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Alphonsus L, Zhang Q, Jairath V. Multifocal Epstein-Barr Virus-Positive Mucocutaneous Ulcers in a Patient With Crohn's Disease. ACG Case Rep J 2024; 11:e01468. [PMID: 39221233 PMCID: PMC11361628 DOI: 10.14309/crj.0000000000001468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 06/23/2024] [Accepted: 07/11/2024] [Indexed: 09/04/2024] Open
Abstract
Epstein-Barr Virus-positive mucocutaneous ulcer (EBVMCU) is a rare and new category of mature B-cell neoplasms commonly linked to immunosuppression. It often has a benign course and regresses spontaneously after discontinuation or dose reduction of immunosuppressive agents. We report the case of a 48-year-old woman on long-term azathioprine therapy for rectosigmoid Crohn's disease. In contrast to the prevalent sites typically associated with EBVMCU, such as the oral mucosa and skin, this patient was found to have locations in the gastrointestinal tract and upper neck. These areas tested positive for histopathology consistent with EBVMCU and were excised due to bowel perforation and concern for malignancy.
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Affiliation(s)
- Lotus Alphonsus
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Qi Zhang
- Pathology and Laboratory Medicine, Schulich School of Medicine and Dentistry, Western University and London Health Sciences Centre, London, Ontario, Canada
| | - Vipul Jairath
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Lawson Health Research Institute, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
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2
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Hayashi I, Toida M. Epstein-Barr Virus-Positive Mucosal Skin Ulcer Resulting in Oral Lesions During Concomitant Use of Tacrolimus and Prednisolone. Cureus 2024; 16:e57091. [PMID: 38681285 PMCID: PMC11053295 DOI: 10.7759/cureus.57091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2024] [Indexed: 05/01/2024] Open
Abstract
Epstein-Barr virus-positive mucocutaneous ulcer (EBVMCU) is a subtype of Epstein-Barr virus-positive lymphoproliferative disease with a favorable prognosis that can develop either due to medical interventions or as a consequence of aging. Medical-onset cases caused by immunosuppressive drugs may require a reduction or discontinuation of the causative drugs. However, specific methods for drug adjustment in cases where multiple immunosuppressive drugs are used have not yet been established. Herein, we present the case of a 63-year-old man with interstitial pneumonia who developed an EBVMCU on the right side of his tongue. He was on multidrug therapy with tacrolimus and prednisolone and was treated conservatively by discontinuation of the tacrolimus and switching to prednisolone monotherapy. The lesion resolved within two months following the adjustment. This case report provides evidence that conversion to monotherapy, rather than multiple immunosuppressive drugs, is a potentially effective treatment option for EBVMCU.
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Affiliation(s)
- Itsuki Hayashi
- Oral and Maxillofacial Surgery, Sugita Genpaku Memorial Obama Public Hospital, Obama, JPN
| | - Makoto Toida
- Oral and Maxillofacial Surgery, Sugita Genpaku Memorial Obama Public Hospital, Obama, JPN
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3
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Song JH, Choi JE, Kim JS. Mucocutaneous ulcer positive for Epstein-Barr virus, misdiagnosed as a small bowel adenocarcinoma: A case report. World J Gastrointest Surg 2023; 15:2362-2366. [PMID: 37969717 PMCID: PMC10642452 DOI: 10.4240/wjgs.v15.i10.2362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/18/2023] [Accepted: 08/31/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Epstein-Barr virus (EBV)-positive mucocutaneous ulcers (MCUs) are an uncommon disorder characterized by ulcerative lesions in the skin, oral cavity or gastrointestinal tract in patients with iatrogenic or aging-induced immunosuppression. The nonspecific lesions are difficult to differentiate from small bowel adenocarcinomas. We present the case of a 69-year-old woman who was initially misdiagnosed with a small bowel adenocarcinoma but was later surgically diagnosed with and treated for EBV-MCU. Through this case, we aim to emphasize the importance of accurately distinguishing between the two conditions. CASE SUMMARY The patient presented with an incidental finding of a small bowel tumor during computed tomography (CT) examination performed for hematuria. The CT scan showed irregular thickening of the distal ileum, which was suggestive of a malignant small bowel tumor. An exploratory laparotomy revealed an 8-cm mass in the distal ileum; thus, a segment of the small intestine, including the mass, was resected. Histopathological analysis revealed an ulceroinfiltrative mass-like lesion with luminal narrowing, marked inflammatory cell infiltration, and large atypical lymphoid cells (positive for EBV-encoded small RNA). A final diagnosis of an EBV-MCU was established. The postoperative course was uneventful, and the patient was discharged on postoperative day 7. The patient remained recurrence-free until 12 mo after surgery. CONCLUSION This case highlights the diagnostic challenges for EBV-MCUs and emphasizes the importance of comprehensive evaluation and accurate histopathological analysis.
