EBV-associated T-cell lymphoproliferative diseases (EBV T-cell LPDs) in non-immunocompromised hosts are a heterogenous syndrome which is challengeable for both diagnosis and treatment. Here, we report four young patients of EBV T-cell LPDs with unusual histopathological and immunophenotypic features. They presented with intermittent high fever (4/4), multiple lymphadenopathy (4/4), hepatosplenom egaly (4/4), hematochezia (2/4) and high blood EBV antibodies titer (4/4) for seven months to one year. The enteroscopic examination revealed multiple ileocecus ulcers in three of four cases. Histologically, three cases showed similar dense infiltration of polymorphic composition including variable reactive components such as plasma cells and histiocytes as well as atypical lymphocytes and one case was characterized by proliferation of monomorphic atypical lymphocytes. The infiltrating lymphocytes were medium-sized with hyperchromatic nuclei and showed mild cytologic atypia. Abundant eosinophils infiltration and formation of eosinophilic abscess were seen in all cases. Multiple foci of necrosis with granuloma were observed in lymph nodes of all cases, but hemophagocytosis was absent. The immunohistochemical staining showed that infiltrative lymphocytes were CD2 TIA1 CD56 ﹣ , suggesting cytotoxic T-cells origin, but loss of pan-T markers CD3 (2/4), CD5 (4/4) and CD7 (2/4) were frequently observed. Negativity for both CD4 and CD8 (4/4) and silent T-cell receptor (TCR) expression (3/3) were detected. EBV positivity in numerous T-cells was identified by double staining of CD3 and EBER. Three patients died within one year and one patient is alive six months after initial presentation. These unusual pathologic findings prompt us being aware of EBV T-cell LPDs and add to the understanding of this rare disease.
Epstein-Barr virus (EBV) is a ubiquitous virus that can cause both acute and chronic active infections [
CAEBV is found to be prevalent in Asian countries and characterized by proliferation of the EBV-infected T/NK cells which is related with EBV-associated T/NK-cell lymphoproliferative disorders (EBV+ T/NK-LPDs) [
Because of its rarity and complexity, it is necessary to find more pathological information of EBV+ T-cell LPDs in favour of diagnosis and treatment. In this study, we report four cases of EBV+ T-cell LPDs with unusual immunophentypic and histopathological features including negativity for CD4 and CD8, multiple foci of necrosis, abundant eosinophils inflitration and granuloma, which adds to the understanding of these rare diseases.
Formalin-fixed, paraffin-embedded tissue blocks of intestine and lymph node biopsies were available for evaluation. Clinical and laboratory information was obtained from the medical records, the referring pathologists, and the clinicians. The diagnosis of CAEBV was defined according to previously proposed criteria [
Immunohistochemistry (IHC) was performed using formalin-fixed, paraffin embedded tissue sections on a Bond-III Autostainer (Leica Biosystems, Melbourne, Australia) according to the company’s protocol with slight modifications. The antibody panel included CD2, CD3, CD5, CD8, CD20 (all from MXB Biotechnologies, Fuzhou, Fujian, China), CD4, CD56, Ki-67 (all from Dako, Copenhagen, Denmark), TIA-1, CD7 (all from Gene Tech Company Limited, Shanghai, China), TCR-βF1 and TCR-cγM1 (all from Thermo Scientific, Rockford, IL, USA). Appropriate positive and negative tissue controls were used for these studies.
The presence of EBV was examined by in situ hybridization (ISH). Epstein Barr-encoded RNA-in situ hybridization (EBER-ISH) was performed using the Bond-Max Autostainer (Leica Biosystems, Melbourne, Australia) with ISH kits for EBV (Leica Biosystems, Newcastle Upon Tyne, UK) following manufacturer’s instructions. Double staining for EBER-ISH and CD3 or CD20 immunohistochemistry were performed following the above-described methods.
