Long-term use of burosumab for the treatment of tumor-induced osteomalacia

Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome caused by tumoral overproduction of FGF-23. Due to local recurrence, we describe the long-term efficacy and safety profile of burosumab, an anti-FGF-23 monoclonal antibody, in a TIO patient after three unsuccessfully surgical attempts.

INTRODUCTION

TIO is a rare paraneoplastic syndrome caused by tumoral overproduction of fibroblast growth factor 23 (FGF23), resulting in hyperphospaturia, hypophosphatemia, and osteomalacia. Surgery is the only definitive treatment, but tumor can locally recur, even after years from primary surgery. Furthermore, some tumors cannot be removed by surgery due to their location.

METHODS

We describe the case of a 54-year-old woman affected by recurrent TIO who, after three unsuccessful surgical attempts of tumor removal, was treated with burosumab, an anti-FGF-23 monoclonal antibody.

RESULTS

The patient was referred to our Bone Unit after experiencing several fractures in different sites, both traumatic and non-traumatic. At the time of first evaluation, at the age of 46, serum-phosphate (SP) was 1.2 mg/dL (reference range (RR) 2.5-4.5), 24-h urinary phosphate was 842 mg (RR 400-1000), and intact-FGF-23 was 117 pg/mL (RR 25-45). Imaging showed a metabolic pre-sacral lesion that firstly underwent to exploratory laparotomy. Then, patient underwent to surgical excision of tumor. After 18 months of well-being, tumor relapsed and even the subsequent surgery was not able to completely remove it. Since 2015, patient was maintained in phosphorus supplements and 1,25(OH)₂vitamin D₃, but SP levels never normalized. In September 2019, she was started on burosumab, initially at the dose of 0.3 mg/kg/month, progressively increased to the current 0.8 mg/kg/month, with great improvement of pain, physical performance, and normalization of SP levels. Burosumab was temporary and cautionary discontinued for COVID-19 pneumonia, with a worsening of SP. After restart of burosumab, biochemistry returned to normal.

CONCLUSIONS

To our knowledge, this is the first European patient affected by TIO treated with burosumab for more than 2 years. Burosumab is a promising therapy in the medical treatment of TIO refractory or not eligible for definitive surgery, with good efficacy and safety profile.

Successful retrieval of a needle point from the breast through a vacuum-assisted breast biopsy system

Stereotactic vacuum-assisted breast biopsy (VABB) system is generally used to perform breast biopsies after identifying suspicious lesions that are occult on ultrasound. In this case, we used an 8-Gauge VABB to retrieve a needle point retained in the outer-lower quadrant of the right breast of a patient previously treated with lumpectomy. The use of stereotactic VABB system in this specific clinical setting has been never described before and resulted minimally invasive and perfectly suitable for correct localisation and retrieval of the 3-mm needle point; moreover, it may be easily reproduced elsewhere.

Pathogenesis of chronic rhinosinusitis in patients affected by β-thalassemia major and sickle cell anaemia post allogenic bone marrow transplant

OBJECTIVES

Sickle cell anemia (SCA) and β -thalassemia major are well-recognized beta-globin gene disorders of red blood cells associated to mortality and morbidity included bone morbidities due to ineffective erythropoiesis and bone marrow expansion, which affect every part of the skeleton. While there are an abundance of described disease manifestations of the head and neck, the manner of paranasal sinuses involvement and its relations to β-thalassemia and SCA process was not studied yet. Therefore, the aim of this study was to investigate a possible increased risk of rhinosinusitis and the real pathogenetic mechanism of it, comparing these two hematological diseases using msCT, gold standard for paranasal sinuses evaluation.

METHODS

A retrospective analysis of 90 patients affected by β-thalassemia major or SCA (respectively 59 and 31) underwent allogeneic bone marrow transplantation (BMT), and 44 control subjects was performed. Both patient categories and control group have been subjected to hematological and radiological evaluation using 64-multidetector-row CT scanner without contrast injection.

RESULTS

Statistical analysis reveals that patients of the two study groups exhibit a significantly increased risk of sinusitis in comparison with the normal controls (RR: 3.55 for β-thalassemic pediatric subjects; RR: 3.35 for SCA pediatric subjects). A significant difference (p < 0,5) was found between the β -thalassemic patients on the one side, and SCA and control group on the other side, with regard to the evaluation of the typical anatomic alteration of maxillary sinus: β-thalassemic children had significant increase in the bone thickness of anterior and lateral sinus walls and significant reduction in volume and density compared to SCA patients and control group, with normal conditions of these parameters.