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Affiliation(s)
- Ji Hyeong Song
- Department of Surgery, Chungnam National University Sejong Hospital, Sejong 30099, South Korea
| | - Ji Eun Choi
- Department of Pathology, Chungnam National University Sejong Hospital, Sejong 30099, South Korea
| | - Jin Soo Kim
- Department of Surgery, Chungnam National University Sejong Hospital, Sejong 30099, South Korea
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4
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Macklin PS, Fisher R, Stonard C, Matin RN, Ieremia E. Skin-Limited, Methotrexate-Associated Epstein-Barr Virus-Positive Mucocutaneous Ulcer-A Mimicker of High-Grade Lymphoma. A Report of 4 Cases and Review of the Literature. Am J Dermatopathol 2023; 45:519-531. [PMID: 37462204 DOI: 10.1097/dad.0000000000002419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
ABSTRACT Immunodeficiency-associated lymphoproliferative disorders (IA-LPDs) constitute a diverse range of conditions including posttransplant lymphoproliferative disorders, other iatrogenic IA-LPDs, and lymphoproliferative disorders associated with an underlying primary immune disorder or HIV infection. IA-LPDs are clinically and pathologically heterogeneous, and there is a lack of standardization of diagnostic terminology. They can represent a potential serious diagnostic pitfall because the histological features of clinically indolent proliferations may mimic those of high-grade lymphoma. However, correct identification of these entities is essential given that complete remission may occur upon reversal of the underlying cause of immunosuppression without the need for systemic therapy. IA-LPDs presenting in the skin are rare but well documented. One form of iatrogenic IA-LPD, methotrexate-associated lymphoproliferative disorder (MTX-LPD), can present with cutaneous nodules, plaques, or ulcers. Predominantly, MTX-LPD develops in the context of long-term treatment of autoimmune conditions, such as rheumatoid arthritis, dermatomyositis, and Sjögren syndrome, and may be associated with underlying Epstein-Barr virus (EBV) infection. We present 4 cases of cutaneous EBV-positive B-cell MTX-LPD and describe their clinical and morphological findings. Comparison of our histological findings to the diagnostic criteria for EBV-positive mucocutaneous ulcer (EBVMCU) revealed significant overlap, highlighting the intersection between MTX-LPD and EBVMCU. Withdrawal of methotrexate resulted in healing of all lesions at a mean time of 2 months. In summary, close clinicopathological correlation is vital to identify MTX-LPD presenting as cutaneous EBVMCU given that the initial treatment strategy is that of withdrawal of methotrexate without the need for immediate systemic therapy.
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Affiliation(s)
- Philip S Macklin
- Doctor, Department of Cellular Pathology, Oxford University Hospitals, NHS Foundation Trust, Oxford, Oxfordshire, United Kingdom
| | - Rachel Fisher
- Doctor, Department of Dermatology, Royal Berkshire, NHS Foundation Trust, Reading, Berkshire, United Kingdom; and
| | - Christopher Stonard
- Doctor, Department of Cellular Pathology, Oxford University Hospitals, NHS Foundation Trust, Oxford, Oxfordshire, United Kingdom
| | - Rubeta N Matin
- Doctor, Department of Dermatology, Oxford University Hospitals, NHS Foundation Trust, Oxford, Oxfordshire, United Kingdom
| | - Eleni Ieremia
- Doctor, Department of Cellular Pathology, Oxford University Hospitals, NHS Foundation Trust, Oxford, Oxfordshire, United Kingdom
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5
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Sawada K, Momose S, Iijima Y, Takahashi T, Kaneko T, Yamamoto W, Yamashita T, Higashi M, Kizaki M, Tamaru JI. EBV-positive mucocutaneous ulcer arising in methotrexate-treated rheumatoid arthritis patients: a clinicopathological study of 12 cases with analysis of PD-L1 expression. J Clin Exp Hematop 2023; 63:90-98. [PMID: 37245972 PMCID: PMC10410618 DOI: 10.3960/jslrt.22048] [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: 12/29/2022] [Revised: 03/14/2023] [Accepted: 04/01/2023] [Indexed: 05/30/2023] Open
Abstract
Epstein-Barr virus-positive mucocutaneous ulcer (EBVMCU) is a newly recognized disease entity characterized by EBV-positive atypical B-cell proliferation. EBVMCU is a localized self-limited disease that affects mucosa and skin, especially the oral cavity. EBVMCU develops in immunosuppressive patients, such as those with methotrexate (MTX)-administrated rheumatoid arthritis (RA). Here we clinicopathologically analyzed 12 EBVMCU patients in a single institution. All cases were administrated MTX for RA, and five cases occurred in the oral cavity. All cases except one had demonstrated spontaneous regression after withdrawal of the immunosuppressive agent. We found 4 of 5 cases in the oral cavity had preceding traumatic events in the same site within a week before the onset of EBVMCU. Although there is no detailed and large study that has analyzed the trigger of EBVMCU, a traumatic event would indeed be a significant trigger for EBVMCU in the oral cavity. The cases were histologically classified; six cases were diffuse large B-cell lymphoma-type, five were polymorphous-type, and one was Hodgkin-like lesion type due to morphological appearance and immunophenotype. The PD-L1 expression was also examined by two antibodies for PD-L1 (E1J2J and SP142). Both antibodies revealed identical results for PD-L1 expression, and three cases were positive for PD-L1. The application of SP142 for evaluating the immune status of lymphomagenesis has also been proposed. Nine of 12 cases were negative for PD-L1, which implies that most EBVMCU cases may be caused by an immunodeficiency, rather than an immune-evasion, mechanism. However, as three cases were positive for PD-L1, immune escape may underly the pathogenesis in a subset of EBVMCU cases.
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6
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Lupo J, Truffot A, Andreani J, Habib M, Epaulard O, Morand P, Germi R. Virological Markers in Epstein–Barr Virus-Associated Diseases. Viruses 2023; 15:v15030656. [PMID: 36992365 PMCID: PMC10051789 DOI: 10.3390/v15030656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 02/21/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023] Open
Abstract
Epstein–Barr virus (EBV) is an oncogenic virus infecting more than 95% of the world’s population. After primary infection—responsible for infectious mononucleosis in young adults—the virus persists lifelong in the infected host, especially in memory B cells. Viral persistence is usually without clinical consequences, although it can lead to EBV-associated cancers such as lymphoma or carcinoma. Recent reports also suggest a link between EBV infection and multiple sclerosis. In the absence of vaccines, research efforts have focused on virological markers applicable in clinical practice for the management of patients with EBV-associated diseases. Nasopharyngeal carcinoma is an EBV-associated malignancy for which serological and molecular markers are widely used in clinical practice. Measuring blood EBV DNA load is additionally, useful for preventing lymphoproliferative disorders in transplant patients, with this marker also being explored in various other EBV-associated lymphomas. New technologies based on next-generation sequencing offer the opportunity to explore other biomarkers such as the EBV DNA methylome, strain diversity, or viral miRNA. Here, we review the clinical utility of different virological markers in EBV-associated diseases. Indeed, evaluating existing or new markers in EBV-associated malignancies or immune-mediated inflammatory diseases triggered by EBV infection continues to be a challenge.
