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Plaza JA, Gru AA, Sangueza OP, Lourenco SV, Puccio FB, Sanches JA, Miyashiro D, Toussaint S, Sangueza MJ. An update on viral-induced cutaneous lymphoproliferative disorders. CME Part I. J Am Acad Dermatol 2023; 88:965-980. [PMID: 36041557 DOI: 10.1016/j.jaad.2021.11.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 10/19/2021] [Accepted: 11/03/2021] [Indexed: 11/21/2022]
Abstract
Viral-induced cutaneous T-cell lymphomas are an uncommon group of lymphoproliferative disorders characterized by a viral infection of T and natural killer (NK) cells. This group of cutaneous T-cell lymphomas is more commonly encountered in Asians and Native Americans from Central and South America compared with Western populations. Viral-associated lymphoproliferative disorders include a spectrum of entities that range from nonneoplastic lesions, such as chronic active Epstein-Barr virus infection and infective dermatitis to malignant diseases, such as extranodal NK/T-cell lymphoma, hydroa vacciniforme-like T-cell lymphoma, and adult T-cell leukemia/lymphoma. This review article will focus on hydroa vacciniforme-like lymphoproliferative disorder, extranodal NK/T-cell lymphoma, adult T-cell leukemia/lymphoma, lymphomatoid granulomatosis, and Epstein-Barr virus-positive mucocutaneous ulcers. We will review the pathogenesis of these conditions and the challenges of making a timely diagnosis in early-stage disease and discuss the common clinicopathologic manifestations, mutational landscape, and approaches to treat these highly aggressive and frequently lethal types of lymphoma.
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MESH Headings
- Education, Medical, Continuing
- Lymphoproliferative Disorders/pathology
- Lymphoproliferative Disorders/therapy
- Lymphoproliferative Disorders/virology
- Skin Diseases/pathology
- Skin Diseases/therapy
- Skin Diseases/virology
- Epstein-Barr Virus Infections
- Lymphoma, T-Cell, Cutaneous/pathology
- Lymphoma, T-Cell, Cutaneous/therapy
- Lymphoma, T-Cell, Cutaneous/virology
- Skin Neoplasms/pathology
- Skin Neoplasms/therapy
- Skin Neoplasms/virology
- Hydroa Vacciniforme/pathology
- Hydroa Vacciniforme/therapy
- Leukemia-Lymphoma, Adult T-Cell/pathology
- Leukemia-Lymphoma, Adult T-Cell/therapy
- Lymphomatoid Granulomatosis/pathology
- Lymphomatoid Granulomatosis/therapy
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Affiliation(s)
- Jose A Plaza
- Division of Dermatopathology, Department of Pathology and Dermatology, The Ohio State University Wexner Medical Center (OSUWMC), Columbus, Ohio.
| | - Alejandro A Gru
- Division of Dermatopathology, Department of Pathology, University of Virginia, Charlottesville, Virginia
| | - Omar P Sangueza
- Division of Dermatopathology, Department of Pathology, Wake Forest Baptist Health, Winston-Salem, North Carolina
| | - Silvia V Lourenco
- Department of Stomatology, Dental School, University of Sao Paolo, São Paulo, Brazil
| | - Francisco B Puccio
- Department of Dermatology, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Jose A Sanches
- Department of Dermatology, University of São Paulo, São Paulo, Brazil
| | - Denis Miyashiro
- Department of Dermatology, University of São Paulo, São Paulo, Brazil
| | - Sonia Toussaint
- Department of Dermatology, National Autonomous University, Mexico City, Mexico
| | - Martin J Sangueza
- Department of Pathology and Dermatology, Hospital Obrero, La Paz, Bolivia
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Fukuzawa S, Yamagata K, Terada K, Uchida F, Ishibashi-Kanno N, Bukawa H. Age Related Immunosenescence Epstein-Barr Virus-positive Mucocutaneous Ulcer of the Palate Mimicking Medication-related Osteonecrosis of the Jaw. Indian J Otolaryngol Head Neck Surg 2022; 74:4593-4597. [PMID: 36742844 PMCID: PMC9895354 DOI: 10.1007/s12070-021-02859-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 09/08/2021] [Indexed: 02/07/2023] Open
Abstract
Epstein-Barr virus (EBV) -positive mucocutaneous ulcer (EBVMCU) was first described as a lymphoproliferative disorder in 2010. In recent years, EBVMCU has been reported in the field of oral surgery. On the other hand, medication-related osteonecrosis of the jaw (MRONJ) is an osteomyelitis that occurs in patients receiving antiresorptive agents including bisphosphonates (BP) and/or denosumab developing with bacterial infections such as dental diseases and mucositis. MRONJ caused by EBVMCU in the elderly has not been reported. Here, we report a rare case of MRONJ caused by EBVMCU in the elderly. The patient, an 82-year-old woman, had received BP for more than 2 years. An ulcerative lesion was found in the palatal mucosa; biopsy performed from the site confirmed the diagnosis of EBVMCU. At follow-up, the lesion disappeared spontaneously. At the 6-month follow-up, bone formation was observed at the site of the lesion, and the sequestrum was removed. At the 12-month follow-up healing of the EBVMCU region was seen indicating a good prognosis.
