A case of Epstein-Barr virus–associated hemophagocytic lymphohistiocytosis with severe cardiac complications
Kawamura et al. BMC Pediatrics
A case of Epstein-Barr virus-associated hemophagocytic lymphohistiocytosis with severe cardiac complications
Yoshiki Kawamura 0 1
Hiroki Miura 0
Yuji Matsumoto 0
Hidetoshi Uchida 0
Kazuko Kudo 0
Tetsushi Yoshikawa 0
0 Department of Pediatrics, Fujita Health University School of Medicine , 1-98 Dengakugakubo, Kutsukake-cho, Toyoake 470-1192 , Japan
1 Present address: Division of Viral Products, Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration , 10903 New Hampshire Avenue, Silver Spring, MD 20993 , USA
Background: Hemophagocytic lymphohistiocytosis (HLH) is a life threatening hematological disorder associated with severe systemic inflammation caused by an uncontrolled and ineffective immune response resulting in cytokine storm. Epstein-Barr virus (EBV) is the most common infectious agent in patients with the viral-associated HLH. Limited numbers of cases with cardiac complication have been demonstrated in other viral-associated HLH patients. Herein, we report a pediatric case of severe EBV-associated HLH with cardiac complications. Case presentation: A previously healthy 4-year-old Japanese female was admitted to a local hospital with a four day history of fever. Despite antibiotic treatment, her fever persisted to day 7 of the illness. Finally, the diagnosis of HLH was confirmed by fulfilling diagnostic criteria for HLH and pathological analysis of bone marrow aspiration. Real-time PCR detected a high copy number of EBV DNA in the peripheral blood mononuclear cells (PBMCs) at the time of hospital admission. During treatment according to HLH-2004 protocol, sudden cardiopulmonary arrest (CPA) occurred on day 30 of the illness and immediate resuscitation was successful. Acute myocarditis was considered the cause of the CPA. Although the treatment regimen was completed on day 88 of the illness, a remarkably high copy number of EBV DNA was still detected in her PBMCs. Based on our flow cytometric in situ hybridization analysis that revealed EBV infection of only B lymphocytes, we decided to administer rituximab to control the abnormal EBV infection. Afterwards the amount of EBV DNA decreased gradually to undetectable level on day 130 of the illness. Unfortunately, a coronary artery aneurysm was discovered at the left main coronary artery on day 180 of the illness. Finally, the patient was discharged from the hospital on day 203 of the illness without sequelae except for a coronary aneurysm. Conclusions: In this case report, EBV-HLH was complicated with cardiac symptoms such as myocarditis and coronary artery aneurysm. Although remarkably high copy number of EBV DNA was detected in PBMCs after completion of the HLH-2004 protocol, rituximab treatment resulted in a dramatic decrease of EBV DNA to undetectable levels. Rituximab treatment might have been beneficial for the patient's survival.
Epstein-Barr virus; Hemophagocytic lymphohistiocytosis; Coronary artery lesion; Myocarditis; Rituximab
Hemophagocytic lymphohistiocytosis (HLH) is a life
threatening hematological disorder associated with
severe systemic inflammation caused by an uncontrolled
and ineffective immune response, such as activation and
aberrant proliferation of macrophages, lymphocytes, and
dendritic cells resulting in cytokine storm . HLH is
divided into two types based on its etiology: primary
(genetic) and secondary (acquired) HLH. Primary HLH
is due to genetic defects in cellular cytotoxicity, whereas
secondary HLH is associated with viral infections
including Epstein-Barr virus (EBV), autoimmune diseases,
malignant diseases, and acquired immune deficiency
conditions. EBV is the most common infectious agent in
patients with the viral-associated HLH.
Limited numbers of cases with cardiac complication
have been demonstrated in the viral-associated HLH
patients [2, 3]. Additionally, distinguishing between
HLH and Kawasaki disease (KD) that also causes
hypercytokinemia was difficult because of similar clinical
symptoms . KD is one of the most common vasculitis
of childhood which shows characteristic bilateral
nonexudative conjunctivitis, erythema of the lips and
oral mucosa, rash, extremity changes, and cervical
lymphadenopathy. It is well known that KD can cause
arteritis resulting in coronary aneurism. Coronary artery
aneurism was observed in the patients with HLH, who
fulfilled the diagnostic criteria of KD .
