
Pax-5 B-cell (F) markers.
CHRONIC ACTIVE EBV DISEASE IN THE UNITED STATES 5837BLOOD, 2 JUNE 2011 VOLUME 117, NUMBER 22
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Table 2. Symptoms of chronic active EBV
Patient Fever Lymphadenopathy Splenomegaly Hepatomegaly
CNS
disease
Peripheral
neuropathy
Interstitial
pneumonitis Pancytopenia Hepatitis Hemophagocytosis Hypogammaglobulinemia Other
Unknown whether
B-, T-, or
NK-cell disease
1⫹⫹ ⫹ ⫹
2⫹⫹⫹ ⫹
4⫹ ⫹
5⫹⫹Autoimmune hemolytic
anemia, sinusitis
B-cell disease
3⫹⫹Autoimmune hemolytic
anemia,
neutropenia, skin
disease, vasculitis,
sinusitis,
thrombocytopenia
6⫹⫹⫹ ⫹ Uveitis
7 Sinusitis, vasculitis
8⫹⫹
9⫹⫹ ⫹ ⫹
11 ⫹⫹ ⫹ ⫹ Autoimmune hemolytic
anemia
12 ⫹⫹ ⫹ Eye disease, skin
disease
13 ⫹⫹ ⫹ ⫹⫹ Skin disease
14 ⫹⫹
16 ⫹⫹ ⫹
17 ⫹⫹ ⫹⫹Sinusitis
T-cell disease
10 ⫹⫹Sinusitis,
thrombocytopenia
15 ⫹⫹ Hydroa vacciniforme
18 ⫹⫹ ⫹ ⫹ Conjunctivitis
NK-cell disease
19 Skin disease, mosquito
bite hypersensitivity
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skin in 16% (Figure 2, Table 3). Patients with T-cell CAEBV more
often had fever (100% for T-cell vs 45% for B-cell), hepatitis
(100% vs 36%), and hepatomegaly (66% vs 27%), whereas
patients with B-cell CAEBV more often had hypogammaglobuline-
mia (55% for B-cell vs 0% for T-cell).
Clonality was determined in tumors from 11 of the patients
(Table 3). Sixty-three percent of patients with B-cell CAEBV
had clonal lymphoid proliferations, and 100% of those with
T-cell CAEBV had clonal lesions. Thirty-eight percent (3/8) of
those with clonal tumors were alive at last follow-up, whereas
67% (2/3) with nonclonal lymphoproliferative lesions were
alive at follow-up.
Absence of mutations in cellular genes involved in control of EBV
SAP is mutated in patients with X-linked lymphoproliferative
disease; other studies of Japanese patients have shown no evidence
of SAP mutations in patients with CAEBV.2Because CAEBV
shares some of the features of X-linked lymphoproliferative
disease, we sequenced genes encoding proteins (SLAM, 2B4,
NTB-A) that interact with SAP. In addition we determined the
sequence of perforin (because patient 3 was previously reported to
have mutations in the gene),11 as well as granulysin, which like
perforin is also present in cytotoxic granules of NK and CTLs.
Finally we sequenced X-linked inhibitor of apoptosis protein,
Figure 2. EBV disease involving skin, lymph nodes,
and spleen. Skin from patient 12 shows a perivascular
lymphocytic infiltrate (A) that is positive for EBER (B).
Lymph node (C) and spleen (D) with hemophagocytosis
from patient 9.
Table 3. Organs infiltrated with EBVcells and clonality
Organs infiltrated with EBVcells and clonality
ClonalityLymph node BM Liver Spleen Lung Other
Unknown whether B-, T-, or
NK-cell disease
1⫹⫹ ⫹Intestine ND
2 ND* ND
4ND
5ND
B-cell disease
3⫹⫹ ND
6⫹⫹ ⫹ ND
7 Sinus Yes
8Brain ND
9⫹⫹Yes
11 ⫹⫹ Yes
12 Skin No
13 CSF Yes
14 Tonsil No
16 ⫹⫹ No
17 ⫹⫹ Yes
T-cell disease
10 ⫹⫹ ⫹ Kidney Yes
15 Skin Yes
18 ⫹⫹ Yes
NK-cell disease
19 Skin ND
ND indicates not done; and NK, natural killer.
*The patient had a brain biopsy that showed encephalitis; however, insufficient material was available for EBV EBER staining.
CHRONIC ACTIVE EBV DISEASE IN THE UNITED STATES 5839BLOOD, 2 JUNE 2011 VOLUME 117, NUMBER 22
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which has been reported to be mutated in some patients with severe
EBV infections. None of the 10 patients tested (patients 2, 6, 7, 8, 9,
10, 12, 13, 14, and 16) had mutations in these genes.
Antibodies to EBV proteins and loss of Igs and B cells in
patients with CAEBV evaluated at NIH
Antibody to EBV VCA IgG was elevated to 1:5260 in 53% of
those tested; 100% with T-cell CAEBV and 50% with B-cell
disease had antibody titers this high (Table 4). Antibody to EBV
VCA IgM was elevated at the time of referral in 5 of 17 patients
tested; the antibody became negative in 3 of 4 patients who were
initially positive and were subsequently retested (supplemental
data and supplemental Table 1). Antibody to EBV VCA IgA was
elevated in 8 of 8 patients tested with a conventional immunofluo-
rescence assay; in 6 of 8 patients the titer was 1:256. Of the
5 patients whose blood was tested by real-time PCR for EBV DNA,
the median viral load was 320 000 copies per million cells (range,
5700-1.7 million copies per million cells).