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Affiliation(s)
- Satoshi Fukuzawa
- Department of Oral and Maxillofacial Surgery, Faculty of Medicine, Institute of Clinical Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575 Japan
| | - Kenji Yamagata
- Department of Oral and Maxillofacial Surgery, Faculty of Medicine, Institute of Clinical Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575 Japan
| | - Kazuhiro Terada
- Department of Oral and Maxillofacial Surgery, Faculty of Medicine, Institute of Clinical Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575 Japan
| | - Fumihiko Uchida
- Department of Oral and Maxillofacial Surgery, Faculty of Medicine, Institute of Clinical Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575 Japan
| | - Naomi Ishibashi-Kanno
- Department of Oral and Maxillofacial Surgery, Faculty of Medicine, Institute of Clinical Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575 Japan
| | - Hiroki Bukawa
- Department of Oral and Maxillofacial Surgery, Faculty of Medicine, Institute of Clinical Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575 Japan
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3
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Co-Occurrence of EBV-Positive Mucocutaneous Ulcer (EBV-MCU) and CLL/SLL in the Head and Neck Region. Curr Oncol 2022; 29:2749-2767. [PMID: 35448198 PMCID: PMC9026795 DOI: 10.3390/curroncol29040224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/09/2022] [Accepted: 04/13/2022] [Indexed: 11/16/2022] Open
Abstract
EBV-positive mucocutaneous ulcer (EBV-MCU) was classified as a rare new entity of the lymphoproliferative B-cell diseases by the WHO in 2017 and must be distinguished from head and neck squamous cell carcinoma by early biopsy. The aim of the study is to raise awareness of the disease and to give a review of the current literature and a recommendation for EBV-MCU management. All EBV-MCU cases of the head and neck region published so far were included. We also report a case of a pharyngeal EBV-MCU in an 89-year-old patient who was immunosuppressed by chronic lymphatic leukaemia/small lymphocytic lymphoma (CLL/SLL). In contrast to all previously described cases, histopathology showed a co-infiltration of EBV-MCU and CLL/SLL. A total of 181 cases were identified on PubMed and summarised. EBV-MCU was predominantly caused by immunosuppressive drug therapy. Complete remission could be achieved in 68% of cases and was mainly attributed to a reduction of the immunosuppressive therapy alone (72%). However, some severe cases require more aggressive treatment. Regarding the various histopathologic similarities to other lymphoproliferative disorders, the diagnosis of EBV-MCU can be misleading, with a great impact on patient care and treatment. This diagnosis must be made with caution and requires a combination of clinical, morphological and immunophenotypic features.
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Forster M, Fedoriw Y, Tuchman S, Grover N. Epstein–Barr virus mucocutaneous ulcer followed by Hodgkin lymphoma in multiple myeloma patient. Clin Case Rep 2022; 10:e05528. [PMID: 35280097 PMCID: PMC8894576 DOI: 10.1002/ccr3.5528] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 02/17/2022] [Accepted: 02/20/2022] [Indexed: 11/08/2022] Open
Abstract
Epstein–Barr virus mucocutaneous ulcers (EBV MCU) are B‐cell lymphoproliferative disorders associated with immunosuppression. We report EBV MCU in a multiple myeloma patient on lenalidomide maintenance after stem cell transplant that resolved with decreased immunosuppression. Furthermore, the subsequent development of classical Hodgkin lymphoma suggests an underlying predisposition to EBV‐driven lymphoproliferative disorders.