In addition to HLH, in some rare cases EBV can cause
a chronic active EBV (CAEBV) infection, which is a
non-familial syndrome that reflects a specific
immunodeficiency and impairment of host responses against
EBV . In immunocompetent individuals, EBV
establishes a latent infection in B lymphocytes after primary
viral infection. However, in some cases of EBV infection
a chronic active viral infection of T lymphocytes and
natural killer cells may be detected. Previous studies
have described CAEBV patients with cardiac
complications, including coronary artery aneurism . Thus, not
only HLH but also CAEBV can cause severe cardiac
symptoms similar to Kawasaki disease. Herein, we report
a pediatric case of severe EBV-associated HLH that did
not fulfill with criteria for KD with cardiac complications
including myocarditis and a coronary artery aneurism.
A previously healthy 4-year-old Japanese female was
admitted to a local hospital with a four day history of
fever as high as 39 °C. Although she had pharyngitis,
lymphoadenopathy and hepatosplenomegaly, no
symptom suggesting KD such as conjunctivitis, extremity
changes and skin rash was demonstrated at the time of
admission. Despite antibiotic treatment, her fever
persisted to day 7 of the illness. HLH was suspected
because of pancytopenia (WBC, 1000/μL [4000-9000/
μL]; Plt, 2.7 × 104/μL [20-40 × 104/μL]; Hb, 4.2 g/dL
[12-15 g/dL]) as well as elevated levels of ferritin
(greater than 40000 ng/mL [24-336 ng/mL]) and LDH
(5540 IU/L [140-180 IU/L]). Finally, the diagnosis of
HLH was confirmed by fulfilling diagnostic criteria for
HLH and pathological analysis that revealed
hemophagocytosis in a bone marrow sample . She was
transferred to our hospital on day 9 of the illness because
she failed to respond to the conventional treatments for
HLH, including dexamethasone, cyclosporine, and a
high dose of immunoglobulins. The patient’s treatment
course and cytokine profile is summarized in Fig. 1.
At the time of admission to our hospital, she was
unconscious (Glasgow coma scale was E2V2M4) with
disseminated intravascular coagulation (DIC) and acute
renal injury (blood urea nitrogen, 22.5 mg/dL; creatinine,
0.69 mg/dL). Therefore, in addition to recombinant
thrombomodulin that has been suggested to be effective
treatment for DIC patients , continuous
hemodiafiltration was also carried out. Real-time PCR detected a high
copy number of EBV DNA (6.6 × 106 copies/μg DNA) in
the peripheral blood mononuclear cells (PBMCs) at the
time of hospital admission. Although EBV-VCA-IgM,
-IgA, EBV-EA DR-IgG, -IgA, and EBV-EBNA IgG titers
were negative, EBV-VCA-IgG was positive (×80) by
immunofluorescence assay. Additionally, EBV-infected cells
were identified as T and B lymphocytes using the flow
cytometric in situ hybridization method . Again, this
patient did not fulfill the diagnostic criteria of Kawasaki
disease because of lacking conjunctivitis, extremity
changes and skin rash during the observation period .
Despite intensive treatments, her condition
deteriorated, and etoposide (VP-16) administration was started
on day 19 of the illness according to the treatment
guideline, HLH-2004 . After starting the
chemotherapy, DIC gradually improved and the EBV-DNA load
decreased. However, sudden cardiopulmonary arrest (CPA)
occurred on day 30 of the illness and immediate
resuscitation was successful. Acute myocarditis was considered
the cause of the CPA because elevated N-terminal
probrain natriuretic peptide (49554 pg/mL [<300 pg/mL] )
and cardiac markers (creatine kinase (CK), 189 IU/L
[22-198 IU/L] ; CK-myoglobin, 12.4 ng/mL [<4.3 ng/mL]
; troponin I, 0.40 ng/mL [<0.03 ng/mL] ), an
enlargement of the cardiac silhouette in chest X-ray, low QRS
voltage at the chest lead electrocardiogram, and
abnormal echocardiography findings such as myocardial
thickness were observed. Angiotensin-converting enzyme
inhibitor was started for myocardial protection, and
dexamethasone, cyclosporine, and VP-16 administrations
were discontinued from days 30 to 46 of the illness.