CONCLUSIONS

In these hematological patients, there is an increased incidence of sinonasal infections due their therapy-induced immunosuppression post transplantation. In β-thalassemic patients, furthermore, the specific anatomical variants play an important confounding factor in radiological interpretation of CT images. Therefore, a cranio-facial CT scan evaluation could be a useful tool in the management of upper airway infections after BMT and should be a routinely exams in order to avoid useless surgical or antibiotic approaches.

Detection of Epstein-Barr virus in leucoreduced blood products

This study examined the prevalence of three human herpesviruses (HHV), namely HHV-4 (Epstein-Barr virus/EBV), HHV-6b and HHV-7 in leucoreduced blood products obtained from the Sainte-Justine Hospital blood bank. A total of 100 specimens, including 34 red blood cell concentrates, 33 platelet bags and 33 plasma units, were collected and screened by a sensitive PCR assay using virus-specific primers. Positive units were then retested by quantitative PCR. Of the 100 specimens, one platelet unit tested positive for EBV.

Inhibition of IκB kinase by thalidomide increases hepatitis C virus RNA replication

Hepatic fibrosis is an integral element in the progression of chronic liver disease. Elevated hepatic interleukin (IL)-8 is an important contributor to fibrosis in patients chronically infected with the hepatitis C virus (HCV). Thalidomide has been used to reduce liver inflammation and fibrosis in HCV-infected patients, but its impact on HCV replication remains unclear. This study examined the effect of thalidomide on HCV replication in vitro. Results revealed that while thalidomide reduced IL-8 and nuclear factor kappa B (NF-κB) activity by 95% and 46% in Huh-7 cells, increasing concentrations of thalidomide correlated with a linear rise in HCV replication (17-fold at 200 μm). The NF-κB inhibitors, wedelolactone and NF-κB activation inhibitor-1, which mimic the actions of thalidomide by preventing phosphorylation and activation of IκB kinase (IKK) and hence block NF-κB activity, increased HCV RNA by 18- and 19-fold, respectively. During in vitro HCV replication in Huh-7 cells, we observed a 30% increase in IKKα protein and 55% decrease in NF-κB(p65)/RelA protein relative to cellular β-actin. Ectopic expression of IKKα to enhance the inactive form of IKK in cells undergoing virus replication led to a 13-fold increase in HCV RNA. Conversely, enhanced expression of NF-κB(p65)/RelA in infected cells resulted in a 17-fold reduction in HCV RNA. In conclusion, HCV RNA replication was significantly augmented by the inhibition of IKK activation and subsequent NF-κB signalling, whereas a restoration of NF-κB activity by the addition of NF-κB/RelA markedly reduced HCV replication. This study lends added importance to the role of the NF-κB signalling pathway in controlling HCV replication.

Cleavage of intracellular hepatitis C RNA in the virus core protein coding region by deoxyribozymes

Hepatitis C virus (HCV) infection represents an important global health problem. Current antiviral therapeutics for HCV have proven inadequate in stemming the disease process. A novel therapeutic strategy involves the use of deoxyribozymes, also known as DNA enzymes or DNAzymes. These catalytic DNA molecules, designed to target and cleave specific RNA sequences, have shown promise in in vitro experimental models for various diseases and may serve as an alternative or adjunct to current HCV drug therapy. We designed and tested several deoxyribozymes that can bind and cleave highly conserved RNA sequences encoding the HCV core protein in in vitro systems. One of these deoxyribozymes reduced the level of our HCV RNA target by 32% and 48% after 24 h of cell exposure when tested in human hepatoma and epithelial cell lines, respectively. As this deoxyribozyme showed significant cleavage activity against HCV core protein target RNA in human cells, it may have potential as a therapeutic candidate for clinical trial in HCV infected patients.

The Epstein-Barr virus and post-transplant lymphoproliferative disease: interplay of immunosuppression, EBV, and the immune system in disease pathogenesis

Transplant patients are at particular risk for developing post-transplant lymphoproliferative disease (PTLD) following administration of immunosuppressive therapy. In many cases the PTLD lesions express Epstein-Barr virus (EBV) latent and lytic genes as well as elevated levels of host cytokines. An outline of the potential contributions of EBV, host cytokines and T cells, and the immunosuppressive cyclosporine A, tacrolimus, and anti-CD3 antibody in the mechanism and pathogenesis of this disease is presented and discussed.