Titers of antibodies to early EBV proteins (BMRF1-DNA
polymerase processivity factor, BHRF1-bcl-2 homolog, BMLF1-
transporter of intronless RNAs) were significantly greater
(P.011) in CAEBV patients than in EBV-seropositive control
patients (Figure 3). Antibodies to immediate-early (BZLF1-Z
transactivator) and late (BFRF3-p18 capsid, BLRF2-p23 capsid)
EBV proteins were greater in CAEBV patients than EBV-
seropositive control patients, but the difference did not reach
statistical significance. Antibody titers to EBV early antigen
(diffuse) were elevated in 10 of 11 patients tested with a
conventional immunofluorescence assay; in 7 of 11 patients the
titer was 1:5120 (supplemental data). In contrast, EBV titers
to latent protein EBNA1 were significantly lower in CAEBV
patients than in EBV-seropositive control patients (P.007).
Antibody titers to each of the aforementioned immediate-early,
early, and late proteins (except for BLRF2-p23 capsid) were
greater in patients with T-cell CAEBV than in patients with
B-cell CAEBV. In contrast, antibody to EBNA1 was greater in
patients with B-cell CAEBV than in those with T-cell CAEBV.
Thus, patients with CAEBV have greater titers of antibodies to
certain EBV lytic proteins and lower titers of antibody to
EBNA1 than control patients.
A striking feature of our patients was a progressive loss of
B cells and hypogammaglobulinemia, even in the absence of
rituximab therapy. Forty-two percent developed hypogammaglobu-
linemia, 43% had low numbers of CD19 cells in the absence of
rituximab therapy, 31% had low NK cells, 38% had low CD4 cells,
and 44% had low CD8 cells (Table 4). Patients with B-cell CAEBV
more often had CD19 cell numbers less than normal (56% of B-cell
CAEBV patients vs 0% of T-cell CAEBV patients), and the mean
percent of CD19 cells in patients with B-cell CAEBV (5.6%) was
lower than that for patients with T-cell CAEBV (14.5%).
Table 4. Hematologic data for patients with chronic active EBV seen at NIH
Pt CD4% CD8% CD19% CD20% NK% EBV VCA IgG titer EBV load*
Serum IgG
High Low
Unknown whether B-, T-, or
NK- cell disease
1 ND ND ND ND ND 20 480 ND 2830 540
2 60 30 0 0.1 5.5 40 960 ND 5440 504
4 50 21 ND ND 10 2560 ND 3080 682
5 20 45 5.6 4.6 0.7 1280 ND 3148 745
B-cell disease
3 59 38 0.3 0.5 3 20 480 ND 3570 907
6 83 12 0 0 1.2 10 240 ND 914 756
7 22 59 2.9 2.9 16.4 20 480 ND 2680 328
8 22 23 13 6 16 2560 1:1000† 1640 617
9 79 13 0.5 0.5 1.5 2560 1:10‡ 2180 225
11 50 41 ND ND 7 163 840 1:100§ 6530 ND
12 56 36 0.8 0.7 5 640 5.0 105643 479
13 64 8 17 ND 5 ND 1.7 106734 ND
14 25 55 11 10 5.1 1280 5.7 103793 553
16 42 32 5 5 17 320 4.6 104916 910
17 ND ND ND ND ND 10 240 2.2 106432 ND
T-cell disease
10 43 24 21 21 8 40 960 1:10 000¶ 2330 2120
15 24 59 8 ND 4 ND 3.2 1051910 ND
18 ND ND ND ND ND 10 240 1.2 105824 ND
NK-cell disease
19 23 14 16 ND 47 320 2.6 1051010 817
Normal values are CD4 362-1275 (29%-57%), CD8 344-911 (25%-51%), CD19 47-409 (3.5%-17%), CD20 49-424 (3.7%-16%), and CD56 87-505 (4.6%-30%); normal
values for serum IgG for patients 1-16 at NIH are 642-1730 mg/dL, and for patients 17-19 at Baylor College of Medicine are 641-1353 mg/dL.
ND indicates not done; NIH, National Institutes of Health; Pt, patient; and VCA, dilution of antibody to EBV viral capsid antigen that is positive in the serum.
All laboratory data are shown before rituximab therapy given; low IgG and low CD19% were present before cytotoxic chemotherapy was given except for patient 3.
*EBV load expressed as dilution of peripheral blood lymphocytes in which EBV PCR is positive (patients 8-11) or EBV copies per 106genomes from PBMCs (patients
12-16) or EBV copies per g of DNA (patients 17-19). The lower limit of detection was 10 EBV copies per 106cellular genomes (assay used for patients 12-16) and 4 genomes
of EBV per g of DNA (assay used for patients 17-19).
†Estimated to be 11 000 copies/mL.
‡Estimated to be 1200 copies/mL.
§Estimated to be 4400 copies/mL.
¶Estimated to be 11 000 copies/mL.
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Cytokine levels in patients with CAEBV evaluated at NIH
The mean serum levels of IL-6, IL-10, TNF-, and IFN-were
significantly greater for patients with CAEBV (B- and T-cell) than
control patients, or for patients with B-cell CAEBV than controls
(all P.006, Figure 4). Although serum levels of IL-12 were
2.4-fold greater in patients with CAEBV (B- and T-cell) than
controls, and 3.3-fold greater in patients with B-cell CAEBV than
control patients, the results did not reach statistical significance.
Similarly, levels of GM-CSF were 1.3-fold greater in patients with
CAEBV (B- and T-cell) than control patients and 1.8-fold greater in
patients with B-cell CAEBV than control patients, but the results
did not reach statistical significance. In contrast, levels of IL-5 were
similar in those with CAEBV as in control patients.
Response to treatment in patients with CAEBV
Patients were treated with a variety of agents (Table 5), including
antiviral therapy with acyclovir or valacyclovir (63%), intravenous
IgG (42%), IFN-(32%), or other IFNs (11%) without improve-
ment. Several patients were treated with immunosuppressive
therapy, including corticosteroids (79%), cyclosporine (26%), or
Figure 3. Levels of antibody to EBV lytic proteins and EBNA1 by the luciferase immunoprecipitation system assay in EBV-seropositive control patients (CTRL),
patients with CAEBV, and EBV-seronegative control patients. Each point represents an individual sample from an uninfected control or a person infected with EBV.