Genomic DNA of intestine lesions and lymph nodes was isolated using QIAamp FFPE Tissue Kit (Qiagen, Germantown, MD, USA) and was amplified by polymerase chain reaction (PCR) according to the BIOMED-2 clonality assays. TCR gene clonality including TCR β and γ gene was determined by multiplex PCR using the BIOMED-2 multiplex PCR kits (Yuan Qi Biomed, Shanghai, China) according to the standard BIOMED-2 multiplex PCR protocol and PCR primer sets as previously described [
The clinical features of the patients are summarized in
Case no. | Sex | Age (Year) | Clinical presentation | EBV serology | Treatment | Outcome (months) | |
---|---|---|---|---|---|---|---|
anti-VCA IgG | anti-VCA IgM | ||||||
1 | M | 22 | Intermittent high fever, abdominal pain and hematochezia for 8 months; pancytopenia, bnormal liver function tests, multiple mesenteric lymphadenopathy, hepatosplenomegaly, multiple ileocecus ulcers | Positive | Positive | Supportive therapy, antibiotics and surgery | DOD (12) |
2 | F | 23 | Repeated fever and abdominal pain for 10 months; multiple lymphadenopathy (bilateral neck, axillary, groin), hepatosplenomegaly, multiple ileocecus ulcers | Positive | NA | Supportive therapy and surgery | DOD (12) |
3 | F | 18 | Repeated fever, abdominal pain and hematochezia for 1 year; multiple lymphadenopathy (left neck, mediastinal, retroperitoneal, mesenteric), hepatosplenomegaly, multiple ileocecus ulcers | Positive | NA | Surgical resection of the lesional intestine | DOD (1) |
4 | M | 14 | Intermittent high fever, purpura and weight loss for 7 months; pancytopenia, abnormal liver function tests, multiple lymphadenopathy (bilateral neck,axillary, mediastinal, retroperitoneal), hepatosplenomegaly | Positive | Negative | Chemotherapy | AWD (6) |
VCA, viral capsid antigen; M, male; F, female; NA, not available; DOD, dead of disease; AWD, alive with disease.
males and two females with ages ranging from 14 to 23 years (median age, 20 years). All cases were Chinese without opportunistic infections or other indications of any congenital immunodeficiency, nor had they received immunosuppressive medications. All four patients presented with long term intermittent high fever, multiple lymphadenopathy and hepatosplenomegaly for seven months to one year. The other clinical symptoms and signs including hematochezia (2/4), abdominal pain (3/4), and multiple intestinal ulcers (3/4) were also observed. Symptoms like weight loss and purpura were also found. One patient (case 1) had elevated lactate dehydrogenase (LDH) levels (745 IU/L) and two patients (case 1 and case 4) had pancytopenia and abnormal liver function tests. No patient was associated with hemophagocytosis. All four patients showed positive EBV antiviral capsid antigen (anti-VCA) IgG titers with positive or abscent anti-VCA IgM antibodies. Antibodies to hepatitis viruses and cytomegalo virus were negative in all patients. As with the treatments and outcomes of our cases, two patients had only supportive therapy and surgery and died 1 year after presentation. One patient died of postoperative complications after surgical resection of the lesional intestine and the other received chemotherapy and remained in stable disease for six months.
