A review of Epstein-Barr virus infection in patients with immunodeficiency disorders

Inborn Errors of Immunity and Cancer

Simple Summary

Inborn Errors of Immunity (IEI) are a heterogeneous group of disorders characterized by a defect in the function of at least one, and often more, components of the immune system. The overall risk for cancer in children with IEI ranges from 4 to 25%. Several factors, namely, age of the patient, viral infection status and IEI type can influence the development of different cancer types. Immunologists and oncologists should interact to monitor and promptly diagnose the potential development of cancer in known IEI patients, as well as an underlying IEI in newly diagnosed cancers with suggestive medical history or high rate of therapy-related toxicity. The creation of an international registry of IEI cases with detailed information on the occurrence of cancer is fundamental to optimizing the diagnostic process and to evaluating the outcomes of new therapeutic options, with the aim of improving prognosis and reducing comorbidities.

Abstract

Inborn Errors of Immunity (IEI) are a heterogeneous group of disorders characterized by a defect in the function of at least one, and often more, components of the immune system. The aim of this narrative review is to discuss the epidemiology, the pathogenesis and the correct management of tumours in patients with IEI. PubMed was used to search for all of the studies published over the last 20 years using the keywords: “inborn errors of immunity” or “primary immunodeficiency” and “cancer” or “tumour” or “malignancy”. Literature analysis showed that the overall risk for cancer in children with IEI ranges from 4 to 25%. Several factors, namely, age of the patient, viral infection status and IEI type can influence the development of different cancer types. The knowledge of a specific tumour risk in the presence of IEI highlights the importance of a synergistic effort by immunologists and oncologists in tracking down the potential development of cancer in known IEI patients, as well as an underlying IEI in patients with newly diagnosed cancers. In the current genomic era, the creation of an international registry of IEI cases integrated with malignancies occurrence information is fundamental to optimizing the diagnostic process and to evaluating the outcomes of new therapeutic options, with the hope to obtain a better prognosis for these patients.

Primary immunodeficiency associated with defects in CD1 and CD1-restricted T cells

CD1 is a family of atypical MHC class I molecules that present various endogenous and exogenous lipid antigens to CD1-restricted T cells. While little is known about the function of CD1a-, CD1b-, and CD1c-restricted lipid-reactive T cells due to their absence in mice, CD1d-restricted natural killer T (NKT) cells have been extensively studied since their description almost 20 years ago. NKT cells, effector memory cells that share characteristics of innate and adaptive lymphocytes, are among the earliest responders in immune reactions and have broad effects on the activation of other immune cell lineages, including NK cells, T cells, and B cells. Accordingly, studies in mice have revealed critical roles of NKT cells in infectious, malignant, and autoimmune diseases. The recent description of primary immunodeficiencies associated with defects in CD1 and CD1-restricted T cells has provided a unique opportunity to study the biological role of lipid antigen presentation in human disease. Intriguingly, these studies revealed that defects in lipid immunity are associated with susceptibility to selected infectious and malignant diseases but not with broad immunodeficiency.

IL-2-inducible T-cell kinase deficiency: clinical presentation and therapeutic approach

Mutations in the IL-2-inducible T-cell kinase gene have recently been shown to cause an autosomal recessive fatal Epstein Barr virus (EBV) associated lymphoproliferation. We report 3 cases from a single family who presented with EBV-positive B-cell proliferation diagnosed as Hodgkin's lymphoma. Single nucleotide polymorphism array-based genome-wide linkage analysis revealed IL-2-inducible T-cell kinase as a candidate gene for this disorder. All 3 patients harbored the same novel homozygous nonsense mutation C1764G which causes a premature stop-codon in the kinase domain. All cases were initially treated with chemotherapy. One patient remains in durable remission, the second patient subsequently developed severe hemophagocytic lymphohistiocytosis with multi-organ failure and died, and the third patient underwent a successful allogeneic bone marrow transplantation. IL-2-inducible T-cell kinase deficiency underlies a new primary immune deficiency which may account for part of the spectrum of Epstein Barr virus related lymphoproliferative disorders which can be successfully corrected by bone marrow transplantation.

EBV detection in HIV-related oral plasmablastic lymphoma

OBJECTIVES

Plasmablastic lymphoma (PBL) of the oral cavity is an aggressive neoplasm derived from B cell, considered to be the second more common among human immunodeficiency virus (HIV)-associated malignancies. As Epstein-Barr virus (EBV) infection has been associated with this neoplasm, the aim of the present study was to assess the presence of EBV in 11 cases of oral HIV-related PBL and investigate the controversial issue of the presence of Human herpesvirus-8 (HHV-8) in these tumors.