Antibody titers are expressed in LU. Pvalues were calculated with the Mann-Whitney Utest. The solid horizontal lines indicate the geometric mean antibody titers in each
group, and the vertical lines show the 95% confidence interval.
Figure 4. Cytokine levels in patients with CAEBV.
Levels of IL-6, IL-10, TNF-, and IFN-are shown in
pg/mL. CTRL indicates healthy EBV-seropositive control
patients; B, patients with B-cell CAEBV; B T, com-
bined patients with B-cell and T-cell CAEBV.
CHRONIC ACTIVE EBV DISEASE IN THE UNITED STATES 5841BLOOD, 2 JUNE 2011 VOLUME 117, NUMBER 22
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Table 5. Treatment for CAEBV
Patient Acyclovir or valacyclovir Steroids Cyclosporine Azathioprine IFN-IVIG Rituximab Cytotoxic chemotherapy Other
Unknown whether B-, T-, or
NK-cell disease
1⫹⫹ Desciclovir, plasmapheresis
2⫹⫹Cy
4⫹ ⫹
5⫹⫹ Cy Splenectomy
B-cell disease
3⫹⫹ Cy, Vin, Adria Splenectomy
6⫹⫹ MTX, Vin IFN-, 2-chlorodeoxyadenosine, splenectomy
7⫹⫹ Cy, MTX, Vin
8⫹⫹ ⫹
9⫹⫹ Cy, AraC, VP16 IFN-, ATG, splenectomy, allogeneic HSCT
11 ⫹⫹ Ganciclovir, plasmapheresis, splenectomy
12 ⫹⫹EPOCH Bortezomib, autologous EBV-specific cytotoxic
T cells followed by allogeneic HSCT
13 ⫹⫹EPOCH-R, Cy, Flu Bortezomib/ganciclovir, allogeneic HSCT
14 Autologous EBV LCL-specific and LMP
1/2-specific cytotoxic T cells, lenalidomide
16 ⫹⫹EPOCH-R Allogeneic HSCT
17 ⫹⫹ ⫹EPOH, MTX Autologous EBV-specific cytotoxic T cells
followed by allogeneic HSCT
T-cell disease
10 ⫹⫹ Splenectomy
15 CHOEP, hyper CVAD,
MTX
High-dose cytarabine with L-asparaginase,
allogeneic HSCT
18 ⫹⫹ VP16 Syngeneic HSCT
NK-cell disease
19 Autologous EBV-specific cytotoxic T cells
followed by allogeneic HSCT
Adria indicates adriamycin; AraC, cytarabine;ATG, antithymocyte globulin; CHOEP,cyclophosphamide-doxorubicin-vincristine-etoposide-prednisolone; CTL, cytotoxic T lymphocyte; Cy, cyclophosphamide; EPOCH, etoposide-prednisone-
vincristine-cyclophosphamide-doxorubicin; EPOCH-R, EPOCH-rituximab; Flu, fludarabine; EPOH, etoposide-prednisone-vincristine-doxorubicin; HSCT, hematopoietic stem cell transplantation; hyperCVAD, cyclophosphamide-vincristine-
doxorubicin-dexamethasone; IVIG, intravenous immunoglobulin; LCL, lymphoblastoid cell line (EBV-transformed B cell line); LMP, latent membrane protein; MTX, methotrexate; NK, natural killer; Vin, vincristine; and VP16, etoposide.
5842 COHEN et al BLOOD, 2 JUNE 2011 VOLUME 117, NUMBER 22
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azathioprine (21%). Although immunosuppressive therapy tran-
siently relieved symptoms in most patients, it did not provide a
lasting effect in any patient. Five patients (26%) received rituximab
alone or as part of their chemotherapeutic regimen; in 3 (patients
12, 13, 16), CD20-negative lymphoproliferative lesions developed
after rituximab therapy. Twelve patients (63%) received cytotoxic
chemotherapy, resulting in transient or no response. 3 patients
(16%) received autologous EBV-specific CTLs21 before HSCT and
one in the absence of transplantation; these patients either had no
response (patients 12, 17, and 19; Figure 5A-B) or a transient
response (patient 14). Patient 14 had widespread lymphadenopa-
thy; a biopsy showed an EBV B-cell lymphoproliferative disorder,
and her EBV DNA was 953 copies/g in peripheral blood before
her first infusion of EBV-specific CTLs. After the infusion, her viral
load remained elevated, but her lymphadenopathy partially dimin-
ished. When her lymphadenopathy increased and a biopsy showed
progressive disease with features of polymorphic B-cell lymphoma
2 years later, she received 2 infusions of LMP1/2-specific CTLs,
but her disease did not respond to treatment. She is currently being
considered for HSCT. Other treatments included plasmapheresis
(1 patient) and the combination of bortezomib and ganciclovir in an
attempt to induce EBV lytic replication and killing of replicating
cells (1 patient); these were ineffective. Although some of these
treatments, particularly immunosuppressive therapy, rituximab,
cytotoxic chemotherapy, and autologous virus-specific CTLs, re-
sulted in transient improvement, none had a lasting effect.
HSCT for CAEBV
Although patients were first seen in 1982 and various therapies
were tried, HSCT was not begun in our patients until 1999. Most of
the patients who underwent HSCT, like those who did not receive
this therapy, had active disease involving vital organs (lung, CNS,
BM). Despite active disease at the time of HSCT several were
cured. Eight patients received HSCT. Three patients were at the
NIH, 1 at New York Presbyterian Morgan Stanley Children’s
Hospital, and 4 at Baylor; 7 were allogeneic transplantations, and
1 was a syngeneic transplantation (Table 6 and supplemental data).