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Affiliation(s)
- Julien Lupo
- Institut de Biologie Structurale, Université Grenoble Alpes, UMR 5075 CEA/CNRS/UGA, 71 Avenue des Martyrs, 38000 Grenoble, France
- Laboratoire de Virologie, CHU Grenoble Alpes, CS 10217, CEDEX 09, 38043 Grenoble, France
- Correspondence:
| | - Aurélie Truffot
- Institut de Biologie Structurale, Université Grenoble Alpes, UMR 5075 CEA/CNRS/UGA, 71 Avenue des Martyrs, 38000 Grenoble, France
- Laboratoire de Virologie, CHU Grenoble Alpes, CS 10217, CEDEX 09, 38043 Grenoble, France
| | - Julien Andreani
- Institut de Biologie Structurale, Université Grenoble Alpes, UMR 5075 CEA/CNRS/UGA, 71 Avenue des Martyrs, 38000 Grenoble, France
- Laboratoire de Virologie, CHU Grenoble Alpes, CS 10217, CEDEX 09, 38043 Grenoble, France
| | - Mohammed Habib
- Institut de Biologie Structurale, Université Grenoble Alpes, UMR 5075 CEA/CNRS/UGA, 71 Avenue des Martyrs, 38000 Grenoble, France
| | - Olivier Epaulard
- Institut de Biologie Structurale, Université Grenoble Alpes, UMR 5075 CEA/CNRS/UGA, 71 Avenue des Martyrs, 38000 Grenoble, France
- Service de Maladies Infectieuses, CHU Grenoble Alpes, CS 10217, CEDEX 09, 38043 Grenoble, France
| | - Patrice Morand
- Institut de Biologie Structurale, Université Grenoble Alpes, UMR 5075 CEA/CNRS/UGA, 71 Avenue des Martyrs, 38000 Grenoble, France
- Laboratoire de Virologie, CHU Grenoble Alpes, CS 10217, CEDEX 09, 38043 Grenoble, France
| | - Raphaële Germi
- Institut de Biologie Structurale, Université Grenoble Alpes, UMR 5075 CEA/CNRS/UGA, 71 Avenue des Martyrs, 38000 Grenoble, France
- Laboratoire de Virologie, CHU Grenoble Alpes, CS 10217, CEDEX 09, 38043 Grenoble, France
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7
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Epstein-Barr Virus-positive Mucocutanous Ulcer of the Uterine Cervix: Report of a Rare and Evolving Entity. Int J Gynecol Pathol 2023; 42:21-25. [PMID: 35512213 DOI: 10.1097/pgp.0000000000000861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Epstein-Barr virus (EBV)-positive mucocutaneous ulcer (EBVMCU) is a newly described lymphoproliferative lesion characterized by the proliferation of EBV-positive atypical B cells in a variable inflammatory background associated with mucosal or cutaneous ulcers. Commonly involved sites include the oropharyngeal tract, skin, and gastrointestinal tract, with emerging reports describing EBVMCU of genitalia. To date, no lesions have been described of the uterine cervix. Herein, we report the first cervical EBVMCU incidentally discovered at large loop excision of the transformation zone performed for treating human papillomavirus induced high-grade squamous intraepithelial lesion. The patient was a 35-yr-old, human immunodeficiency virus-positive woman with a history of pulmonary tuberculosis. Histologic and immunohistochemical findings showed classic Hodgkin lymphoma-like features. Systemic lymphoproliferative disease was excluded by appropriate clinical and imaging modalities. This case report highlights the prototypical histologic features of cervical EBVMCU. We emphasize the importance of clinicopathologic correlation to avoid overtreatment of a lesion that can otherwise meet histologic criteria for a lymphoma. Clinicians and pathologists should familiarize themselves with this entity, as this indolent, pseudomaligant lesion typically occurs in immunocompromised patients and spontaneously regresses when the cause for the immunosuppression is addressed.
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8
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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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9
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Sun C, Wang Q, Dong Y, Nong L, Cai Y, Wang L, Sun Y, Wang W, Liu X. Primary Epstein-Barr Virus-Positive Mucocutaneous Ulcer of Esophagus: A Rare Case Report. J Clin Med 2022; 11:jcm11164915. [PMID: 36013154 PMCID: PMC9410325 DOI: 10.3390/jcm11164915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/06/2022] [Accepted: 08/16/2022] [Indexed: 11/16/2022] Open
Abstract
Primary EBV-positive mucocutaneous ulcer (EBVMCU) is a rare and indolent disorder occurring in the oropharynx, skin, and gastrointestinal tract, with remission after removal of the immunosuppressive causes. We present a 69-year-old woman with heartburn, regurgitation of gastric acid, enlarged lymph nodes, and parotid glands. The endoscopic examination showed a circumscribed ulcer in the lower esophagus. A biopsy pathology indicated an esophageal EBV-associated lymphoproliferative disorder and a parotid gland/lymph node indolent B-cell lymphoma. Interestingly, the patient did not undergo any treatment, but the endoscopic ulcer improved significantly after more than 2 months. The last pathology showed EBV negativity, and EBVMCU was considered in combination with clinical and endoscopic manifestations. We followed up with the patient at 6 months, and the symptoms of acid reflux and heartburn had disappeared. Our case demonstrates that EBVMCU may occur in the esophagus with spontaneous regression.