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Affiliation(s)
- Moriah Forster
- Department of Internal Medicine University of North Carolina Chapel Hill North Carolina USA
| | - Yuri Fedoriw
- Department of Pathology and Lab Medicine University of North Carolina Chapel Hill North Carolina USA
| | - Sascha Tuchman
- Lineberger Comprehensive Cancer Center Department of Hematology University of North Carolina Chapel Hill North Carolina USA
| | - Natalie Grover
- Lineberger Comprehensive Cancer Center Department of Hematology University of North Carolina Chapel Hill North Carolina USA
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Alamoudi WA, Azar A, Barta SK, Alawi F, Tanaka TI, Stoopler ET, Sollecito TP. EBV-positive B-cell ulcerative proliferation in the oral cavity associated with EBV-negative follicular lymphoma in a patient with common variable immunodeficiency: A case report and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol 2021; 133:e10-e19. [PMID: 34645592 DOI: 10.1016/j.oooo.2021.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 09/07/2021] [Indexed: 10/20/2022]
Abstract
Lymphoproliferative disorders (LPDs) are a group of conditions characterized by excessive production of lymphocytes manifested in various patterns including lymphadenopathy, tumor-like lesions, and lymphomas. LPD may be stimulated by Epstein-Barr virus (EBV) infection that most commonly appears in the setting of immunocompromised status such as long-term use of immunosuppressive medications and in individuals with primary immunodeficiency disorders. EBV mucocutaneous ulcer is a benign LPD reaction that mostly regresses spontaneously but sometimes requires medical or surgical intervention. This article presents a case of oral EBV mucocutaneous ulceration that affected an individual with a history of complex primary immunodeficiency disorders consisted of common variable immunodeficiency disease associated with T-cell dysfunction. This case is unique because the oral lesions led to the diagnosis of concurrent widespread EBV-negative follicular lymphomas, seemingly unrelated to her EBV-positive LPD oral disease. Yet, both occurred in the setting of severe immunosuppression from the primary immunodeficiency disorders.
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Affiliation(s)
- Waleed A Alamoudi
- Resident, Department of Oral Medicine, School of Dental Medicine, University of Pennsylvania, Philadelphia.
| | - Antoine Azar
- Assistant Professor, Division of Allergy and Clinical Immunology, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Stefan K Barta
- Associate Professor, Department of Hematology/Oncology, School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Faizan Alawi
- Professor of Pathology, Department of Basic & Translational Sciences, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA
| | - Takako I Tanaka
- Professor of Oral Medicine, Department of Oral Medicine, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA
| | - Eric T Stoopler
- Professor of Oral Medicine, Department of Oral Medicine, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA
| | - Thomas P Sollecito
- Professor of Oral Medicine, Department of Oral Medicine, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA
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6
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Ikeda T, Gion Y, Nishimura Y, Nishimura MF, Yoshino T, Sato Y. Epstein-Barr Virus-Positive Mucocutaneous Ulcer: A Unique and Curious Disease Entity. Int J Mol Sci 2021; 22:ijms22031053. [PMID: 33494358 PMCID: PMC7865427 DOI: 10.3390/ijms22031053] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 12/11/2022] Open
Abstract
Epstein–Barr virus (EBV)-positive mucocutaneous ulcer (EBVMCU) was first described as a lymphoproliferative disorder in 2010. EBVMCU is a unifocal mucosal or cutaneous ulcer that often occurs after local trauma in patients with immunosuppression; the patients generally have a good prognosis. It is histologically characterized by proliferating EBV-positive atypical B cells accompanied by ulcers. On the basis of conventional pathologic criteria, EBVMCU may be misdiagnosed as EBV-positive diffuse large B-cell lymphoma or other lymphomas. However, its prognosis differs from that of EBV-associated lymphomas, in that patients with EBVMCU frequently show spontaneous regression or complete remission without chemotherapy. Therefore, EBVMCU is now recognized as a low-grade malignancy or a pseudo-malignant lesion. Avoiding unnecessary chemotherapy by distinguishing EBVMCU from other EBV-associated lymphomas will reduce the burden and unnecessary harm on patients. On the basis of these facts, EBVMCU was first described as a new clinicopathological entity by the World Health Organization in 2017. In this review, we discuss the clinicopathological characteristics of previously reported EBVMCU cases, while focusing on up-to-date clinical, pathological, and genetic aspects.