Four patients received donor-derived EBV-specific CTLs after
undergoing transplantation.22 Patients 15, 17, 18, and 19 received
EBV- or LMP-specific T cells after undergoing allogeneic transplan-
tation on clinical trials at Baylor College of Medicine,21,22 which
were open to patients receiving allogeneic transplantation for an
EBV-associated disease. The goal of these studies was to boost
their cellular immune response to EBV and prevent or treat disease
recurrence. Patients 15 and 17 received prophylactic EBV- or
EBV-LMP1/2–specific CTLs after HSCT as consolidation therapy
at a time when the EBV DNA load was undetectable. Patient 18
received both EBV- and EBV-LMP1/LMP2–specific CTLs be-
cause of persistently elevated EBV DNA in the blood and
lymphadenopathy after transplantation; the patient’s disease pro-
gressed and he died of EBVT-cell lymphoma. Patient 19 received
EBV-specific CTLs for elevated EBV DNA in blood after
Figure 5. Clinical course. Clinical course for patients 12 (A) and 17 (B) is
shown. Time from initial clinic visit is shown on the x-axis and EBV DNA
viral load is on the y-axis. Chemo indicates chemotherapy; EPOCH-RF,
etoposide-vincristine-doxorubicin-cyclophosphamide-prednisone-
rituximab-fludarabine.
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Table 6. Outcome of hematopoietic stem cell transplant for patients with chronic active EBV
Patient
EBV
cells Age at Tx, y
Duration
disease
before
Tx, y
Previous
therapy Donor
Disease status at
transplant Conditioning
GVHD
prophylaxis
Donor EBV CTLs
posttransplant
EBV PCR
posttransplant
Outcome, time after
transplant
Transplanted at
the NIH
Clinical
Center
12 B cell 58 4 IFN, IVIG,
bortezomib,
EPOCH,
rituximab,
fludarabine,
autologous CTLs
6/6 sibling Persistent disease Cyclophosphamide,
fludarabine
MTX, CyA No PCR, then ,
then
Alive, 6 years
13 B cell 45 0.5 IFN, EPOCH,
rituximab,
ganciclovir
bortezomib,
6/6 sibling Persistent disease Cyclophosphamide,
fludarabine
CyA sirolimus No PCR, then Died, 20 days, central
pontine
myelinolysis,
residual B-cell
lymphoma,
multiorgan failure
16 B cell 30 1 IFN, steroids,
EPOCH, rituximab
Sibling/
URD
Persistent
disease
EPOCH-FR;
fludarabine/TBI
CyA, sirolimus, tacrolimus No PCRDied, 16 months,
residual B-cell
lymphoma
Transplanted at
New York
Presbyterian
Morgan
Stanley
Children’s
Hospital
15 T cell 12 4 CHOEP,
hyperCVAD,
cytarabine,
asparaginase,
MTX
5/6 sibling Persistent disease Thiotepa,
cyclophosphamide,
fludarabine
Tacrolimus, MMF Yes; 2 infusions of
2107/m2EBV
LMP1/2-specific CTLs
PCRAlive, 2 years
Transplanted at
Baylor
College of
Medicine
9 B cell 25 8 Acyclovir, CyA,
steroids, etoposide
6/6 URD Persistent T-cell
lymphoma
Cyclophosphamide
/cytarabine
/ATG/TBI
CD6/8 T cell depletion,
CyA
No PCR- Alive, CR 11 years
17 B cell 10 5 CyA, steroids,
etoposide,
rituximab, VAMP,
autologous CTLs
5/6 URD 4th CR Busulphan/
cyclophosphamide
/cytarabine/campath
CyA Yes; 1 infusion of
2107/m2EBV-
specific CTLs
PCR Low positive
/negative
Alive, CR 6 years
18 T cell 6 2 IVIG, acyclovir,
steroids,
etoposide, CyA
Syngeneic Refractory T-cell
lymphoma
Busulphan/
cyclophosphamide
/alemtuzumab
MTX, Tacrolimus Yes; 1 infusion of
2107/m2EBV-
specific CTLs and 6
infusions of 2 107/m2
EBV LMP1/LMP2-
specific CTLs
PCRDied, 4 years, relapsed
T-cell lymphoma
19 NK cell 12 4 autologous CTLs 5/6 URD Persistent disease Cyclophosphamide/
cytarabine
/alemtuzumab/TBI
MTX, tacrolimus Yes; 1 infusion of
2107/m2EBV-
specific CTLs
PCR, then ,
then
Alive, CR 2 years
ATG indicates antithymocyte globulin; CHOEP, cyclophosphamide-doxorubicin-vincristine-etoposide-prednisone; CR, complete remission; CTLs, cytotoxic T lymphocytes; CVAD, cyclophosphamide-vincristine-doxorubicin-
dexamethasone; CyA, cyclosporine; EPOCH, etoposide-prednisone-vincristine-cyclophosphamide-doxorubicin; FR, fludarabine-rituximab; IVIG, intravenous immunoglobulin; LMP, latent membrane protein; MMF,mycophenolate mofetil; MTX,
methotrexate; NK, natural killer; TBI, total body irradiation; TX, transplant; URD, unrelated donor; and VAMP, vincristine-doxorubicin-methotrexate-prednisone.
5844 COHEN et al BLOOD, 2 JUNE 2011 VOLUME 117, NUMBER 22
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transplantation; the EBV DNA decreased and it has remained
undetectable.