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Affiliation(s)
- Chunping Sun
- Department of Geriatric, Peking University First Hospital, Peking University, Beijing 100034, China
| | - Qingya Wang
- Department of Hematology, Peking University First Hospital, Peking University, Beijing 100034, China
| | - Yujun Dong
- Department of Hematology, Peking University First Hospital, Peking University, Beijing 100034, China
| | - Lin Nong
- Department of Pathology, Peking University First Hospital, Peking University, Beijing 100034, China
| | - Yunlong Cai
- Department of Gastroenterology, Peking University First Hospital, Peking University, Beijing 100034, China
| | - Lihong Wang
- Department of Hematology, Peking University First Hospital, Peking University, Beijing 100034, China
| | - Yuhua Sun
- Department of Hematology, Peking University First Hospital, Peking University, Beijing 100034, China
| | - Wensheng Wang
- Department of Hematology, Peking University First Hospital, Peking University, Beijing 100034, China
- Correspondence: (W.W.); (X.L.); Tel.: +86-133-6612-3205 (W.W.); +86-137-0138-6256 (X.L.)
| | - Xinmin Liu
- Department of Geriatric, Peking University First Hospital, Peking University, Beijing 100034, China
- Correspondence: (W.W.); (X.L.); Tel.: +86-133-6612-3205 (W.W.); +86-137-0138-6256 (X.L.)
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10
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Sakamoto K, Baba T, Takatori H, Nagao K, Misawa J, Honda T. A case of methotrexate‐associated Epstein‐Barr virus‐positive mucocutaneous ulcer. SKIN HEALTH AND DISEASE 2022; 2:e108. [PMID: 35677919 PMCID: PMC9168019 DOI: 10.1002/ski2.108] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/31/2022] [Accepted: 03/06/2022] [Indexed: 11/19/2022]
Abstract
Epstein‐Barr virus‐positive mucocutaneous ulcer (EBVMCU) is a B‐cell proliferative disorder that has been designated as a provisional entity in the 2017 World Health Organization classification for lymphoid neoplasms. While EBVMCU may contain varying numbers of cells with Hodgkin and Reed‐Sternberg cells‐like morphology, the clinical course is benign and must be distinguished from lymphomas. Patients who develop EBVMCU are commonly immunocompromised, with methotrexate (MTX) as the leading cause. Most previously reported cases of EBVMCU describe mucosal ulcers with very little documentation on skin lesions and its course. Here, we report a case of MTX‐associated EBVMCU of the lower leg that underwent spontaneous regression after MTX withdrawal, during which negative conversion of local Epstein‐Barr virus activation was confirmed.
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Affiliation(s)
- Keiko Sakamoto
- Department of Dermatology Hamamatsu Medical Center Hamamatsu Shizuoka Japan
- Department of Dermatology Hamamatsu University School of Medicine Hamamatsu Shizuoka Japan
- Dermatology Branch National Institute of Arthritis and Musculoskeletal and Skin Diseases National Institutes of Health Bethesda Maryland USA
| | - Takeshi Baba
- Department of Pathology Hamamatsu Medical Center Hamamatsu Shizuoka Japan
| | - Hiroaki Takatori
- Department of Rheumatology Hamamatsu Medical Center Hamamatsu Shizuoka Japan
| | - Keisuke Nagao
- Dermatology Branch National Institute of Arthritis and Musculoskeletal and Skin Diseases National Institutes of Health Bethesda Maryland USA
| | - Junko Misawa
- Department of Dermatology Hamamatsu Medical Center Hamamatsu Shizuoka Japan
| | - Tetsuya Honda
- Department of Dermatology Hamamatsu University School of Medicine Hamamatsu Shizuoka Japan
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11
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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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12
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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] [Key Words] [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 MedicineUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Yuri Fedoriw
- Department of Pathology and Lab MedicineUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Sascha Tuchman
- Lineberger Comprehensive Cancer Center Department of HematologyUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Natalie Grover
- Lineberger Comprehensive Cancer Center Department of HematologyUniversity of North CarolinaChapel HillNorth CarolinaUSA
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13
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Kunmongkolwut S, Amornkarnjanawat C, Phattarataratip E. Multifocal Oral Epstein-Barr Virus-Positive Mucocutaneous Ulcers Associated with Dual Methotrexate and Leflunomide Therapy: A Case Report. Eur J Dent 2022; 16:703-709. [PMID: 35016227 PMCID: PMC9507604 DOI: 10.1055/s-0041-1739545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Epstein-Barr virus (EBV)-positive mucocutaneous ulcer (EBVMCU) is a unique clinicopathologic entity of lymphoproliferative disorder, occurring in immunosuppressed patients. Due to its rarity, EBVMCU may be under-recognized by clinicians as well as pathologists. In addition, its clinical and histopathologic features overlap with other benign and malignant conditions, making a diagnosis challenging. This report presents an unusual case of multifocal oral EBVMCUs in a 52-year-old female patient with rheumatoid arthritis, receiving the combination of methotrexate and leflunomide for 5 years. The patient presented with persistent multiple large painful ulcers involving her palate and gingiva for 6 months. The histopathologic examination revealed extensive ulceration with diffuse polymorphic inflammatory infiltrate admixed with scattered atypical lymphoid cells showing occasional Hodgkin and Reed/Sternberg-like cell features. These atypical cells showed immunoreactivity for CD20, CD30 and MUM1/IRF4. EBV-encoded small RNA in situ hybridization was positive, validating the presence of EBV-infected cells. Two months after discontinuation of both immunosuppressive medications, oral lesions gradually regressed. At 9-month follow-up, no evidence of relapsing oral EBVMCU has been observed. The multifocal presentation of EBVMCU is rare and could be resulted from the overwhelming immune suppression by long-term use of dual immunosuppressants. Its diagnosis requires comprehensive correlation of patient history, clinical findings, histopathologic, and immunophenotypic features. The ability of EBVMCU to regress following removal of immunosuppressive causes is in drastic contrast to a variety of its potential clinical and histopathologic mimics. Therefore, accurate diagnosis is crucial to avoid unnecessary patient management and achieve optimal patient outcomes.