METHODS

DNA was extracted from nine cases of HIV-associated oral lymphomas, diagnosed as PBL, and genomic material was amplified by polymerase chain reaction to verify the presence of EBV. In situ hybridization (ISH) for EBV was performed in five cases. Immunohistochemical analysis was conducted to confirm previous diagnosis and verify HHV-8 infection.

RESULTS

The 11 cases had diagnosis confirmed by immunohistochemical analysis. Only nine cases presented an adequate amount of DNA for analysis, and EBV was detected in seven of them. The five cases tested for EBV viral infection by ISH showed positive signals. All 11 cases were negative for HHV-8.

CONCLUSION

The presence of EBV in all cases studied favors a direct role of this virus in the development of HIV-related PBL, and this finding could be considered when dealing with HIV patients.

Spontaneous regression of EBV-associated diffuse lymphoproliferative disease in a patient with rheumatoid arthritis after discontinuation of etanercept treatment

We describe the case of a 64-year-old female patient with rheumatoid arthritis (RA), who presented with lymphoproliferative disease (LPD) soon after the administration of etanercept, and regressed very shortly after the withdrawal of it. The occurrence was also associated with the Epstein-Barr virus (EBV) infection. The case of our patient may provide the evidence that etanercept plays an etiologic role in LPD in patients with RA.

KSHV targets multiple leukocyte lineages during long-term productive infection in NOD/SCID mice

To develop an animal model of Kaposi sarcoma-associated herpesvirus (KSHV) infection uniquely suited to evaluate longitudinal patterns of viral gene expression, cell tropism, and immune responses, we injected NOD/SCID mice intravenously with purified virus and measured latent and lytic viral transcripts in distal organs over the subsequent 4 months. We observed sequential escalation of first latent and then lytic KSHV gene expression coupled with electron micrographic evidence of virion production within the murine spleen. Using novel technology that integrates flow cytometry with immunofluorescence microscopy, we found that the virus establishes infection in murine B cells, macrophages, NK cells, and, to a lesser extent, dendritic cells. To investigate the potential for human KSHV-specific immune responses within this immunocompromised host, we implanted NOD/SCID mice with functional human hematopoietic tissue grafts (NOD/SCID-hu mice) and observed that a subset of animals produced human KSHV-specific antibodies. Furthermore, treatment of these chimeric mice with ganciclovir at the time of inoculation led to prolonged but reversible suppression of KSHV DNA and RNA levels, suggesting that KSHV can establish latent infection in vivo despite ongoing suppression of lytic replication.

High fatality rate of Epstein-Barr virus-associated lymphoproliferative disorder occurring after bone marrow transplantation with rabbit antithymocyte globulin conditioning regimens

Epstein-Barr virus (EBV)-associated lymphoproliferative disorder (EBV-LPD) following bone marrow transplantation can be fatal. The major risk factors for the development of EBV-LPD are ex vivo T-cell depletion or in vivo T-cell depletion with either antithymocyte globulin (ATG) or monoclonal anti-T-cell antibodies. Between March 1999 and January 2001, a total of 23 transplants with ATG of equine source (20 transplants) and ATG of rabbit source (3 transplants) used as part of the preparatory regimen were performed at the Barbara Ann Karmanos Cancer Institute in Detroit, Mich. The three patients who received rabbit ATG developed EBV-LPD between 60 and 90 days following bone marrow transplantation. However, there were no cases of EBV-LPD in the equine group. Treatment given in these cases consisted of tapering immunosuppression, antiviral therapy, unprocessed donor lymphocyte infusion, mobilized peripheral blood progenitor cell rescue infusion (one patient), and chemotherapy (one patient). All three patients died of complications from EBV-LPD. The association of rabbit ATG with the development of EBV-LPD suggests that patients receiving rabbit ATG as part of their preparatory regimens require close monitoring of the EBV viral load and possible early intervention with antiviral therapy.