Effect of spironolactone and its metabolites on contractile property of isolated rat aorta rings

Spironolactone and its active metabolites canrenone and potassium canrenoate are normally used as antihypertensive drugs. Although they are classified as antagonists of aldosterone, their mechanism of action cannot be ascribed solely to the regulation of ion transport in the distal tubule of nephrons. Here we have evaluated the effects of spironolactone, canrenone, and potassium canrenoate on contractile properties of isolated rat aorta rings. Spironolactone (1-300 microM), canrenone (1-300 microM), and potassium canrenoate (0.01-10 mM), in a concentration-dependent manner, relaxed rat aorta rings precontracted with phenylephrine (1 microM) or KCl (40 mM). These relaxant effects were not affected by prior treatment with either aldosterone (100 microM), glibenclamide (10 microM), or tetraethylammonium (10 mM), excluding the possibility that these drugs can be involved in either the nongenomic effect of aldosterone or on activation of potassium channels. Spironolactone and canrenone at concentrations of 30 and 100 microM, but not at 10 microM, and potassium canrenoate at concentrations of 0.3 and 1 mM, but not at 0.1 mM, significantly inhibited the phenylephrine (0.001-3 microM) concentration-response curve. Conversely, all tested concentrations of spironolactone (10, 30, and 100 microM), canrenone (10, 30, and 100 microM), and potassium canrenoate (0.1, 0.3, and 1 mM) significantly inhibited the concentration-response curve induced by cumulative concentrations of KCI (10-80 mM). Because both phenylephrine- and KCl-induced contractions imply an intracellular Ca2+ influx, we suggest that these drugs could act through an inhibition of voltage-dependent Ca2+ channels.

Activation of transcription factors NF-kappaB and NF-IL-6 by human immunodeficiency virus type 1 protein R (Vpr) induces interleukin-8 expression

Human immunodeficiency virus (HIV)-positive individuals express elevated levels of interleukin-8 (IL-8), which is believed to be responsible for some of the clinical manifestations occurring during AIDS. We report here that virion-derived HIV type 1 (HIV-1) protein R (Vpr) increased IL-8 expression in primary T cells and macrophages, as well as in the T-cell line Jurkat, the monocytic cell line U937, and the epithelial cell line A549. Vpr appeared to increase IL-8 expression and IL-8 promoter activity by activating transcription factors NF-kappaB and NF-IL-6. Elevated Vpr was also shown to increase transcription of the NF-kappaB and NF-IL-6 enhancer-containing viral promoters for HIV, cytomegalovirus, and simian virus 40, as well as increase the expression of IL-6 and IL-10 in primary macrophages and in A549 cells, tumor necrosis factor alpha expression in primary T cells, and IL-6 and gamma interferon expression in U937 cells. These results suggest a new role for Vpr in the pathogenesis of HIV infection, namely, the activation of transcription factors NF-IL-6 and NF-kappaB.

Epstein-Barr virus induces Fas (CD95) in T cells and Fas ligand in B cells leading to T-cell apoptosis

Epstein-Barr virus (EBV) acute infectious mononucleosis (AIM) is characterized by transient immunosuppression in vivo and increased T-cell apoptosis after ex vivo culture of AIM peripheral blood mononuclear cells. We undertook experiments to test whether EBV or purified virion envelope glycoprotein gp350 could contribute to Fas-mediated T-cell apoptosis. Our in vitro results indicate that EBV increased Fas expression in CD4(+) T cells and Fas ligand (FasL) expression in B cells and macrophages. Purified gp350 was also shown to significantly increase CD95 expression in CD4(+) T cells. When T-cell CD95 was cross-linked, EBV-stimulated T cells underwent apoptosis. The induction of T-cell CD95 by EBV followed by CD95 cross-linking with anti-CD95 monoclonal antibody resulted in a loss in the number of T cells responding to the T-cell mitogens, anti-CD3 antibody, and interleukin-2. These results indicate that, in addition to serving as a principal ligand for the attachment of virus to target cells, gp350 may also act as an immunomodulatory molecule that promotes T-cell apoptosis.

Natural history of Epstein-Barr virus infection in a prospective pediatric cohort born to human immunodeficiency virus-infected mothers

To determine whether Epstein-Barr virus (EBV) constitutes a contributing factor in AIDS and, conversely, whether the human immunodeficiency virus (HIV) alters the course of primary EBV infection in a pediatric population, 62 children born to HIV-infected mothers and prospectively followed were evaluated. EBV infection was documented by EBV-specific serology and polymerase chain reaction and by clinical history. HIV infection status was determined according to the Centers for Disease Control and Prevention pediatric classification system. Demographics from HIV-infected and HIV-uninfected children were comparable. The data suggest that HIV-infected children may acquire primary EBV infection earlier in life. The incidence of accompanying splenomegaly or hepatomegaly (or both) around the time of EBV seroconversion was higher among HIV-infected children than among HIV-uninfected children. In contrast, HIV disease progression and HIV-1 RNA load did not seem to be influenced by primary EBV infection.