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Affiliation(s)
- Sumana Kunmongkolwut
- Department of Oral Pathology, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand
| | | | - Ekarat Phattarataratip
- Department of Oral Pathology, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand
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Zanelli M, Sanguedolce F, Palicelli A, Zizzo M, Martino G, Caprera C, Fragliasso V, Soriano A, Gozzi F, Cimino L, Masia F, Moretti M, Foroni M, De Marco L, Pellegrini D, De Raeve H, Ricci S, Tamagnini I, Tafuni A, Cavazza A, Merli F, Pileri SA, Ascani S. EBV-Driven Lymphoproliferative Disorders and Lymphomas of the Gastrointestinal Tract: A Spectrum of Entities with a Common Denominator (Part 3). Cancers (Basel) 2021; 13:6021. [PMID: 34885131 PMCID: PMC8656853 DOI: 10.3390/cancers13236021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 11/27/2021] [Accepted: 11/28/2021] [Indexed: 12/28/2022] Open
Abstract
EBV is the first known oncogenic virus involved in the development of several tumors. The majority of the global population are infected with the virus early in life and the virus persists throughout life, in a latent stage, and usually within B lymphocytes. Despite the worldwide diffusion of EBV infection, EBV-associated diseases develop in only in a small subset of individuals often when conditions of immunosuppression disrupt the balance between the infection and host immune system. EBV-driven lymphoid proliferations are either of B-cell or T/NK-cell origin, and range from disorders with an indolent behavior to aggressive lymphomas. In this review, which is divided in three parts, we provide an update of EBV-associated lymphoid disorders developing in the gastrointestinal tract, often representing a challenging diagnostic and therapeutic issue. Our aim is to provide a practical diagnostic approach to clinicians and pathologists who face this complex spectrum of disorders in their daily practice. In this part of the review, the chronic active EBV infection of T-cell and NK-cell type, its systemic form; extranodal NK/T-cell lymphoma, nasal type and post-transplant lymphoproliferative disorders are discussed.
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Affiliation(s)
- Magda Zanelli
- Pathology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (A.P.); (M.F.); (L.D.M.); (S.R.); (I.T.); (A.C.)
| | | | - Andrea Palicelli
- Pathology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (A.P.); (M.F.); (L.D.M.); (S.R.); (I.T.); (A.C.)
| | - Maurizio Zizzo
- Surgical Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy;
| | - Giovanni Martino
- Pathology Unit, Azienda Ospedaliera Santa Maria di Terni, University of Perugia, 05100 Terni, Italy; (G.M.); (C.C.); (D.P.); (S.A.)
| | - Cecilia Caprera
- Pathology Unit, Azienda Ospedaliera Santa Maria di Terni, University of Perugia, 05100 Terni, Italy; (G.M.); (C.C.); (D.P.); (S.A.)
| | - Valentina Fragliasso
- Laboratory of Translational Research, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy;
| | - Alessandra Soriano
- Gastroenterology Division, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy;
| | - Fabrizio Gozzi
- Ocular Immunology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (F.G.); (L.C.)
| | - Luca Cimino
- Ocular Immunology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (F.G.); (L.C.)
| | - Francesco Masia
- Dipartimento di Medicina, Università degli Studi di Perugia, 05100 Terni, Italy; (F.M.); (M.M.)
| | - Marina Moretti
- Dipartimento di Medicina, Università degli Studi di Perugia, 05100 Terni, Italy; (F.M.); (M.M.)
| | - Moira Foroni
- Pathology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (A.P.); (M.F.); (L.D.M.); (S.R.); (I.T.); (A.C.)
| | - Loredana De Marco
- Pathology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (A.P.); (M.F.); (L.D.M.); (S.R.); (I.T.); (A.C.)
| | - David Pellegrini
- Pathology Unit, Azienda Ospedaliera Santa Maria di Terni, University of Perugia, 05100 Terni, Italy; (G.M.); (C.C.); (D.P.); (S.A.)
| | - Hendrik De Raeve
- Pathology, University Hospital Brussels, 1090 Brussels, Belgium;
- Pathology, O.L.V. Hospital Aalst, 9300 Aalst, Belgium
| | - Stefano Ricci
- Pathology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (A.P.); (M.F.); (L.D.M.); (S.R.); (I.T.); (A.C.)
| | - Ione Tamagnini
- Pathology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (A.P.); (M.F.); (L.D.M.); (S.R.); (I.T.); (A.C.)
| | - Alessandro Tafuni
- Pathology Unit, Department of Medicine and Surgery, University of Parma, 43121 Parma, Italy;
| | - Alberto Cavazza
- Pathology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (A.P.); (M.F.); (L.D.M.); (S.R.); (I.T.); (A.C.)
| | - Francesco Merli
- Hematology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy;
| | - Stefano A. Pileri
- Haematopathology Division, European Institute of Oncology-IEO IRCCS Milan, 20141 Milan, Italy;
| | - Stefano Ascani
- Pathology Unit, Azienda Ospedaliera Santa Maria di Terni, University of Perugia, 05100 Terni, Italy; (G.M.); (C.C.); (D.P.); (S.A.)