Five patients are still alive 2-11 years after transplantation. Of
these 5 patients, 2 (patients 9 and 15) were persistently EBV PCR
after undergoing transplantation (one of whom received donor
derived EBV-specific CTLs after transplantation). Patient 12 was
initially EBV PCRafter transplantation, transiently became
positive, and is negative now 6 years after transplantation. Patient
17 has had low positive-to-negative PCR results, received EBV-
specific CTLs after transplantation, and is now 5.5 years posttrans-
plantation. Patient 19, who was initially negative after transplanta-
tion, received EBV-specific CTLs when the blood EBV PCR
results came back positive and currently is EBV PCR2 years after
transplantation. Of the 5 patients who are alive after HSCT, 4
received CTLs either before or after transplantation; of the 3 who
died after HSCT, only 1 received CTLs.
Three patients died after transplantation. Patient 13 died of
multiorgan failure, had a single-negative EBV PCR near the time of
death, and at autopsy had primarily necrotic lymphoma. Patient
16 remained EBV PCRand died of refractory EBV B-cell
lymphoma. Patient 18 who received a syngeneic transplantation
remained PCRafter transplantation despite receipt of donor
EBV-specific CTLs after transplantation, and died 4 years later of
recurrent T-cell lymphoma.
In summary, 5 of 8 patients who underwent HSCT survived, and
the other 3 patients died with EBV-positive lymphomas (of B- or
T-cell lineage). Three of the 4 patients who underwent HSCT with
myeloablative pretransplantation conditioning are alive, and 1 died
of progressive EBV-positive lymphoma. Two of the 3 patients who
underwent nonmyeloablative HSCT survived, whereas one died
with central pontine myelinolysis. One patient received 2 transplan-
tations, the first with nonmyeloablative and the second with
myeloablative conditioning; he died with refractory EBV-positive
B-cell lymphoma.
Discussion
We have reviewed our 28-year experience with CAEBV and report
that patients in the United States have several important differences
from previously reported cases in Japan and South or Central
America. Nearly all of the patients in the literature with CAEBV
have been in Asians from Japan, Taiwan, or Korea, or native
Americans from Mexico, Central or South America.2,4-6,23 In
contrast, 68% (13/19) of patients in our study were white or African
Americans. In the largest review of patients with CAEBV, which
included 82 patients from Japan, the mean age at disease onset was
11 years,5whereas the mean age at presentation in our study was
19 years. Kimura et al5reported that older age (8 years) at onset
of disease correlated with a poor prognosis for survival. Signs and
symptoms for CAEBV in Japan and in the United States were
similar, although interstitial pneumonitis, CNS disease, and periph-
eral neuropathy were more common in US patients, whereas
hypersensitivity to mosquito bites (a finding usually associated
with NK cell CAEBV) were more commonly reported in Japan.
Antibody titers to several EBV lytic proteins were greater in
patients with CAEBV compared with control patients. The increase
in antibody titers to EBV lytic proteins in patients with CAEBV
disease compared with EBV-seropositive control patients is prob-
ably because of the uncontrolled proliferation of EBV-infected
cells with expression of viral lytic proteins and subsequent
production of antibody to these proteins. This is likely because of a
cellular immune disorder with failure to regulate EBV latently
infected lymphocytes. Although the authors of other studies have
reported markedly high titers to EBV viral capsid antigen, early
antigen-diffuse and early antigen-restricted in approximately two-
thirds of patients with CAEBV,1,2 we identified the individual viral
proteins that were the target of these antibodies in T-cell and B-cell
CAEBV. Furthermore, we found that patients with T-cell CAEBV
have greater antibody titers to lytic proteins than those with B-cell
CAEBV. Antibody to the EBNA1 latency protein has been reported
to be lacking in approximately 20% of patients with CAEBV2,5;
33% (4/12) of our patients lacked antibody to EBNA1, and patients
with B-cell CAEBV had greater levels of EBNA1 antibody than
those with T-cell CAEBV. Although patients with CAEBV have
high titers of antibodies to EBV, which might neutralize cell-free
virus, CAEBV disease is because of proliferation of EBV latently
infected lymphocytes. Cellular immunity, not antibody, is impor-
tant in controlling proliferating virus-infected lymphocytes, as
evidenced by the effectiveness of infusions of EBV-specific CTLs
to treat PTLD in transplantation recipients.22
Low B-cell numbers have not been reported previously in
CAEBV patients. We found that 43% had low levels of B cells in
the absence of rituximab, and 42% of our patients developed
hypogammaglobulinemia during the course of their disease.
Plasma levels of several cytokines, including IL-1, IL-10, and
IFN-, were reported to be elevated in persons with T-cell or
NK-cell CAEBV; IL-13 was elevated in patients with NK-cell
CAEBV.23 Transcripts for IL-1, IL-2, IL-10, IL-12p35, IL-13,
IL-15, IFN-, and TNF-were also observed to be elevated in
PBMCs from patients with CAEBV.23,24 We found that both Th1
(TNF-, and IFN-) and Th2 (IL-6, IL-10) cytokines were
significantly elevated in the serum of our patients with B-cell
CAEBV compared with control patients. This finding is indicative
of the “unbalanced cytokine profile” that has been reported
previously in these patients.24 Elevated levels of each of these
cytokines has been reported in the serum of patients with he-
mophagocytosis, which is common in CAEBV disease.
Approximately 33% of our patients had low NK-cell numbers.
In a study of 81 patients with CAEBV in Japan, none was reported
to have low NK-cell numbers, and 19% (15/81) had elevated
NK-cell numbers.5One patient in our study (patient 16) had
reduced NK-cell activity, despite a normal number of NK cells.