Anti-interleukin-10 antibodies in patients with chronic active Epstein-Barr virus infection

The Epstein-Barr virus (EBV) genome encodes a protein in its BamHI C restriction fragment rightward open-reading frame-1 (designated BCRF1 or viral interleukin-10 [vIL-10]) that shares protein homology and biologic properties with human IL-10. Several EBV disorders are characterized by prolonged active EBV infection. Because continued EBV replication could allow for increased vIL-10, ELISA and immunoprecipitation were used to determine whether vIL-10 expression during chronic active EBV infection resulted in vIL-10 and IL-10 antibodies. IL-10 antibodies were assayed in patients diagnosed with chronic and acute infectious mononucleosis (CIM, AIM), nasopharyngeal carcinoma (NPC), and EBV-associated lymphoproliferative disease (LPD), as well as from healthy organ transplant patients and EBV-negative or EBV-positive persons. Whether anti-IL-10 antibodies could inhibit IL-10 biologic activity was determined. vIL-10 antibodies were found in CIM, NPC, and LPD patients and antibodies reactive to IL-10 were found in CIM patients. One CIM patient had IL-10 antibodies that neutralized IL-10 bioactivity in vitro.

Antibody and antibody-dependent cellular cytotoxicity responses against the BamHI A rightward open-reading frame-1 protein of Epstein-Barr virus (EBV) in EBV-associated disorders

Antibody-dependent cellular cytotoxicity (ADCC) is an important antiviral effector mechanism. ADCC to the protein encoded by the Epstein-Barr virus (EBV) BamHI A rightward open-reading frame-1 (BARF1) was studied by transducing Raji-tk- cells with the BARF1 gene using a retroviral expression vector. The transduced Raji cells expressed BARF1 on the cell surface, as determined by flow cytometry. Sera from chronic and acute infectious mononucleosis and nasopharyngeal carcinoma patients were found to contain antibodies that react with the BARF1 protein. When BARF1-expressing Raji cells were used as targets for ADCC, sera from several nasopharyngeal carcinoma patients demonstrated significant ADCC reactivity, whereas sera from healthy EBV-seronegative and -seropositive persons lacked such reactivity. BARF1-specific ADCC activity could be competitively inhibited with recombinant BARF1 protein. The level of anti-BARF1 antibody activity in sera of patients with EBV-associated diseases suggests that the BARF1 protein may serve as a target on EBV-infected cells for ADCC.

Antibody responses to two Epstein-Barr virus (EBV) nuclear antigens (EBNA-1 and EBNA-2) during EBV primary infection in children born to mothers infected with human immunodeficiency virus

A variety of antibody response patterns to the latent Epstein-Barr nuclear antigen (EBNA) family have been described in different groups of subjects infected with Epstein-Barr virus (EBV). The purpose of this study was to characterize the immune response to two EBNA proteins, EBNA-1 and EBNA-2, in a population of children who were born to mothers infected with HIV and who underwent EBV seroconversion. Serial serum specimens from 33 children (nine were infected with HIV, and 24 were not infected) were evaluated for the presence of antibodies to EBNA-1 and EBNA-2 by anticomplement immunofluorescence. All the EBNA serology profiles observed for children in our study who were not infected with HIV were consistent with those described for immunocompetent hosts with acute EBV infection, i.e., development of antibodies to EBNA-1, often preceded by the appearance of a humoral immune response to EBNA-2. In contrast, following EBV primary infection in HIV-infected children, antibodies to EBNA-2 arose after antibodies to EBNA-1 and tended to persist. Further studies are needed to investigate the role of EBNA-2 serology as a prognostic marker in HIV-infected children.

Diagnosis of cytomegalovirus (CMV) infection in pediatric transplant patients by the antigenemia, shell vial, and conventional culture assays performed on blood: correlation with CMV disease

BACKGROUND

Human cytomegalovirus (CMV) is a significant cause of morbidity and mortality in transplant recipients. Isolation of CMV from blood leukocytes (CMV viremia) is considered predictive of CMV disease in transplant recipients. Therefore, investigation of methods for the rapid detection of CMV in the blood is important for diagnosis and management of these patients.

OBJECTIVE

To compare three techniques for the diagnosis and monitoring of CMV infection in a pediatric transplant population through the quantitative detection of CMV in peripheral blood leukocytes (PBL).

METHODS

Serial blood specimens were obtained for most patients. After separation of the PBL from each specimen, aliquots of the PBL were used for direct detection of CMV antigenemia by immunoperoxidase staining of acetone-fixed cells (CMV-vue kit, INCSTAR), and by immunofluorescence staining of formaldehyde-fixed cells (Complete 1C3 kit, Biosoft Argene). PBL were also inoculated into conventional cell culture tubes and shell vials. Patients' medical records were reviewed to ascertain the clinical significance of the results.