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Affiliation(s)
- Tomoka Ikeda
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan; (T.I.); (M.F.N.); (T.Y.)
| | - Yuka Gion
- Division of Pathophysiology, Okayama University Graduate School of Health Sciences, Okayama 700-8558, Japan;
| | - Yoshito Nishimura
- Department of General Medicine, Okayama University Hospital, Okayama 700-8558, Japan;
| | - Midori Filiz Nishimura
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan; (T.I.); (M.F.N.); (T.Y.)
| | - Tadashi Yoshino
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan; (T.I.); (M.F.N.); (T.Y.)
| | - Yasuharu Sato
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan; (T.I.); (M.F.N.); (T.Y.)
- Division of Pathophysiology, Okayama University Graduate School of Health Sciences, Okayama 700-8558, Japan;
- Correspondence: ; Tel.: +81-86-235-7150; Fax: +81-86-235-7156
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7
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Ikeda T, Gion Y, Sakamoto M, Tachibana T, Nishikori A, Nishimura MF, Yoshino T, Sato Y. Clinicopathological analysis of 34 Japanese patients with EBV-positive mucocutaneous ulcer. Mod Pathol 2020; 33:2437-2448. [PMID: 32561847 DOI: 10.1038/s41379-020-0599-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/03/2020] [Accepted: 06/03/2020] [Indexed: 12/27/2022]
Abstract
Epstein-Barr virus (EBV)-positive mucocutaneous ulcer (EBVMCU) is a unifocal mucosal or cutaneous ulcer that is histologically characterized by proliferating EBV-positive atypical B cells. While EBVMCU demonstrates a histology similar to that of EBV-positive diffuse large B-cell lymphoma (DLBCL), their clinical behavior differs. Thus, characterizing distinguishing features of EBVMCU and EBV-positive DLBCL is critical. To identify unique characteristics between EBVMCU and lymphoma, we analyzed the clinicopathological and genetic features of 34 Japanese patients with EBVMCU and compared them to those of 24 EBV-positive DLBCL patients and 25 EBV-negative DLBCL patients. All patients with EBVMCU had localized ulcerative lesions, and 31 patients (91%) were using immunosuppressants, such as methotrexate (MTX) or hydroxycarbamide. All patients that were followed up with exhibited good prognosis following immunosuppressant reduction or chemotherapy. In addition, 17 EBV-positive DLBCL patients, and 15 EBV-negative DLBCL patients, received chemotherapy (P < 0.001, P < 0.001, respectively). Our data showed that EBVMCU did not increase indicators associated with lymphoma prognosis, such as soluble interleukin 2 receptor (sIL-2R) and lactate dehydrogenase (LDH) compared to those in the EBV-positive DLBCL or EBV-negative DLBCL groups (sIL-2R, P < 0.001, P = 0.025; LDH, P = 0.018, P = 0.038, respectively). However, histologically, EBVMCU exhibited EBV-positive, variable-sized, atypical B-cell proliferation. Thus, EBVMCU was histologically classified as: (1) polymorphous; (2) large cell-rich; (3) classic Hodgkin lymphoma-like; and (4) mucosa-associated lymphoid tissue lymphoma-like. Moreover, genetic analysis showed that immunoglobin heavy chain (IGH) gene rearrangement did not differ significantly between EBVMCU and EBV-positive DLBCL (44% vs. 32%; P = 0.377), or between EBVMCU and EBV-negative DLBCL (44% vs. 58%; P = 0.280). Therefore, it is difficult to distinguish EBVMCU from EBV-positive DLBCL using only pathological and genetic findings, suggesting that clinical information is important in accurately distinguishing between EBVMCU and EBV-positive DLBCL.
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Affiliation(s)
- Tomoka Ikeda
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yuka Gion
- Division of Pathophysiology, Okayama University Graduate School of Health Sciences, Okayama, Japan.
| | - Misa Sakamoto
- Division of Pathophysiology, Okayama University Graduate School of Health Sciences, Okayama, Japan
| | - Tomoyasu Tachibana
- Department of Otolaryngology, Japanese Red Cross Society Himeji Hospital, Himeji, Japan
| | - Asami Nishikori
- Division of Pathophysiology, Okayama University Graduate School of Health Sciences, Okayama, Japan
| | - Midori Filiz Nishimura
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Tadashi Yoshino
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yasuharu Sato
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan. .,Division of Pathophysiology, Okayama University Graduate School of Health Sciences, Okayama, Japan.