Reduced NK-cell activity has been reported in 8 of 9 patients with
CAEBV from Japan25 and in 2 patients from Canada.10
Most Asians or Native Americans reported with CAEBV have
EBV involving T cells or NK cells. In a review of patients with
CAEBV in Japan, 54% of patients had EBV in T cells, 39% in
NK cells, 4% in T and NK cells, and 3% in B cells.5In our patients
in whom tissue was available, 73% had EBV in B cells and 20% in
T cells in tissues. Four of the 11 patients with EBV in B cells had
prominent T-cell infiltrates in their tissues and in some cases the
T cells were clonal. A similar clonal T-cell expansion in response to
EBV-infected B cells has been reported in infectious
mononucleosis.26
Kimura et al2,5 have shown that T-cell CAEBV has a poorer
prognosis than NK-cell CAEBV. The probability of survival at
5 years after disease onset was 0.59 for patients with T-cell
CAEBV and 0.87 for those with NK-cell CAEBV. In our study, at
5 years after the onset of disease, 66% of patients with T-cell
CAEBV were alive and 73% of those with B-cell CAEBV were
alive. Overall, however, 66% of the patients with T-cell CAEBV
died and 64% of those with B-cell CAEBV died.
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Table 7. Previous reports of hematopoietic stem cell transplant for patients with chronic active EBV
Reference EBVcells Age at Tx, y Duration of disease before Tx, y Type of transplant Follow-up after transplant
33 T/NK 7 3 Allo sib, MA A 134 mo, EBV PCR
34 NK 24 2 Allo sib, MA D 19 d, infection, PCR
35 T 9 0.1 Allo sib, MA A 47 mo, PCR
36 T 8 3 Allo, dad, MA D 26 d, VOD, MOF, PCR
36 T 5 4 Allo, dad, MA A 124 mo, PCR
37 NK 4 11 Allo, MUD, MA D d 14, VOD, infection, RF
37 NK 3 4 Allo, MUD, MA A 110 mo, PCR
37 NK 11 8 Allo, MUD, MA A 110 mo, PCR
38 T 31 1 Allo, sib, NMA A 86 mo, PCR
39 NK 10 5 Allo, sib, MA A 24 mo, PCR
40 T 14 1 Allo, sib, NMA A 27 mo, PCR
41 ND 31 0.5 Allo, sib, MA D 3 mo, liver failure, pancreatitis, PCR
42 T 11 4 Allo, mom, NMA Rejection, carditis, PCR
Allo, mom, NMA Graft failure, GVHD, PCR
Unrelated cord blood A 15 mo, GVHD, zoster, PCR
43 T 8 5 Unrelated cord blood A 15 mo, GVHD, PCR
44 ND 53 3 Auto HSCT Progressed
Unrelated cord blood A 16 mo, acute then chronic GVHD, PCR
12 T 8 7 Allo, mom, NMA A 67 mo
12 T 2 1 Allo, MUD, NMA A 23 mo
12 NK 6 4 Allo, MUD, NMA A 13 mo
12 NK 20 18 Allo, sib, NMA D 2 mo, relapse
12 NK 15 12 Allo, sib, MA D 1 mo, VOD, intracranial bleed
12 ND 31 27 Allo, sib, MA D 67 mo, DIC, acute pancreatitis
12 T 9 5 Allo, sib, MA A 49 mo, rejection, relapse, 2nd Tx
12 NK 9 5 Allo, MUD, MA A 12 mo
12 NK 16 6 Allo, MUD, NMA A 57 mo
12 NK 19 7 Allo, MUD, NMA A 9 mo
12 T 24 11 Allo, MUD, NMA D 10 mo, relapse
12 T 18 4 Allo, sib, MA D 1 mo, intracranial bleed
12 NK 15 1 Allo, sib, NMA D 16 mo, relapse
12 T 24 5 Allo, MUD, NMA D 4 mo, encephalomyelitis
12 T 27 1 Allo, MUD, NMA A 46 mo
45 T 30 0.1 Allo, sib, NMA A 10 mo, rejected donor T cells, reinfused
donor T cells twice, PCR
46 T 5 0.5 Allo, mom, MA A 4 mo, PCR
46 NK 2 0.5 Allo, MUD, MA A 3 mo, PCR
47 NK 13 10 Allo, MUD, NMA A 27 mo, PCR
14 T 10 0.5 Allo, MUD, MA A 101 mo
14 T 18 6 Allo, MUD, MA D, 35 mo
14 T 13 1 Allo, CD34, MA D, 198 d
14 NK 5 1 Allo, MUD, MA A, 69 mo
14 T/NK 18 0.3 Allo, rel, MA D, 1 y
14 T 4 1 Unrelated cord blood, NMA A, 71 mo
14 NK 19 3 Allo, rel, NMA A, 70 mo
14 NK 5 1 Allo, rel, NMA A, 68 mo
14 NK 17 1 Allo, CD34, NMA D, 19 d
14 T 7 1 Allo, rel, NMA Relapse
1.75 Allo, rel, NMA A, 51 mo
14 NK 47 19 Unrelated cord blood, NMA A, 45 mo
14 T 19 0.5 Allo, CD34, NMA A, 43 mo
14 T 11 2.5 Unrelated cord blood, NMA Graft failure
3 Unrelated cord blood, NMA A, 27 mo
14 NK 13.5 1.5 Allo, MUD, NMA A, 27 mo
14 T 9 2 Unrelated cord blood, NMA A, 27 mo
14 T 36 13 Allo, rel, NMA A, 27 mo
14 ND 3 1 Unrelated cord blood, NMA A, 23 mo
14 NK 10 3 Unrelated cord blood, NMA A, 22 mo
14 NK 18.5 0.5 Allo, rel, NMA A, 21 mo
14 T/NK 7 6 Allo, MUD, NMA A, 21 mo
14 T 21 1 Allo, MUD, NMA A, 14 mo
14 NK 38 1 Allo, rel, NMA A, 12 mo
48 NK 59 1 Allo, MUD, NMA D 30 d, GI bleed, PCR
A indicates alive; Allo, allogeneic;Auto, autologous; D, dead; DIC, disseminated intravascular coagulation; GI, gastrointestinal; HSCT, hematopoietic stem cell transplant;
MA, myeloablative; mo, months; MOF,multiorgan failure; MUD, matched unrelated donor; ND, not determined; NK, natural killer; NMA, nonmyeloablative; rel, related; RF, renal
failure; sib, sibling; Tx, transplant; and VOD, veno-occlusive disease.