RESULTS

A total of 154 specimens obtained from 38 pediatric transplant recipients were evaluated. CMV was detected in 16 specimens obtained from eight patients: 11 specimens were found positive with the CMV-vue kit, 10 with the Complete 1C3 kit, four by conventional culture, and one by the shell vial assay. Seven of the eight patients with CMV-positive PBL had clinical signs and other laboratory evidence of active CMV infection. In general, a high-level antigenemia was demonstrated in the presence of clinical disease, but there were exceptions.

CONCLUSIONS

The two antigenemia kits were more sensitive than conventional culture and the shell vial assay for the detection of CMV in the blood of pediatric transplant patients. Our results suggest that CMV antigenemia is a sensitive and specific rapid method for the diagnosis and monitoring of CMV infection in our patient population.

Interactions involving cyclosporine A, interleukin-6, and Epstein-Barr virus lead to the promotion of B-cell lymphoproliferative disease

Post-transplant patients undergoing prolonged Cyclosporine A (CsA) immunosuppressive therapy were reported to have an increased incidence of Epstein-Barr virus (EBV)-associated lymphoproliferative disorders. EBV-infected B cells cultured with CsA demonstrated increased EBV B-cell out-growth as compared to those cultured without CsA. Peripheral blood mononuclear cells (PBMC), following infection with EBV and CsA treatment, demonstrated increased IL-6 activity in the culture supernatant. The induction of IL-6 appeared to differ within the various lymphocyte populations. In monocytes and B cells, IL-6 expression was preferentially induced by EBV, and initiated by the binding of the two major virion glycoproteins, gp350 and gp220, to CD21, or a CD21-like receptor. Expression of IL-6 in T cells appeared to be due mainly to CsA. B cells also expressed IL-6 following EBV exposure, but not following CsA treatment. EBY-immortalized B-cell lines cultured with CsA exhibited both an increased number of cells expressing viral lytic-cycle antigens and increased amounts of lytic-cycle proteins. IL-6, which was induced by CsA in PBMC, was also capable of inducing the lytic viral cycle in several EBV-immortalized cells. When IL-6 was expressed, it was shown to act as an autocrine growth factor for B cells and to inhibit the immune system allowing for the promotion of B-cell tumors by impairing lymphokine-activated killer cells. Thus CsA treatment, in promoting both increased numbers of lytic EBV B cells and expression of the EBV paracrine growth factor, IL-6, within the microenvironment of EBV B:T cell and EBV B:monocyte interactions, may lead to increased EBV B-cell immortalization and ultimately result in the promotion of B-cell lymphomas in immunosuppressed patients.

Epstein-Barr virus transmission from a blood donor to an organ transplant recipient with recovery of the same virus strain from the recipient's blood and oropharynx

A previous study (Savoie et al, Blood 83:2715, 1994) identified eight transplant patients who acquired Epstein-Barr virus (EBV) infection during the peritransplant period. Three of these patients subsequently developed B-cell lymphoproliferative disease within 4 months of transplantation. Among these, there was a 16-year-old liver transplant patient who was negative for EBV at the time of transplant and who received an EBV-negative organ. After transplant, this patient was transfused with 9 U of packed red blood cells. Eight of the donors were EBV-positive and one was EBV-negative. We succeeded in obtaining spontaneous lymphoblastoid cell lines (LCLs) from the blood of three of these donors, one of whom also yielded a cord-blood line established with his throat-wash EBV. Blood from a fourth donor did not yield an LCL, but his throat washing did have transforming activity when inoculated onto cord-blood leukocytes. We initially could establish spontaneous LCLs only from the recipient's blood. However, a throat-wash sample taken 11 weeks later did show transforming activity. The recipient was shown to have acquired the EBV infection from one of eight EBV-seropositive blood donors. Analysis of fragment length polymorphisms after polymerase chain reaction amplification of the EBV BamHI-K fragment was used to establish strain identity. Western blot analysis for existence of size polymorphisms in three classes of Epstein-Barr nuclear antigens (EBNA-1, EBNA-2, and EBNA-3) confirmed the DNA results. It is noteworthy that the blood donor responsible for transmitting his EBV strain to the recipient had experienced clinical infectious mononucleosis 15 months before donating blood. Our results may, thus, indicate a requirement for leukodepletion of blood destined for immunosuppressed EBV-negative patients. Finally, blood donors with a recent history of infectious mononucleosis should probably be identified so that their blood is not given to EBV-negative transplant patients.