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15
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Uygun V, Özsan N, Daloğlu H, Öztürkmen S, Yalçın K, Karasu G, Yeşilipek A. Epstein-Barr virus-related lymphoproliferative disorders in T-cell repleted haploidentical transplantation with post-transplant cyclophosphamide. Int J Hematol 2021; 115:600-604. [PMID: 34826107 DOI: 10.1007/s12185-021-03267-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 11/17/2021] [Accepted: 11/17/2021] [Indexed: 11/29/2022]
Abstract
EBV-associated lymphoproliferative disorders (LPDs) are common in hematopoietic stem cell transplantation (HSCT) with T-cell-depleted grafts, but are extremely rare in HSCT patients with T-cell-replete grafts with post-transplant cyclophosphamide (PTCy). Here we present the cases of two pediatric patients who developed EBV-related LPD after T-cell-replete haplo-HSCT with PTCy. One of these is the first reported case of EBV-positive mucocutaneous ulcer (EBVMCU) developing after PTCy. EBV-related diseases are rare in T-cell-replete haplo-HSCT patients with PTCy. However, in patients with risk factors, it is reasonable to screen for EBV viremia for LPD.
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Affiliation(s)
- Vedat Uygun
- Department of Pediatric Bone Marrow Transplantation Unit, Faculty of Medicine, İstinye University, MedicalPark Antalya Hospital, Fener Mah. Tekelioğlu Cad. No:7 Lara, Antalya, Turkey.
| | - Nazan Özsan
- Department of Pathology, Faculty of Medicine, Ege University, İzmir, Turkey
| | - Hayriye Daloğlu
- Department of Pediatric Bone Marrow Transplantation Unit, Faculty of Health Sciences, MedicalPark Antalya Hospital, Antalya Bilim University, Antalya, Turkey
| | - Seda Öztürkmen
- Department of Pediatric Bone Marrow Transplantation Unit, MedicalPark Antalya Hospital, Antalya, Turkey
| | - Koray Yalçın
- Department of Pediatric Bone Marrow Transplantation Unit, Faculty of Medicine, MedicalPark Göztepe Hospital, Bahçeşehir University, İstanbul, Turkey
| | - Gülsün Karasu
- Department of Pediatric Bone Marrow Transplantation Unit, MedicalPark Göztepe Hospital, İstanbul, Turkey
| | - Akif Yeşilipek
- Department of Pediatric Bone Marrow Transplantation Unit, MedicalPark Antalya Hospital, Antalya, Turkey
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Zanelli M, Sanguedolce F, Palicelli A, Zizzo M, Martino G, Caprera C, Fragliasso V, Soriano A, Valle L, Ricci S, Cavazza A, Merli F, Pileri SA, Ascani S. EBV-Driven Lymphoproliferative Disorders and Lymphomas of the Gastrointestinal Tract: A Spectrum of Entities with a Common Denominator (Part 1). Cancers (Basel) 2021; 13:4578. [PMID: 34572803 PMCID: PMC8465149 DOI: 10.3390/cancers13184578] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 09/02/2021] [Accepted: 09/10/2021] [Indexed: 12/21/2022] Open
Abstract
EBV is the most common persistent virus in humans. The interaction of EBV with B lymphocytes, which are considered the virus reservoir, is at the base of the life-long latent infection. Under circumstances of immunosuppression, the balance between virus and host immune system is altered and hence, EBV-associated lymphoid proliferations may originate. These disorders encompass several entities, ranging from self-limited diseases with indolent behavior to aggressive lymphomas. The virus may infect not only B-cells, but even T- and NK-cells. The occurrence of different types of lymphoid disorders depends on both the type of infected cells and the state of host immunity. EBV-driven lymphoproliferative lesions can rarely occur in the gastrointestinal tract and may be missed even by expert pathologists due to both the uncommon site of presentation and the frequent overlapping morphology and immunophenotypic features shared by different entities. The aim of this review is to provide a comprehensive overview of the current knowledge of EBV-associated lymphoproliferative disorders, arising within the gastrointestinal tract. The review is divided in three parts. In this part, the available data on EBV biology, EBV-positive mucocutaneous ulcer, EBV-positive diffuse large B-cell lymphoma, not otherwise specified and classic Hodgkin lymphoma are discussed.
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Affiliation(s)
- Magda Zanelli
- Pathology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (A.P.); (S.R.); (A.C.)
| | | | - Andrea Palicelli
- Pathology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (A.P.); (S.R.); (A.C.)
| | - Maurizio Zizzo
- Surgical Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy;
| | - Giovanni Martino
- Pathology Unit, Azienda Ospedaliera Santa Maria di Terni, University of Perugia, 05100 Terni, Italy; (G.M.); (C.C.); (S.A.)
| | - Cecilia Caprera
- Pathology Unit, Azienda Ospedaliera Santa Maria di Terni, University of Perugia, 05100 Terni, Italy; (G.M.); (C.C.); (S.A.)
| | - Valentina Fragliasso
- Laboratory of Translational Research, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy;
| | - Alessandra Soriano
- Department of Pathology, Case Western Reserve University, Cleveland, OH 44106, USA;
- Gastroenterology Division, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Luca Valle
- Anatomic Pathology, Department of Integrated Surgical and Diagnostic Sciences (DISC), University of Genoa and Ospedale Policlinico San Martino, 16132 Genoa, Italy;
| | - Stefano Ricci
- Pathology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (A.P.); (S.R.); (A.C.)
| | - Alberto Cavazza
- Pathology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (A.P.); (S.R.); (A.C.)
| | - Francesco Merli
- Hematology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy;
| | - Stefano A. Pileri
- Haematopathology Division, European Institute of Oncology-IEO IRCCS Milan, 20141 Milan, Italy;
| | - Stefano Ascani
- Pathology Unit, Azienda Ospedaliera Santa Maria di Terni, University of Perugia, 05100 Terni, Italy; (G.M.); (C.C.); (S.A.)