Although the treatment regimen based on the
HLH2004 protocol was completed on day 88 of the illness
Fig. 1 Clinical course of the patient and kinetics of EBV-DNA load and biomarkers. The patient had a rapid decrease in EBV-DNA load after initial
treatments with chemotherapy that induced severe bone marrow suppression. No mononuclear cells were obtained from the patient during this
period. CHDF, continuous hemodiafiltration; ACE-I, angiotensin-converting enzyme inhibitor; TM, thrombomodulin alpha; Dexa, dexamethasone;
CSA, cyclosporine; VP-16, etoposide; CPA, cardiopulmonary arrest; EBV, Epstein-Barr virus, IFN; interferon, IL; interleukin, TNF; tumor necrosis
and the general condition of the patient was good, a
remarkably high copy number of EBV DNA was still
detected in her PBMCs (50,193–241,284 copies/μg DNA).
Based on our flow cytometric in situ hybridization
analysis that revealed EBV infection of only B lymphocytes,
we decided to administer rituximab (375 mg/m ) only
one time to control the abnormal EBV infection. The
amount of EBV DNA decreased gradually to
undetectable level on day 130 of the illness. Although
lymphocytopenia (Minimum lymphocyte 0/μL) were observed for
a month after administration of rituximab, it
spontaneously improved. Unfortunately, a coronary artery
aneurysm was discovered at the left main coronary
artery and aspirin was administered from day 105 of the
illness. Subsequent coronary angiography showed an 8 ×
4 mm sized coronary artery aneurysm at the left
coronary artery on day 180 of the illness (Fig. 2). The patient
was eventually discharged from the hospital on day 203
of the illness without sequelae except for a coronary
artery aneurysm on day 203 of the illness.
In order to elucidate pathophysiology of the patient,
kinetics of serum ferritin and levels of cytokines
including interferon (IFN)-γ, tumor necrosis factor (TNF)-α,
interleukin (IL) -2, 4, 6, and 10 were examined (Fig. 1).
The concentrations of cytokines were measured by the
cytometric bead array kit–BDTM CBA Human Th1/Th2
Cytokine Kit (BD Biosciences, San Jose, CA). Although
serum ferritin, IFN-γ (9993 pg/mL), IL-6 (368 pg/mL)
and IL-10 (1322 pg/mL) concentrations were elevated
remarkably at the time of hospital admission, IFN-γ and
IL-10 levels decreased quickly and ferittin and IL-6 also
decreased slightly after starting the intensive treatments.
Transient increases in levels of IL-6, IFN-γ, TNF-α and
IL-10 concentrations corresponding to an increase in
Fig. 2 Left coronary angiography on the day 180 of the illness.
Injection of the left coronary artery demonstrated a large, saccular
aneurysm in the proximal left anterior descending and circumflex
coronary arteries (White arrow)
EBV DNA load were demonstrated probably due to the
recovery of bone marrow.
Both HLH and CAEBV infection can cause
hypercytokinemia, which may be associated with cardiac
complications such as myocarditis and coronary artery aneurysms
. Although several etiologies have been suggested to
be involved in HLH, to date only one EBV-HLH case
with a coronary artery aneurysm has been reported .
The previously reported EBV-HLH case fulfilled the
diagnostic criteria of Kawasaki disease and was initially
treated with high-dose intravenous immunoglobulins
and oral aspirin. The patient in that report was
subsequently diagnosed with EBV-HLH because of prolonged
hepatosplenomegaly, abnormal laboratory data
suggesting hypercytokinemia, and the pathological finding of
hemophagocytosis. Meanwhile, our case lacked the
typical symptoms suggestive of Kawasaki disease such as
conjunctivitis, extremity changes and skin rash.