Induction of interleukin-6 after stimulation of human B-cell CD21 by Epstein-Barr virus glycoproteins gp350 and gp220

The cellular receptor for Epstein-Barr virus (EBV) is the type 2 complement receptor, CD21. At initial infection, EBV virion glycoproteins gp350 and gp220 bind to CD21. We report here that the cross-linking of CD21 by gp350/220 results in increased amounts of interleukin 6 (IL-6) RNA and IL-6 protein. This effect could be blocked with anti-gp350/220 and anti-CD21 monoclonal antibodies. Induction of IL-6 in B cells by EBV could be mimicked by treatment with the protein kinase C (PKC) activator phorbol 12,13-dibutyrate but not with the calcium ionophore ionomycin. IL-6 induction by EBV was inhibited with the PKC-specific inhibitor bisindolylmaleimide or the protein tyrosine kinase inhibitors methyl 2,5-dihydroxycinnamate and herbimycin A, indicating that the induction of IL-6 following CD21 cross-linking is mediated through PKC- and protein tyrosine kinase-dependent pathways.

A solitary plasmacytoma of donor origin arising 14 years after kidney allotransplantation

Allotransplantation of solid organs transfers passenger leucocytes which may give rise to a state of persistent microchimaerism. In this report we describe the case of a patient who developed a solitary plasmacytoma in a transplanted kidney more than 10 years after allografting. The diagnosis was established on the basis of the presence of a monoclonal IgG kappa peak in the serum, and light chain proteinuria, the plasmacytoid features of tumour cells including cell surface expression of IgG, kappa light chains, CD20, CD38 and CD56, the absence of lytic bone lesions and a normal bone marrow biopsy, and the disappearance of the monoclonal IgG peak after graft nephrectomy. A donor origin of the tumour was established by HLA DNA typing of tumour, tumour-free kidney tissue, and peripheral blood leucocytes, respectively.

Direct correlation between the load of Epstein-Barr virus-infected lymphocytes in the peripheral blood of pediatric transplant patients and risk of lymphoproliferative disease

The Epstein-Barr virus (EBV) is known to cause posttransplant lymphoproliferative disease (PTLD) in immunosuppressed transplant patients. The results of this pilot study showed that all EBV- patients pretransplant experienced primary EBV infection within the first 3 months after transplant surgery. Virtually all of these patients had a higher burden of EBV-infected cells in their peripheral blood (PB) after infection by EBV than did the EBV+ pretransplant group when tested at the same intervals posttransplant. Salivary EBV titers also increased in most patients, but the difference between the two groups was statistically significant only at 12 months, whereupon EBV+ patients showed higher titers compared with EBV- (alpha < 0.053). Also, polymerase chain reaction amplification followed by Southern blotting was performed to detect EBV sequences in PB mononuclear cells. This technique allowed confirmation of the blood culture results and constituted a faster alternative compared with the culture assay. The highest increase in the number of EBV-infected lymphocytes at 3 months posttransplant obtained from PB was seen in a patient who developed fatal PTLD and in another with protracted infectious mononucleosis. Thus, the number of EBV-infected cells in PB was found to correlate positively with risk of development of PTLD at 3 months posttransplant in our group of pediatric transplant patients. This study showed that quantitative lymphocyte culture of PB was an accurate index of immunosuppression and a reliable method for assessing the risk of PTLD development.

Radioimmunoprecipitation in the diagnosis of chronic active Epstein-Barr virus infection

Chronic active Epstein-Barr virus (EBV) infection occurs sporadically in a small fraction of individuals infected with EBV. A clear definition of the disease and an unambiguous diagnostic test are still lacking. In an attempt to identify a serologic marker to facilitate the diagnosis, immunoblot and radioimmunoprecipitation assay (RIPA) were compared with standard immunofluorescence on 39 available sera. Results by RIPA revealed that antibodies to a 120 kDa viral protein correlated with the presence of chronic active EBV infection; these antibodies were not detected in sera from other EBV-seropositive individuals, with the exception of one of two patients with ataxia telangiectasia. Also, RIPA was the most sensitive technique for detecting EBV antibodies in sera weakly or doubtfully positive for antibody to EB viral capsid antigen by indirect immunofluorescence. All these sera had antibodies to the 150 kDa protein, also known as p160, the major viral capsid antigen.

Effect of mycophenolic acid on Epstein-Barr virus infection of human B lymphocytes

The effect of mycophenolic acid (MPA) on the growth of Epstein-Barr virus (EBV)-transformed B cells and on EBV lytic-cycle gene expression was investigated. MPA inhibited the proliferation of newly infected or established EBV-transformed B-cell lines but was not able to block cell growth transformation or the viral lytic cycle. These results suggest that MPA might reduce transformed-cell proliferation in transplant patients and possibly decrease the risk of development of EBV-related lymphoproliferative disorders.