Three cases (cases 1 - 3) showed essentially similar histologic findings in the intestine. The intestinal epithelial cells were markedly eroded with ulcers and dense infiltration of atypical lymphocytes intermingled with abundant eosinophils in the mucosa and submucosa (
The normal architecture of lymph nodes was markedly distorted in all four cases. Multiple foci of necrosis were observed in each case and the necrosis was surrounded by epithelioid cells with granuloma (
The immunophenotypic and genetic features of the cases are summarized in
Immunophenotype | |||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Case no. | CD2 | CD3 | CD5 | CD7 | CD4 | CD8 | CD56 | CD20 | TIA-1 | TCR-βF1 | TCR-cγM1 | EBER | TCR gene rearrangements |
1 | + | + | − | + | − | − | − | − | + | − | − | + | Polyclonal |
2 | + | − | − | − | − | − | − | − | + | − | − | + | Polyclonal |
3 | + | − | − | + | − | − | − | − | + | − | − | + | TCR-γ gene monoclonal |
4 | + | + | − | − | − | − | − | − | + | NA | NA | + | TCR-γ gene monoclonal |
markers including CD3 (2/4) (
We report four cases of EBV+ T-cell LPDs in adolescents and young adults with unusual histopathological and immunophenotypic features. Three patients
showed aggressive clinical course and died within one year after the initial presentation and one case remained in stable disease for six months. Because of the complicated clinical and histopathological presentation and lacking characteristic morphologic changes, diagnosis should be made with combined information including clinical symptoms and signs, laboratory examinations and pathological findings instead on the basis of morphology alone. Based on the diagnostic criteria of EBV+ T-cell LPDs, our cases satisfied the diagnosis of EBV+ T-cell LPDs for the following reasons. Firstly, all patients experienced typical infectious mononucleosis (IM)-like symptoms for at least six months including persistent high fever, multiple lymphadenopathy, hepatosplenomegaly and even hematochezia or multiple intestinal ulcers with a high blood EBV antibody titers. Moreover, numerous medium-sized atypical lymphocytes positive for EBER infiltrated the intestine and lymph node. The histopathologic features including multiple foci of necrosis, granuloma, abundant eosinophils infiltration and even the formation of eosinophilic abscess were unusual in EBV+ T-cell LPDs. The infiltrative atypical lymphocytes were CD2+ TIA1+ T cells, whereas double negativity for CD4 and CD8 and silent TCR expression were also uncommon in this rare disease.
Many cases of EBV+ T-cell LPDs clinically overlap with CAEBV and fulminant EBV+ T-cell LPD of childhood which was first identified by Su et al. in 1990 [
The most commonly involved sites of EBV+ T-cell LPDs are liver and spleen followed by lymph nodes, bone marrow, skin and lung [
The EBV-infected T-cells of cases secondary to acute primary EBV infection are unually CD8+ T-cells, whereas cases in the setting of severe CAEBV are often CD4+ T-cells [
Concerning the differential diagnosis, as one case was catergorized as A3 which was monomorphic LPD with clonal proliferation of EBV-infected cells, the differential diagnosis of T-cell and NK-cell lymphoma was raised. It is clear that some EBV+ T/NK-LPDs cases are positive for CD56, cytotoxic molecules and EBER, which is phenotypically identical to that of extranodal NK/T-cell lymphoma, nasal type. Differentiation from these lymphomas is particularly difficult or even impossible in some cases of EBV+ T/NK-LPDs because of their secondary development to those well defined lymphomas during the clinical process [
As for the prognosis of our cases, two of the patients refused to receive further treatment and died one year after initial presentation, one died of postoperative complication after surgical resection of the intestinal lesions, and the other one received chemotherapy and remained in stable disease for six months. Kimura H et al. [
In summary, we report four cases of EBV+ T-cell LPDs in adolescents and young adults with unusual histopathological and immunophentypic features including multiple foci of necrosis, numerous eosinophils inflitration and granuloma in addition to negativity for CD4 and CD8 of atypical lymphocytes. It is important to recognize these unusual immunophenotypic and histopathologic features of this rare complicated disease. We emphasize the comprehensive considering of clinic symptoms and signs, typical laboratory findings, immunophenotypic and histopathological features in reaching a correct diagnosis. Further studies are needed to clarify the nature of this rare disease and relationship with T-cell and NK-cell lymphomas and facilitate the development of effective treatments.
Li, M.Y. (2017) EBV-Associated T-Cell Lymphoproliferative Diseases in Young Adults with Unusual Histopathological and Immunophenotypic Features. Open Access Library Journal, 4: e3951. https://doi.org/10.4236/oalib.1103951