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Ikeda T, Gion Y, Yoshino T, Sato Y. A review of EBV-positive mucocutaneous ulcers focusing on clinical and pathological aspects. J Clin Exp Hematop 2019; 59:64-71. [PMID: 31257347 PMCID: PMC6661964 DOI: 10.3960/jslrt.18039] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Epstein-Barr virus (EBV)-positive mucocutaneous ulcers (EBVMCUs) were first described as a lymphoproliferative disorder in 2010. Clinically, EBVMCUs are shallow, sharply circumscribed, unifocal mucosal or cutaneous ulcers that occur in immunosuppressed patients, including those with advanced age-associated immunosenescence, iatrogenic immunosuppression, primary immune disorders, and HIV/AIDS-associated immune deficiencies. In general, patients exhibit indolent disease progression and spontaneous regression. Histologically, EBVMCUs are characterized by the proliferation of EBV-positive, variable-sized, atypical B-cells. According to conventional histopathologic criteria, EBVMCUs may diagnosed as lymphomas. However, EBVMCUs are recognized as pseudomalignant lesions because they spontaneously regress without anti-cancer treatment. Therefore, overtreatment must be carefully avoided and multilateral differentiation is important. In this article, we reviewed previously reported EBVMCUs focusing on their clinical and pathological aspects in comparison with other EBV-positive B-cell neoplasms.
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9
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Abstract
We describe a series of 9 patients with Epstein-Barr virus (EBV)-positive mucocutaneous lymphoproliferative lesions that broadens the concept of EBV-positive mucocutaneous ulcer. We report 5 female and 4 male patients, with an average age of 74 years (range, 55 to 87 y), 2 of whom were HIV-positive. The lesions were located in the oropharynx, skin, and rectal and/or genital mucosa. Histopathologically, 6 cases showed a polymorphic pattern and 3 had a monomorphic and diffuse one, with angiotropism in 4 cases (2 each with the polymorphic and monomorphic patterns). Three of the cases expressed PDL1. In addition to its presence in the neoplastic lymphoid cells, EBV was also detected in adjacent epithelial cells in an oropharyngeal lesion. All cases responded to local therapy or adapted systemic chemotherapy in selected cases. This series extends the spectrum of this disorder to include some HIV-positive cases, patients with multiple lesions confined to a single anatomic area, lesions with an angiocentric pattern, and some cases with monomorphous large-cell cytology. We discuss the differential clinicopathologic diagnosis of this disorder and that of classic EBV large B-cell lymphoma.
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Wanderlei KC, Quintella DC, Cuzzi T, D’Azambuja Ramos D, Morais JC, Romañach M, Milito CB. EBV-positive mucocutaneous ulcers: a presentation of two cases and a brief literature review. SURGICAL AND EXPERIMENTAL PATHOLOGY 2019. [DOI: 10.1186/s42047-019-0037-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
AbstractMucocutaneous ulcers associated with the Epstein Barr virus constitute an EBV-induced B-cell lymphoproliferative disorder first described in 2010 by Stefan D. Dojcinov et al. These lesions can occur in association with a spectrum of immunosuppressive conditions, including primary immune deficiency, Human Immunodeficiency Virus (HIV) infection, post-transplantation and the use of methotrexate or tumor necrosis factor-alpha (TNF-a) antagonists. Patients clinically present with slowly developing indurated cutaneous and/or mucosal ulcers, especially in the oropharynx. Histopathology reveals circumscribed ulcers containing a mixture of lymphocytes, plasma cells, histiocytes, eosinophils and large transformed cells resembling Hodgkin and Reed-Sternberg cells. The adjacent squamous epithelium presents reactive nuclear atypia and pseudoepitheliomatous hyperplasia. The large transformed cells show positivity for CD20, CD30, Oct-2, PAX5 and EBV. These cells are also positive for MUM1, yet lack CD10 expression, with absent or focal positivity for BCL6. Despite the presence of highly atypical cells, the clinical course is indolent, without progression to disseminated disease. We report herein two cases of diagnosed EBV-positive mucocutaneous ulcers to add to the relatively few cases previously described in the literature.