The Use of Systemic Immune Moderators in Dermatology: An Update

In addition to corticosteroids, dermatologists have access to an array of immunomodulatory therapies. Azathioprine, cyclophosphamide, methotrexate, cyclosporine, and mycophenolate mofetil are the systemic immunosuppressive agents most commonly used by dermatologists. In addition, new developments in biotechnology have spurred the development of immunobiologic agents that are able to target the immunologic process of many inflammatory disorders at specific points along the inflammatory cascade. Alefacept, efalizumab, etanercept, and infliximab are the immunobiologic agents that are currently the most well known and most commonly used by dermatologists. This article reviews the pharmacology, mechanism of action, side effects, and clinical applications of these therapies.

Latent membrane protein 1 of Epstein-Barr virus plays an important role in the serum starvation resistance of Epstein-Barr virus-immortalized B lymphocytes

We have previously shown that SNU-1103, which is a latency type III Epstein-Barr virus (EBV)-transformed lymphoblastoid cell line (LCL) that was developed from a Korean cancer patient, resists serum starvation-induced G(1) arrest. In this study, we examined the role of latent membrane protein-1 (LMP-1) in serum starvation resistance, since LMP-1 is known to be essential for EBV-mediated immortalization of human B lymphocytes. The LMP-1 gene from SNU-1103 was introduced into the EBV-negative BJAB cell line, and shown to be associated with resistance to G(1) arrest during serum starvation. Western blot analyses of the LMP-1-transfected cells revealed several protein alterations as compared to vector-transfected control cells. The expression of key cell-cycle regulatory proteins was affected in the G(1) phase: the expression of cyclin D3, CDK2, p27, and E2F-4 was up-regulated, and the expression of cyclin D2, CDK6, p21, and p103 was down-regulated during serum starvation. These results imply that of the several EBV viral genes expressed in EBV-negative B lymphoma cells, LMP-1 mediates resistance to serum starvation-induced G(1) arrest. However, we cannot rule out the possibility that other EBV genes are also involved in the cell-cycle progression of the EBV-transformed LCL during serum starvation, since the altered protein expression profile of the LMP-1 transfectants was distinct from that of the SNU-1103 cells that expressed all of the EBV viral proteins.

An unexpectedly high incidence of Epstein-Barr virus lymphoproliferative disease after CD34+ selected autologous peripheral blood stem cell transplant in neuroblastoma

The risk of Epstein–Barr virus lymphoproliferative disease (EBV-LPD) increases with the use of highly immunosuppressive therapies. Allogeneic BMT, especially supported by T-cell-depleted stem cell products, is a risk factor for EBV-LPD. Although the risk of EBV-LPD after autologous transplantation is low, case reports of this complication in the autologous setting exist. We report a higher incidence than previously described of EBV-LPD in children undergoing sequential high-dose chemotherapy supported with CD34 selected peripheral blood stem cells (CD34+ PBSC). The median time to LPD after tandem transplant was 3 months (range 1–5 months). Five patients out of 156 (3.5%) developed EBV-LPD while enrolled on two trials of tandem autologous SCT in high-risk pediatric malignancies. Both studies employed five cycles of induction therapy, followed by tandem autologous PBSC transplants. In all, 108 out of 156 patients received CD34+ PBSC; 48 received unselected PBSC. All patients contracting LPD were from the CD34 selected group. Treatment of EBV-LPD included rituximab in four out of five patients, IVIg in two out of five patients, and gancyclovir in two out of five patients. EBV-LPD resolved in four out of five patients. We conclude that the combination of tandem SCT and CD34 selection may have increased immunosuppression in these patients to a point where there is an elevated risk of EBV-LPD.

CD40 ligand is a critical effector of Epstein-Barr virus in host cell survival and transformation

Epstein-Barr virus (EBV), implicated in numerous human diseases, including lymphoid malignancies, persistently infects peripheral B cells and transforms them into lymphoblastoid cell lines. Here we found that EBV equally infected B cells from patients with X-linked hyper IgM syndrome and those from healthy donors; however, it hardly transformed X-linked hyper IgM syndrome B cells, because of the dysfunctional gene of CD40 ligand (CD40L) of the patients. Unlike CD40, CD40L is not usually expressed on B cells. However, we found that EBV infection of normal B cells induced CD40L expression as a critical effector in host cell transformation and survival. Moreover, chronic active EBV infection of peripheral T cells, implicated in T cell malignancies, was associated with ectopic expression of CD40, and, in Jurkat T cells, EBV infection induced CD40 expression. These results suggest that EBV infection induces CD40L/CD40 signaling in host cells, which appears to play an essential role in its persistent infection and malignancies of lymphocytes.