Early events in Epstein-Barr virus infection of human B lymphocytes

The sequence of Epstein-Barr virus (EBV) and B lymphocyte changes in the 3 days following acute infection was analyzed. By 16 hr the average infected lymphocyte had 1 EBV episome. Nuclear protein-2 (EBNA-2) and EBNA-leader protein (-LP) were detected by 12 hr, and by 32 hr were at the levels of stable EBV infection in lymphoblastoid cell lines (LCLs). At 12 hr, all EBNA-LP and EBNA-2 RNAs were initiated from the Pw promoter. By 36 hr a significant EBNA-LP and EBNA-2 RNA fraction initiated from the upstream Pc promoter. Throughout acute infection, a similar fraction of potentially bicistronic EBNA-LP mRNAs had first exon splices which would result in EBNA-LP translation. By 36 hr c-myc RNA was transiently induced, and CD21 and CD23 RNAs were beginning to increase. This coincided with low-level EBNA-1, EBNA-3A, B, and C, and latent membrane protein-1 (LMP-1) expression. By 46 hr, EBNA-1, the EBNA-3s, and LMP-1 were near the levels ordinarily found in LCLs and a substantial fraction of lymphocytes were in S phase. These results are compatible with a key role for EBNA-2 (or EBNA-LP) in regulating virus and cell gene expression. High-level expression of the EBV-encoded small RNAs, EBERs, was delayed beyond 36 hr and may, therefore, be activated by other virus or cell genes. A 65-kDa virion protein persisted in acutely infected cells. This protein could be a mediator of virus or cell gene expression.

Induction of germ-line and mature C epsilon transcripts in human B cells stimulated with rIL-4 and EBV

EBV and rIL-4 induce T cell-independent IgE production by normal human B cells. We demonstrate here that EBV and IL-4 induced the synthesis of IgE by surface IgE-negative B cell precursors isolated by cell sorting. This result suggests that the induction of IgE by EBV and IL-4 results not merely from the expansion of a precommitted surface IgE-positive B cell population but more likely from IL-4-directed switching to IgE. At the molecular level, IL-4 and EBV induced the appearance of 2.0- and of 1.8-kilobase (kb) RNA bands, both of which hybridized with an 0.88-kb HinfI fragment spanning part of the C epsilon 1 exon and the entire C epsilon 2 exon. The 1.8-kb band but not the 2.0-kb band also hybridized with a cloned genomic 0.7-kb SmaI fragment located approximately 2 kb upstream of C epsilon. Thus, EBV and IL-4 induced germline (1.8-kb) as well as mature (2.0-kb) C epsilon transcripts. IL-4 by itself induced germ-line C epsilon transcripts but not mature C epsilon transcripts in purified normal B cells. IL-4 failed to induce IgE synthesis in established EBV B cell lines and failed to induce 2.0-kb mature C epsilon transcripts but induced 1.8-kb germ-line C epsilon transcripts. These data show that IL-4 is sufficient for the induction of C epsilon germ-line transcription. In contrast, the transcription of mature epsilon mRNA requires an additional activating signal, provided by infection with EBV. Established EBV transformation results in a dissociation between germ-line C epsilon transcription and the ability to undergo IgE switching in response to IL-4.

Induction of germ-line and mature C epsilon transcripts in human B cells stimulated with rIL-4 and EBV

EBV and rIL-4 induce T cell-independent IgE production by normal human B cells. We demonstrate here that EBV and IL-4 induced the synthesis of IgE by surface IgE-negative B cell precursors isolated by cell sorting. This result suggests that the induction of IgE by EBV and IL-4 results not merely from the expansion of a precommitted surface IgE-positive B cell population but more likely from IL-4-directed switching to IgE. At the molecular level, IL-4 and EBV induced the appearance of 2.0- and of 1.8-kilobase (kb) RNA bands, both of which hybridized with an 0.88-kb HinfI fragment spanning part of the C epsilon 1 exon and the entire C epsilon 2 exon. The 1.8-kb band but not the 2.0-kb band also hybridized with a cloned genomic 0.7-kb SmaI fragment located approximately 2 kb upstream of C epsilon. Thus, EBV and IL-4 induced germline (1.8-kb) as well as mature (2.0-kb) C epsilon transcripts. IL-4 by itself induced germ-line C epsilon transcripts but not mature C epsilon transcripts in purified normal B cells. IL-4 failed to induce IgE synthesis in established EBV B cell lines and failed to induce 2.0-kb mature C epsilon transcripts but induced 1.8-kb germ-line C epsilon transcripts. These data show that IL-4 is sufficient for the induction of C epsilon germ-line transcription. In contrast, the transcription of mature epsilon mRNA requires an additional activating signal, provided by infection with EBV. Established EBV transformation results in a dissociation between germ-line C epsilon transcription and the ability to undergo IgE switching in response to IL-4.