Additionally, primary EBV infection that is one of the most
important infectious diseases for ruling out for diagnosis
of Kawasaki disease was demonstrated in soon after
admission to the previous hospital. Thus, although these
two cases are both considered to be EBV-HLH, the
previously reported case and our current case had distinct
clinical courses of disease. Thus, in this case report
EBV-HLH lacking clinical symptoms of Kawasaki disease
was associated with cardiac complications such as
myocarditis and coronary artery aneurysm. Parvovirus and
Enterovirus have been suggested to be involved in
infection-associated HLH complicating myocarditis [2,
3]. This case report supports the notion that EBV can
cause not only HLH but also severe cardiac
complications such as myocarditis and coronary artery aneurysm.
It is possible that lacking of genetic analysis such as
mutations in the gene encoding perforin or in X-linked
lymphoproliferative disease might be limitation of this
study. However, EBV infection was confirmed at the
onset of HLH, and the parents didn’t have a
consanguineous marriage. Moreover, this case was female and didn’t
have family medical history. Therefore it was little
chance to be diagnosed with primary HLH.
Kinetics of the cytokines in our patient was consistent
with a previous study which analyzed 24 children with
HLH, which demonstrated the significant increase of
IFN-γ (median level; 901.7 pg/mL), IL-6 (median level;
63.8 pg/mL) and IL-10 (median level; 879.0 pg/mL) in
the acute phase . The same method was used in the
previous study and the present case analysis to measure
concentrations of the cytokines. In comparison to the
study, the levels of the 3 cytokines (IFN-γ; 9993 pg/mL,
IL-6; 368 pg/mL, and IL-10; 1322 pg/mL) were
remarkably high in acute phase sera obtained from our patient.
Thus, remarkably high levels of the cytokines may play
an important role in causing severe clinical
manifestations including coronary artery aneurysm in this patient.
However, as serum cytokine concentrations decreased
temporarily at the time of CPA, preceding high levels of
cytokines may lead to severe cardiac damage in the
Unfortunately, the management of EBV-HLH remains
challenging. Despite the various intensive treatments,
including bone marrow transplantation, more than 30 %
of the patients diagnosed with EBV-HLH succumb to
the disease or its complications . B-cell depleting
agents are not always an effective treatment strategy in
HLH patients because EBV can infect either B
lymphocytes or non-B lymphocytes. In a previous report, only
43 % of HLH patients showed improvements following
the administration of B-cell depleting agents; however,
an initial course of a rituximab-containing regimen may
rapidly reduce EBV-DNA load . In our case,
rituximab was not administered initially, because the initial
flow-cytometric in situ hybridization analysis identified
not only B lymphocytes but also T lymphocytes as the
EBV-infected cells. However, rituximab was eventually
administered once we identified only EBV-infected B
lymphocytes. It has been demonstrated that cell fractions
of EBV infected cells may change during the observation
period in the HLH patient . Although the general
condition of the patient was not so severe after
completion of the HLH-2004 protocol, a remarkably high copy
number of EBV DNA was detected in PBMCs.
Rituximab treatment resulted in a dramatic decrease of EBV
DNA to undetectable levels. Interestingly, previous
reports suggested that the rapid decrease of EBV-DNA
load following rituximab treatment was beneficial for the
patient’s survival . Therefore, it is expected that the
prognosis for our patient is good despite her cardiac
CAEBV: Chronic active Epstein-Barr virus; CK: Creatine kinase;
CPA: Cardiopulmonary arrest; DIC: Disseminated intravascular coagulation;
EBV: Epstein-Barr virus; HLH: Hemophagocytic lymphohistiocytosis;
IFN: Interferon; IL: Interleukin; PBMCs: Peripheral blood mononuclear cells;
TNF: tumor necrosis factor; VP-16: etoposide
Availablity of data and materials
There are no more case specific data that could be shared.
YK participated in its design, interpreted data, and drafted the manuscript.
HM aquired clinical data. KK interpreted and analyzed hematological data.
YM carried out the cytokin analysis. HU and TH interpreted data of
cardiovascular complications. YI and HK carried out virological analysis. TY
participated in coordination and helped to draft the manuscript. All authors
read and approved the final manuscript.
Consent for publication
Written informed consent was obtained from parents of the patient for
publication of this Case report and any accompanying images. A copy of the
written consent is available for review by the Editor of this Journal.
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