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17
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Comparative Study on Epstein-Barr Virus-Positive Mucocutaneous Ulcer and Methotrexate-Associated Lymphoproliferative Disorders Developed in the Oral Mucosa: A Case Series of 10 Patients and Literature Review. Diagnostics (Basel) 2021; 11:diagnostics11081375. [PMID: 34441310 PMCID: PMC8394712 DOI: 10.3390/diagnostics11081375] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 07/27/2021] [Accepted: 07/28/2021] [Indexed: 11/17/2022] Open
Abstract
Methotrexate-associated lymphoproliferative disorder (MTX-LPD) is an iatrogenic immunodeficiency-associated lymphoproliferative disorder that occurs mainly with MTX use. This disorder has been associated with Epstein-Barr virus (EBV) infection. In 2017, the WHO newly defined the disease concept of EBV-positive mucocutaneous ulcer (EBV-MCU) as a good-prognosis EBV-related disease. Here, we report 10 cases of MTX-LPD or EBV-MCU in the oral mucosa. This retrospective, observational study was conducted with MTX-LPD or EBV-MCU in the oral mucosa patients who visited us during the nine year period from 2012 to 2021. We gathered the basic information, underlying disease, histopathological evaluation, treatment and prognosis for the subjects. All were being treated with MTX for rheumatoid arthritis. EBV infection was positive in all cases by immunohistochemistry. A complete or partial response was obtained in all cases with the withdrawal of MTX. Our results suggests that the most common risk factor for developing EBV-MCU is the use of immunosuppressive drugs. The most common site of onset is the oral mucosa, which may be attributed to the mode of EBV infection and the high incidence of chronic irritation of the oral mucosa. A small number of patients had been diagnosed with MTX-LPD, but we consider that these cases were EBV-MCU based on our study.
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18
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Ishikawa E, Satou A, Nakamura M, Nakamura S, Fujishiro M. Epstein-Barr Virus Positive B-Cell Lymphoproliferative Disorder of the Gastrointestinal Tract. Cancers (Basel) 2021; 13:3815. [PMID: 34359715 PMCID: PMC8345108 DOI: 10.3390/cancers13153815] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 07/23/2021] [Accepted: 07/25/2021] [Indexed: 12/12/2022] Open
Abstract
Epstein-Barr virus positive B-cell lymphoproliferative disorder (EBV+ B-LPD) encompasses a broad clinicopathological spectrum and distinct clinical behavior that relatively favors the gastrointestinal (GI) tract. In this review, we provide an update on the clinicopathological features and biological behavior of EBV-positive mucocutaneous ulcer (EBVMCU) and primary EBV+ diffuse large B-cell lymphoma (DLBCL) of the GI tract. EBVMCU is a newly recognized entity but well known as an indolent and self-limited EBV+ B-LPD occurring in various immunodeficiencies. In contrast, EBV+ DLBCL constitutes the largest group of EBV+ B-LPDs and is regarded as an aggressive neoplasm. These two distinct diseases have historically been distinguished in the reappraisal of age-related EBV-associated B-LPDs but are challenging in routine practice regarding their differential diagnostic and therapeutic approaches. An increasing number of reports indicate that they are epidemiologically prevalent beyond western and eastern countries, but their comprehensive analysis is still limited. We also describe the PD-L1 positivity of tumorous large cells and non-malignant immune cells, which is relevant for the prognostic delineation among patients with primary DLBCL of the GI tract with and without EBV on tumor cells.
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Affiliation(s)
- Eri Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya 466-8560, Japan; (M.N.); (M.F.)
| | - Akira Satou
- Department of Surgical Pathology, Aichi Medical University Hospital, Nagakute 480-1195, Japan;
| | - Masanao Nakamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya 466-8560, Japan; (M.N.); (M.F.)
| | - Shigeo Nakamura
- Department of Pathology and Laboratory Medicine, Nagoya University Hospital, Nagoya 466-8550, Japan;
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya 466-8560, Japan; (M.N.); (M.F.)
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Epstein-Barr Virus Mucocutaneous Ulcer: An Unexpected Diagnosis of a New Entity. Case Rep Otolaryngol 2021; 2021:9989756. [PMID: 34046233 PMCID: PMC8128617 DOI: 10.1155/2021/9989756] [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: 03/31/2021] [Accepted: 05/04/2021] [Indexed: 11/21/2022] Open
Abstract
Epstein–Barr virus mucocutaneous ulcer (EBVMCU) is a new entity, only recently included in World Health Organisation classification of lymphoid neoplasms. Almost all cases described to date have been in patients with a predisposing risk factor of immunosuppression. This case presents a 21-year-old male admitted with tonsillitis and no overt immunosuppression, who is subsequently diagnosed with EBVMCU of likely iatrogenic origin.