Expression of Epstein-Barr virus transformation-associated genes in tissues of patients with EBV lymphoproliferative disease

Epstein-Barr virus (EBV) has been associated with serious or fatal lymphoproliferative disease in immunocompromised patients. EBV nuclear protein 2 and latent membrane protein are characteristically expressed in B lymphocytes proliferating in vitro in response to growth transformation by EBV. These two proteins are thought to be effectors of lymphocyte growth since they increase the expression of B-lymphocyte activation (CD23) and cell-adhesion (LFA 3 and ICAM 1) molecules in vitro. Using monoclonal antibody-immune microscopy, we have demonstrated that these two EBV proteins and their associated B-lymphocyte activation or adhesion molecules are expressed in the infiltrating B lymphocytes in immunocompromised patients with EBV lymphoproliferative disease. These monoclonal antibodies should be useful in the early diagnosis of EBV lymphoproliferative disease and in distinguishing it from other B-lymphocyte cancers associated with EBV, such as Burkitt's lymphoma. The finding of EBV nuclear protein 2 and latent membrane protein and their associated activation or adhesion molecules provides a further pathophysiologic link between EBV and the proliferation of B lymphocytes in immunocompromised patients.

Brief report: killer cell defect and persistent immunological abnormalities in two patients with chronic active Epstein-Barr virus infection

Two members of a family have manifested a syndrome of chronic active Epstein-Barr virus (EBV) infection. A father and his daughter suffered prolonged or recurrent mononucleosis, with splenomegaly, anemia, and intermittent fever; persistent immunological abnormalities included defective natural killer (NK) cytotoxicity, inverted CD4/CD8 ratios, hyper IgG1, high EBV viral capsid antigen (VCA) and early antigen (EA) antibodies, and low or undetectable EBV nuclear antigen (EBNA) antibody titers. The EBV seronegative member of the family was free of these abnormalities. However, NK activity in the seronegative individual was low-normal and its EBV-specific antibody-dependent K-cell cytotoxicity (EBV-ADCC) was abnormally low, suggesting that this K-NK cell defect may be primary. The father, who suffered from the syndrome for more than 15 years, lacked (or lost) antibodies to EBV-envelope and infected cell membranes, such as antibody-dependent cellular cytotoxicity (ADCC), neutralizing (NT), and gp 350/220 antibodies. Slow improvement over a period of years was heralded by rising NK cytotoxicity.

Biomolecular analysis of a defective nontransforming Epstein-Barr virus (EBV) from a patient with chronic active EBV infection

A virus recovered from the saliva of a child with chronic active Epstein-Barr virus (EBV) infection for 8 years was shown to induce EBV early antigen (EBV-EA) in Raji cells and to be expressed into EBV-EA in fresh EBV-negative peripheral blood leukocytes. However, it did not replicate its DNA. Oropharyngeal epithelial cells scraped from recurrent mouth lesions were similarly positive for EBV-EA. DNA extracted from these cells and digested with BamHI contained a 6-kilobase-pair fragment homologous to BamHI fragment V and B1 EBV DNA probes. Furthermore, Southern blots of the BamHI and EcoRI digests of the DNA extracted from the cell lines of the patient (transformed with EBV strain B95-8) and of her mother (spontaneous) revealed, in addition to the expected BamHI G, H, H2, and B1 fragments used as probes, additional shorter ones of a presumably endogenous defective virus.

Lytic, nontransforming Epstein-Barr virus (EBV) from a patient with chronic active EBV infection

A new wild-type isolate of Epstein-Barr virus (EBV) was identified in follow-up studies of a case of chronic active EBV infection in an 8-year-old girl who had high titres of antibody to viral capsid antigen and early antigen (EA) (greater than 20 480 and 2560 respectively), persistent splenomegaly and abnormal immunologic features. More than 10 throat washings from this patient failed to transform cord blood lymphocytes (CBL), but at least 7 were able to induce EA in Raji cells. Supernatants from cultures of the lymphoblastoid cell line obtained by in-vitro infection of this patient's leukocytes with the B95-8 strain of EBV revealed a herpesvirus particle when examined by electron microscopy. The same supernatants were unable to transform CBL but could induce EA in Raji cells upon superinfection. In 30 or more trials the patient's lymphocytes never transformed spontaneously but did become positive for EBV nuclear antigen and EA in the first week of culture at least twice. Parallel studies performed on the father of the patient yielded similar results. This, then, is the first report documenting lytic activity associated with a wild-type EBV isolate.