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Takahama A, de Lima HG, Ito FA, Ribeiro-Silva A, León JE. Epstein-Barr Virus–Positive Mucocutaneous Ulcer Mimicking Peri-Implantitis in a Patient With Systemic Lupus Erythematosus. J Oral Maxillofac Surg 2019; 77:977-984. [DOI: 10.1016/j.joms.2018.12.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 12/27/2018] [Accepted: 12/28/2018] [Indexed: 01/31/2023]
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12
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Sinit RB, Horan KL, Dorer RK, Aboulafia DM. Epstein-Barr Virus-Positive Mucocutaneous Ulcer: Case Report and Review of the First 100 Published Cases. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 19:e81-e92. [PMID: 30442566 DOI: 10.1016/j.clml.2018.10.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 10/06/2018] [Indexed: 12/15/2022]
Affiliation(s)
- Ryan B Sinit
- Floyd and Delores Jones Cancer Institute, Virginia Mason Medical Center, Seattle, WA
| | - Kathleen L Horan
- Department of Pulmonary and Critical Care Medicine, Virginia Mason Medical Center, Seattle, WA
| | - Russell K Dorer
- Department of Pathology, Virginia Mason Medical Center, Seattle, WA
| | - David M Aboulafia
- Floyd and Delores Jones Cancer Institute, Virginia Mason Medical Center, Seattle, WA; Division of Hematology, University of Washington School of Medicine, Seattle, WA.
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13
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Daroontum T, Kohno K, Eladl AE, Satou A, Sakakibara A, Matsukage S, Yakushiji N, Ya-In C, Nakamura S, Asano N, Kato S. Comparison of Epstein-Barr virus-positive mucocutaneous ulcer associated with treated lymphoma or methotrexate in Japan. Histopathology 2018; 72:1115-1127. [PMID: 29314151 DOI: 10.1111/his.13464] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 12/31/2017] [Indexed: 01/01/2023]
Abstract
AIMS The aim of the present study was to compare treated lymphoma-associated Epstein-Barr virus (EBV)-positive mucocutaneous ulcer (EBVMCU) and methotrexate (MTX)-associated EBVMCU. METHODS AND RESULTS Of a series of 15 Japanese patients (11 women, four men; median age 74 years, range 35-84 years), seven received MTX for the treatment of autoimmune disease and eight developed EBVMCU after treatment of malignant lymphoma [diffuse large B-cell lymphoma (n = 4) without EBV association, adult T-cell leukaemia/lymphoma (n = 2), angioimmunoblastic T-cell lymphoma (n = 1), and follicular lymphoma (n = 1)]. Ulcers were observed in the oral cavity (n = 11), gastrointestinal tract (n = 2), and skin (n = 2). All were histologically characterised by a mixture of EBV-positive large B-cell proliferation and Hodgkin/Reed-Sternberg-like cells on a polymorphous background. A total of 46% (6/13) had monoclonal immunoglobulin heavy chain gene rearrangement, but none had clonal T-cell receptor gene rearrangement. Spontaneous regression occurred in 13 of 15 cases (87%); the other two cases (13%) achieved complete remission after treatment. Of two patients in the treated lymphoma-associated subgroup, one developed multiple new ulcerative lesions on previously unaffected skin, and the other had a relapse of EBVMCU in the oral cavity. No significant clinicopathological differences were found between the subgroups. Notably, none of the patients died from EBVMCU. However, the treated lymphoma-associated subgroup had lower overall survival (P = 0.004) and a shorter follow-up period (P = 0.003) than the MTX-associated subgroup, owing to death from non-associated causes. CONCLUSIONS Treated lymphoma-associated EBVMCU, which is an indolent and self-limited condition, must be recognised to avoid misdiagnosing it as a relapse of malignant lymphoma during treatment.