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Patients with CAEBV received several therapies before HSCT,
including antiviral agents (acyclovir and valacyclovir). Acyclovir
acts by inhibiting the viral DNA polymerase, which is expressed
during EBV lytic, but not latent gene expression. Although there
have been anecdotal reports that acyclovir may have activity in
some cases,7the observation that EBV-infected cells from patients
with CAEBV have a type 2 or 3 latency pattern without lytic gene
expression11,23,27 is consistent with the lack of response to antiviral
therapy that we and most others have observed. Similarly, although
anecdotal reports suggest that CAEBV may respond to immuno-
modulatory agents (eg, IFN-,28 IL-229), we and others have found
these agents to be ineffective. Immunosuppressive agents (eg,
corticosteroids, cyclosporine) have been effective in the treatment
of EBV-associated hemophagocytosis,30 which was seen in 32% of
our patients and was reported in 24% of patients in Japan5;
however, these agents did not result in long-term remissions in our
patients. Rituximab has been effective in some cases of X-linked
lymphoproliferative disease and was temporarily effective in
several patients with B-cell CAEBV; however, in most of our
patients EBV was found in both CD20and CD20B cells in the
initial lesions, and after treatment with rituximab several patients
had lesions that were EBV-positive solely in CD20B cells.
Cytotoxic chemotherapy has been effective for treatment of B-cell
lymphomas in patients without CAEBV; however, combination
chemotherapy (including EPOCH [etoposide, prednisone, vincris-
tine, cyclophosphamide, and doxorubicin] with rituximab), bort-
ezomib, and the combination of bortezomib and ganciclovir were
ineffective in our patients (Table 5).
Transfer of autologous EBV-specific CTLs or HLA-identical
EBV-specific CTLs from an HLA-identical sibling have been used
to treat CAEBV. A transient decrease in EBV DNA in blood in a
patient with CAEBV was reported with EBV-specific CTLs.31 In
patients with a milder form of EBV-associated disease, defined as
6 months of symptoms (usually fever and fatigue) and either
elevated EBV DNA in the blood, free EBV DNA in serum/
cerebrospinal fluid, or EBV VCA antibody titer 1:640, autolo-
gous EBV-specific CTLs resulted in improvement of symptoms.32
However, these patients had milder disease than that seen with
CAEBV and did not have biopsy-proven evidence of tissue
infiltration with EBV-positive lymphocytes. Four patients in our
study (patients 12, 14, 17, and 19) received autologous EBV-
specific CTLs. Patients 12, 17, and 19 did not respond to treatment;
patient 14 had a transient response after receiving 3 courses of
CTLs. All 4 patients eventually relapsed and 3 underwent alloge-
neic HSCT. The lack of long-term benefit from infusions of
autologous EBV-specific T cells is likely because of impaired
function of the patient’s CTLs. In contrast, infusions of virus-
specific T cells after transplantation from donors that are able to
control EBV infection have been shown to be useful in prevention
or treatment of EBV lymphoproliferative disease after transplanta-
tion.22 In a review of 101 HSCT recipients given EBV-specific
CTLs either prophylactically after high-risk transplantations (eg,
transplantations from matched unrelated donors with CD8 T-cell
depletion or transplantations for EBV lymphoma) none of the
patients developed PTLD.22 In the same review 11 of 13 HSCT
recipients given EBV-specific CTLs for EBV PTLD or increasing
levels of EBV DNA in the blood and symptoms consistent with
EBV PTLD had sustained long-term remissions. Thus, in patients
with CAEBV disease who may not have fully engrafted and who
have moderate or high levels of EBV DNA in the blood after
transplantation, infusions of donor-derived EBV-specific T cells
may be effective.
Fifty-six individual cases of CAEBV treated with allogeneic
HSCT from Japan12,14,33-47 and 1 case from the Netherlands48 have
been reported in the literature (Table 7). Forty-six percent (26/57)
were T cell in origin, 42% (24/57) were NK cell, 5% (3/57) were
NK/T, and 7% (4/57) were of undetermined origin; none were
B cell in origin. In contrast, of the 8 CAEBV patients who
underwent HSCT in this report, 5 were B-cell CAEBV, 2 were
T-cell, and 1 was NK-cell. Of the 57 patients in the literature,
25 (44%) received HSCT from related donors, 20 (35%) from
matched unrelated donors, 7 (12%) underwent cord blood transplan-
tations, 1 underwent an allogeneic-related transplantation followed
by unrelated cord blood, 1 underwent an autologous transplantation
followed by unrelated cord blood, and 3 were reported only to
receive peripheral blood CD34cells. In our series, 4 received
sibling donor, nonmyeloablative transplantation (1 was followed
by an unrelated donor nonmyeloablative transplantation), 3 under-
went unrelated donor myeloablative transplantation, and 1 under-
went transplantation from his identical twin donor.
Seventy-two percent (41/57) of CAEBV patients who under-
went HSCT in the literature survived after transplantation, whereas
63% (5/8) of our patients survived. Of the patients reported in the
literature that were transplanted who died versus those who
survived, there was no difference in the frequency of T-cell or
NK-cell disease; however, survivors presented at an earlier age
(mean, 14.4 years vs 21.2 years), had a shorter duration of disease
before transplantation (3.5 years vs 6.5 years), and were more
likely to have undergone nonmyeloablative transplantations (69%
vs 38%) than myeloablative transplantations. Deaths reported in
the literature and in our study were primarily because of progres-
sive disease, relapsed disease, or transplantation-related complica-
tions. All but one of our patients whom we have followed for more
than 5 years and who did not receive an allogeneic HSCT died from
complications related to CAEBV.