Overview and problematic standpoints of severe chronic active Epstein-Barr virus infection syndrome

Epstein-Barr virus (EBV) is an ubiquitous human herpesvirus. Its infection is generally subclinical. However, in certain circumstances, EBV causes infectious mononucleosis (IM) and lymphoproliferative disorders (LPD) in immunologically compromised individuals. Furthermore, EBV infection is etiologically linked to human malignancies such as Burkitt's lymphoma (BL), nasopharyngeal carcinoma (NPC) and miscellaneous malignant diseases because of the presence of viral genome in their tumor tissues. Since the late 1970s, a chronic undefined illness possibly associated with EBV infection, named such as severe chronic active EBV infection syndrome (SCAEBV), has been of interest due to its unique manifestations that often result in a poor prognosis. This review is an overview of SCAEBV with respect to its; history, diagnosis, pathogenesis, therapeutic approaches, and ideas on how to further recognize this enigmatic disease.

Immunological aspects of Epstein-Barr virus infection

Epstein-Barr virus (EBV) is a member of ubiquitous gamma herpes viruses, which primarily induces acute infectious mononucleosis (IM) or subclinical infection in susceptible subjects. The host reactions account for the clinical manifestation of IM. This virus also contributes to the development of lymphoid or epithelial malignancies. The outgrowth of EBV-infected B-cells is first controlled by interferon (IFN)-gamma and natural killer (NK) cells, and later by EBV-specific cytotoxic T-lymphocytes (CTL). To overcome the host responses and establish the persistent infection, EBV conducts the protean strategies of immune evasion. Several EBV genes modulate apoptotic signals and cytokine balances to persist B-cell infection without insulting the host. Uncontrolled lymphoproliferation occurs as EBV(+) B-cell lymphoproliferative disease (LPD)/lymphoma in AIDS, posttransplant, or primary immunodeficiency diseases (PID). On the other hand, EBV(+) T/NK cells are involved in EBV-associated hemophagocytic lymphohistiocytosis (EBV-HLH) or chronic active EBV infection (CAEBV) in children having no underlying immunodeficiencies, and at times lead to the clonal evolution of T/NK-cell LPD/lymphomas. Recent advance in molecular techniques has enabled us to analyze the clonality of EBV-infected lymphocytes and to quantify the gene expression of EBV and cytokines. Dominant autocrine loop of T helper (Th) 2 and Th1 may exert in EBV(+) B-LPD and T-LPD, respectively. Intensive studies on the immunological interface between effector components and EBV(+) target cells will provide more information on clarifying the pathogenesis of EBV-associated lymphoid malignancies, as well as on exploiting the therapeutic and preventive strategies for the formidable EBV-associated disease in childhood.

Epstein-Barr virus reactivation after superinfection of the BJAB-B1 and P3HR-1 cell lines with cytomegalovirus

BACKGROUND

Studies examining herpesvirus-herpesvirus (cytomegalovirus (CMV)-Epstein-Barr virus (EBV)) interactions are limited, and many of the studies have been clinical observations suggesting such an interaction exists. This report aims to examine the in vitro susceptibilities of BJAB-B1 and P3HR-1 cells (EBV positive Burkitt's lymphoma B-cell lines) to a CMV superinfection; and show that EBV reactivation occurs after CMV superinfects these cell lines.

RESULTS

The BJAB-B1 and P3HR-1 cells were observed to be susceptible to a CMV superinfection by detecting the major immediate early (MIE) viral transcript and protein (p52) expression. The BZLF1 transcript was observed in both cell lines superinfected with CMV, indicating EBV reactivation. BZLF1 protein was observed in the BJAB-B1 cells. Antigen detection was not performed in the P3HR-1 cells.

CONCLUSION

The results from the in vitro superinfections support the in vivo studies suggesting a CMV infection is related to an EBV reactivation and suggests that CMV may be important as a co-factor in EBV pathogenesis in the immunocompromised patient.

Epstein-Barr virus in patients with immunodeficiency disorders

The Epstein-Barr virus (EBV), one of eight known human herpesviruses, causes a wide spectrum of diseases under certain conditions. In particular, in the setting of immunodeficiency, which includes primary or secondary/acquired immunodeficiencies, they have been increasingly reported. The major clinical phenotype is the EBV genome-positive lymphoproliferative disorder, which ranges from benign lymphoproliferation to malignant lymphoma with cytogenetic alterations. Severe or fatal infectious mononucleosis may develop in some patients with immunodeficiencies such as X-linked lymphoproliferative disease.