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Affiliation(s)
- Teerada Daroontum
- Department of Pathology and Laboratory Medicine, Nagoya University Hospital, Nagoya, Japan.,Department of Pathology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Kei Kohno
- Department of Pathology and Laboratory Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Ahmed E Eladl
- Department of Pathology and Laboratory Medicine, Nagoya University Hospital, Nagoya, Japan.,Department of Pathology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Akira Satou
- Department of Surgical Pathology, Aichi Medical University Hospital, Nagakate, Japan
| | - Ayako Sakakibara
- Department of Pathology and Laboratory Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Shoichi Matsukage
- Department of Pathology and Division of Dermatology, Uwajima City Hospital, Uwajima, Japan
| | - Naoki Yakushiji
- Department of Pathology and Division of Dermatology, Uwajima City Hospital, Uwajima, Japan
| | - Charin Ya-In
- Department of Pathology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Shigeo Nakamura
- Department of Pathology and Laboratory Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Naoko Asano
- Department of Clinical Laboratory, Nagano Prefectural Suzaka Hospital, Nagano, Japan
| | - Seiichi Kato
- Department of Pathology and Molecular Diagnostics, Aichi Cancer Centre Hospital, Aichi, Japan
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Epstein-Barr Virus-associated Mucocutaneous Ulcer in a Patient With T-Cell Acute Lymphoblastic Leukemia: Importance of Accurate Diagnosis and Conservative Management. J Pediatr Hematol Oncol 2017; 39:e338-e341. [PMID: 27879545 DOI: 10.1097/mph.0000000000000709] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Epstein-Barr virus-associated mucocutaneous ulcer (EBV-MCU) is a recently characterized entity that falls under the spectrum of EBV-lymphoproliferative disorders. First described in 2010 by Dojcinov et al, it is an EBV-driven localized proliferation of B cells, occurring in mucocutaneous tissues including the skin, the oropharynx, and the gastrointestinal tract of immunosuppressed patients in the absence of an intact T-cell repertoire. Typically, it has been described in elderly patients with age-related immunosenescence and patients who are on immunosuppressive therapy. However, only 2 cases have been reported in pediatric, adolescent, and young adult age groups, with all these patients manifesting after solid organ transplant. To the best of our knowledge there are no case reports of EBV-MCU occurring in association with hematologic malignancy. Here, we present a case of EBV-MCU in a young adult patient with T-cell acute lymphoblastic leukemia. Our report serves to promote awareness among clinicians regarding this newly described and extremely rare clinical entity in young immunosuppressed patients. In addition, we highlight the importance of accurate diagnosis to prevent overtreatment of this indolent, often self-resolving disease that has a significant clinicopathologic overlap with other aggressive forms of EBV-lymphoproliferative disorders that require more intensive therapy.
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Diagnostic and therapeutic challenges of EBV-positive mucocutaneous ulcer: a case report and systematic review of the literature. Exp Hematol Oncol 2016; 5:13. [PMID: 27127726 PMCID: PMC4848873 DOI: 10.1186/s40164-016-0042-5] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 04/21/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Epstein-Barr virus-positive mucocutaneous ulcer (EBVMCU) is a recently recognized B cell lymphoproliferative disorder that is driven by latent EBV infection and causes discrete ulcerations in the oropharynx, gastrointestinal tract, and skin. Local attenuation of immunosurveillance associated with iatrogenic immunosuppressant use, primary immunodeficiency, or age-associated immunosenescence has been implicated as a predisposing factor. This disorder is likely under reported, as it was only first defined in 2010 and shares histological features with other B-cell proliferative neoplasms. The first case series that described EBVMCU suggested that EBVMCU is generally self-limited and is likely to resolve without treatment. Since that publication, additional cases have been reported that describe a more heterogeneous clinical course, often requiring aggressive therapy. We now systematically review all published cases of EBVMCU and detail a case of aggressive and progressive EBVMCU, including diagnostic and management challenges, as well as successful treatment with radiation therapy. CASE PRESENTATION A forty-nine year old woman presented with painful and debilitating multifocal oral EBVMCU that initially responded to four weekly doses of rituximab. Her disease relapsed within 3 months and continued to progress and cause significant morbidity. She was successfully treated with local external beam radiation therapy of 30 Gy in 15 fractions, with duration of response of at least 6 months. CONCLUSIONS We suggest that although many patients with EBVMCU experience a self-limited course, for others EBVMCU can be a debilitating, persistent disorder that requires aggressive therapy to prevent disease progression. CD20- and CD30-directed antibody therapy, local radiation therapy, local surgical excision, systemic chemotherapy, and a combination of these therapies have all been successfully used to treat EBVMCU with high rates of durable clinical remission. As EBVMCU is not currently included in the 2008 WHO classification of lymphoproliferative disorders and no evidence-based guidelines or expert opinions have been proposed to guide therapy, this case report and systematic review provides a foundation on which to guide therapeutic decisions.