In conclusion, CAEBV in the United States is most often
because of uncontrolled EBV infection in B cells, and many of
these patients have a progressive loss of B cells and hypogam-
maglobulinemia. Antiviral therapy is usually ineffective; although
patients may have a temporary response to rituximab, immunosup-
pressive therapy, cytotoxic chemotherapy, autologous CTLs, or
syngeneic HSCT, these treatments are not curative, and most
patients succumb to their disease. Allogeneic HSCT is often
curative for CAEBV disease. Both myeloablative and nonmyeloab-
lative conditioning regimens have been successful even with
progressive CAEBV disease at the time of transplantation. Unfortu-
nately, death from progressive CAEBV disease remains the pri-
mary cause of failure after transplantation. Therefore, allogeneic
HSCT should be considered early in the course of the disease when
the patient is better able to tolerate transplantation.
Note added in proof. Patient 14 has recently undergone alloge-
neic HSCT.
Acknowledgments
We thank Gary Fahle of the NIH Clinical Center and Greg Storch
of Washington University for measuring EBV DNA in blood,
Stacey Rickleffs and Steve Porcella of Rocky Mountain Laborato-
ries NIAID for DNA sequence analysis, Karen Thatcher and
Ronald Hornung of SAIC Frederick for cytokine measurements,
and Thomas Fleisher of the NIH Clinical Center for peripheral
blood flow cytometry measurements The paper is dedicated to
Stephen Straus, who initiated the work and inspired us.
CHRONIC ACTIVE EBV DISEASE IN THE UNITED STATES 5847BLOOD, 2 JUNE 2011 VOLUME 117, NUMBER 22
For personal use only. by guest on October 13, 2011. bloodjournal.hematologylibrary.orgFrom
This work was supported by the intramural research programs
of the National Institute of Allergy and Infectious Diseases, the
National Cancer Institute, and the National Institute of Dental and
Craniofacial Research and extramural grants CA094237 and
P50CA126752.
Authorship
Contribution: J.I.C. and S.E.S. designed and supervised the study;
J.I.C. wrote the manuscript; E.S.J. and S.P. were responsible for
diagnosis and reviewing pathology; J.K.D., H.E.H., C.M.R., S.G.,
C.M.B., V.K.R., A.M., A.S.W., R.F.L., M.S.C., D.F., C.S., M.R.B.,
and W.W. provided data on patients, participated in clinical care
and decision-making on patients, and reviewed the manuscript;
S-P.T., R.F., and N.K.E. assisted with patient care; and P.D.B.
performed antibody assays.
Conflict-of-interest disclosure: The authors declare no compet-
ing financial interests.
Correspondence: Jeffrey I. Cohen, Laboratory of Infectious
Diseases, 50 South Dr, Bldg 50, Rm 6134, MSC 8007, National
Institutes of Health, Bethesda, MD 20892-8007; e-mail: jcohen@
niaid.nih.gov.
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CHRONIC ACTIVE EBV DISEASE IN THE UNITED STATES 5849BLOOD, 2 JUNE 2011 VOLUME 117, NUMBER 22
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... CAEBV infection is a rare but fatal disorder resulting from a persistent EBV infection state and usually affects children and adolescents. Regions with high incidence are mostly East Asia countries (9,10). The clinical features are highly diverse and insidious, with potential involvement of different organs, and its severity varies clinically. ...
... Cases reported from Western countries are usually associated with proliferation of EBV-infected B cells, with cases of T-and NK cell disease less common. This distribution is analogous to that of extranodal NK/T cell lymphoma, also referred to as nasal NK/T-cell lymphoma, which is also thought to be precipitated by EBV infection (9,27). More geographical studies are required for this racial distribution. ...
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Chronic active Epstein-Barr virus infection (CAEBV), which often manifests as persistent infectious mononucleosis-like symptoms and can involve multiple organs, is a prolonged or reactivated status of primary EBV infection. Cardiovascular damage is one of the rare but severe complications correlated with poor prognosis among all CAEBV patients. Few published articles have demonstrated systemic arterial lesions involving branches of the aorta as cardiovascular complications. Herein, we report a rare pediatric case of CAEBV associated with giant sinus of Valsalva aneurysms and aorta and its branch dilations.
... Standard therapy regimens for CAEBV infection have not been established. Hematopoietic stem cell transplantation (HSCT) is currently the only regimen that can cure the disease (10,11). However, HSCT presents significant risks and complications for patients. ...
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... Kimura et al. (1,9) demonstrated that liver dysfunction, thrombocytopenia, fever (more than once a week), splenomegaly, anemia, and time from onset of more than 8 years are important poor prognostic predictors in patients with CAEBV. The prognosis for patients with T cell clonal proliferation is even worse than the NK cell type as reported by Cohen et al. in a retrospective analysis (12). ...
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A 44-year-old Japanese man presented with fever and sore throat. He had a history of refractory chronic sinusitis that did not respond to several years of pharmacotherapy, and underwent endoscopic sinus surgery (ESS) 5 months prior to his presentation, but his symptoms persisted. A biopsy specimen was taken from the right nasal cavity, and extranodal natural killer/T-cell lymphoma, nasal type (ENKTL) was diagnosed. Two years after complete remission was achieved by chemoradiation therapy, he developed hemophagocytic lymphohistiocytosis (HLH) without recurrence of ENKTL. Epstein-Barr virus (EBV)-DNA copy number was relatively high and EBV-infected lymphocytes (CD8 + T cells) were detected in the peripheral blood. Pathological review of the biopsy specimens taken during ESS showed that CD8 + T cells with slightly atypia infiltrating the stroma were EBV positive. These findings suggested that the patient had underlying chronic active EBV infection (CAEBV) that caused the refractory chronic sinusitis, eventually developed into ENKTL, and also caused HLH. Clinicians should consider adult-onset CAEBV in the differential diagnosis of patients with refractory chronic sinusitis.
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