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20
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Almazyad A, Alabdulaaly L, Noonan V, Woo SB. Oral hairy leukoplakia: a series of 45 cases in immunocompetent patients. Oral Surg Oral Med Oral Pathol Oral Radiol 2021; 132:210-216. [PMID: 34030995 DOI: 10.1016/j.oooo.2021.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 02/07/2021] [Accepted: 03/21/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Oral hairy leukoplakia (OHL) is a benign Epstein-Barr virus infection typically presenting as a white lesion on the lateral border of the tongue. Historically, OHL was described in patients who are severely immunocompromised, such as those with HIV/AIDS and organ transplant patients. OHL is increasingly seen in patients who are not severely immunocompromised. This study reviews 45 cases of OHL in a single institution and characterizes the clinical features of these relatively immunocompetent patients. STUDY DESIGN Retrospective study. RESULTS There were 45 cases with 23 male patients (51.1%) and a median age of 64 (range, 24-100 years). The lateral/ventral tongue was the affected site in 41 cases (91.1%), and 5 cases presented bilaterally. A review of the medical history and medications showed the most common conditions were hypertension (53.3%), hyperlipidemia (42.2%), and chronic respiratory conditions (33.3%); 8 patients (17.8%) had diabetes mellitus, and 1 had rheumatoid arthritis. Eleven cases (24.4%) reported no underlying medical conditions or history of medications. The most frequently reported medications included antihypertensive drugs (21.0%), steroid inhalers (14.6%), and cholesterol-lowering drugs (11.0%). CONCLUSIONS OHL is not exclusively seen in profoundly immunocompromised patients. Localized immunosuppression (from steroid inhalers) and immunosenescence (aging) are possible contributing factors.
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Affiliation(s)
- Asma Almazyad
- Maxillofacial Surgery and Diagnostic Sciences Department, King Saud bin Abdulaziz University of Health Sciences, Riyadh, Saudi Arabia; King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia.
| | - Lama Alabdulaaly
- Maxillofacial Surgery and Diagnostic Sciences Department, King Saud bin Abdulaziz University of Health Sciences, Riyadh, Saudi Arabia; King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia; Department of Oral Medicine, Infection, and Immunity, Harvard School of Dental Medicine, Boston, MA, USA
| | - Vikki Noonan
- Boston University Henry M. Goldman School of Dental Medicine, Boston, MA, USA; Center of Oral Pathology, StrataDx, Lexington, MA, USA
| | - Sook-Bin Woo
- Department of Oral Medicine, Infection, and Immunity, Harvard School of Dental Medicine, Boston, MA, USA; Center of Oral Pathology, StrataDx, Lexington, MA, USA; Division of Oral Medicine and Dentistry, Brigham and Women's Hospital, Boston, MA, USA
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21
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Plummer RM, Linden MA, Beckman AK. Update on B-cell lymphoproliferative disorders of the gastrointestinal tract. Semin Diagn Pathol 2021; 38:14-20. [PMID: 33863577 DOI: 10.1053/j.semdp.2021.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 02/25/2021] [Accepted: 03/22/2021] [Indexed: 12/14/2022]
Abstract
The gastrointestinal (GI) tract is home to a significant portion of the immune system, which interacts daily with the antigenic milieu of its contents. Therefore, the presence of white blood cells within the walls of the GI tract upon histologic examination is a familiar sight on GI biopsies-both in health and disease. The GI tract is the most common site of extranodal lymphomas, most of which are B-cell neoplasms. Here, we review common and uncommon B-cell neoplasms of the GI tract - extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma), mantle cell lymphoma, duodenal-type follicular lymphoma, diffuse large B-cell lymphoma, plasmablastic lymphoma, EBV-positive mucocutaneous ulcer, and post-transplant lymphoproliferative disorders - with special focus on literature published during the past five years. Along with the other articles in this edition of Seminars in Diagnostic Pathology, it is the authors' hope that this review proves to be a useful resource in the workup of the array of hematopoietic processes that can involve the GI tract.
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Affiliation(s)
- Regina M Plummer
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, USA
| | - Michael A Linden
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, 420 Delaware St. SE, Minneapolis, MN 55455, USA
| | - Amy K Beckman
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, 420 Delaware St. SE, Minneapolis, MN 55455, USA.
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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: 23] [Impact Index Per Article: 7.7] [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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Tokuhira M, Tamaru JI, Kizaki M. Clinical management for other iatrogenic immunodeficiency-associated lymphoproliferative disorders. J Clin Exp Hematop 2019; 59:72-92. [PMID: 31257348 PMCID: PMC6661962 DOI: 10.3960/jslrt.19007] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Other iatrogenic immunodeficiency-associated lymphoproliferative disorders (OIIA-LPD), a category of immunodeficiency-associated LPD according to the World Health Organization classification, is associated with immunosuppressive drugs (ISDs). Several factors, including autoimmune disease (AID) activity, Epstein-Barr virus (EBV) infection, ISD usage, and aging, influence the development of OIIA-LPD, resulting in complicated clinical courses and outcomes. Most OIIA-LPD develops in patients with rheumatoid arthritis using methotrexate (MTX-LPD). The management of MTX-LPD is based on the clinical course, i.e., with/without regression, with/without relapse/regrowth event (RRE), LPD subtype, and ISDs for AIDs after LPD development. There are three clinical courses after ISD withdrawal: regressive LPD without relapse/regrowth (R-G), regressive LPD with RRE (R/R-G), and persistent LPD (P-G). The majority of EBV+ diffuse large B-cell lymphomas are classified in R-G, whereas classic Hodgkin lymphoma is generally classified in R/R-G. Polymorphic LPD (P-LPD) in MTX-LPD develops with heterogeneous pathological features similar to monomorphic LPD. Chemotherapy for MTX-LPD is selected according to that for de novo LPD, although the strategy for aggressive P-LPD and non-specific LPD is not well established. The absolute lymphocyte count in the peripheral blood has been suggested as a candidate marker for MTX-LPD development and RRE. Several clinical issues, including correct diagnosis among overlapping clinicopathological features in MTX-LPD and clinical management of LPD by ISDs other than MTX, require further investigation.
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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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