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Au JK, Said JW, Sepahdari AR, St John MA. Head and neck Epstein-Barr virus mucocutaneous ulcer: Case report and literature review. Laryngoscope 2016; 126:2500-2504. [PMID: 27113560 DOI: 10.1002/lary.26009] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 02/18/2016] [Accepted: 03/07/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS To report the clinical presentation, treatment, and management outcomes of patients with Epstein-Barr virus-positive mucocutaneous ulcer (EBVMCU) of the head and neck, which is a newly characterized pathologic entity with aggressive morphology but follows an indolent, self-limiting clinical course. STUDY DESIGN Case report and literature review. METHODS A case of EBVMCU of the base of tongue is reported and a retrospective review of all cases of EBVMCU of the head and neck at a single academic institution was conducted between January 1, 1986 and April 1, 2015. The MEDLINE database was additionally queried from January 1, 1950 to April 1, 2015 for all reports of EBVMCU of the head and neck, and all pertinent clinical data were extracted. RESULTS The clinical presentation, treatment, and response of a patient with EBVMCU of the base of tongue are presented. Interim follow-up of the patient has revealed a complete remission with discontinuation of immunosuppression and rituximab therapy. A review of the literature supports conservative management and reduction of immunosuppression. Overall, 96.6% of patients with follow-up greater than 2 months achieved complete remission with conservative management. The current study is the largest series to report on the clinical presentation and treatment outcomes of EBVMCU of the head and neck. CONCLUSIONS EBVMCU tends to follow an indolent and self-limiting clinical course, responding to reduction of immunosuppression and conservative treatment. It is imperative for clinicians to consider EBVMCU in the differential diagnosis of mucocutaneous ulcers of the head and neck to avoid excessive treatment. LEVEL OF EVIDENCE Laryngoscope, 126:2500-2504, 2016.
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Affiliation(s)
- Joshua K Au
- Department of Head and Neck Surgery, University of California Los Angeles Medical Center, Los Angeles, California
| | - Jonathan W Said
- Department of Pathology and Laboratory Medicine, University of California Los Angeles Medical Center Medical Center, Los Angeles, California.,University of California Los Angeles Head and Neck Cancer Program, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California.,Jonsson Comprehensive Cancer Center, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, California
| | - Ali R Sepahdari
- University of California Los Angeles Head and Neck Cancer Program, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California.,Department of Radiology, University of California Los Angeles Medical Center, Los Angeles, California
| | - Maie A St John
- Department of Head and Neck Surgery, University of California Los Angeles Medical Center, Los Angeles, California. .,University of California Los Angeles Head and Neck Cancer Program, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California. .,Jonsson Comprehensive Cancer Center, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, California.
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Shamsuyarova A, Ghorab Z, Higgins K, Klieb H. Bilateral palatal ulcers in a patient on immunosuppressive therapy. Oral Surg Oral Med Oral Pathol Oral Radiol 2015; 121:205-9. [PMID: 26460273 DOI: 10.1016/j.oooo.2015.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 07/31/2015] [Accepted: 08/15/2015] [Indexed: 11/19/2022]
Affiliation(s)
| | - Zeina Ghorab
- Department of Anatomic Pathology, University of Toronto, Toronto, Ontario, Canada
| | - Kevin Higgins
- Department of Otolaryngology, University of Toronto, Toronto, Ontario, Canada
| | - Hagen Klieb
- Department of Anatomic Pathology and Department of Dentistry, University of Toronto, Toronto, Ontario, Canada
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Kanemitsu M, John D, Lim A, Jaffe ES, Aoki J. Clonal Epstein-Barr virus-positive mucocutaneous ulcer mimicking a mature B-cell lymphoma in a patient with mycophenolate-induced immune suppression. Leuk Lymphoma 2015; 56:1908-10. [PMID: 25379620 DOI: 10.3109/10428194.2014.982646] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Kleinman S, Jhaveri D, Caimi P, Cameron R, Lemonovich T, Meyerson H, Hostoffer R, Tcheurekdjian H. A rare presentation of EBV⁺ mucocutaneous ulcer that led to a diagnosis of hypogammaglobulinemia. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2014; 2:810-2. [PMID: 25439381 DOI: 10.1016/j.jaip.2014.07.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 07/11/2014] [Accepted: 07/14/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Sara Kleinman
- Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio.
| | - Devi Jhaveri
- Division of Allergy and Immunology, University Hospitals Richmond Medical Center, Richmond Heights, Ohio
| | - Paolo Caimi
- Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Robert Cameron
- Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Tracy Lemonovich
- Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Howard Meyerson
- Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Robert Hostoffer
- Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio; Allergy/Immunology Associates Inc, Cleveland, Ohio
| | - Haig Tcheurekdjian
- Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio; Allergy/Immunology Associates Inc, Cleveland, Ohio
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