Epstein-Barr virus-associated erythema nodosum after living-donor liver transplantation: A case report

Abstract

A 1-year-old girl underwent living-donor liver transplantation (LDLT) for biliary atresia. The postoperative course was uneventful, and the patient was progressing under tacrolimus-based immunosuppression (trough levels: 5 ng/mL).After 2 years of good progress after LDLT with normal liver function, however, she developed fever and erythema nodosum (EN) for the first time during the current course (Fig. 1). No symptoms had been seen for up to 2 years after transplantation. Laboratory data showed a remarkably increased C-reactive protein level (10.2 mg/dL) and eosinophilia (980/mm 3 ). Atypical lymphocytes were detected in peripheral blood ( Fig. 2A). The Epstein-Barr virus (EBV) DNA level was 9800 copies/g of DNA. At the time of LDLT, serological studies for EBV showed that the patient had already been infected with EBV on the basis of serum levels of immunoglobulin G. Results were negative for EBV viral capsid antigen immunoglobulin M, whereas levels of viral capsid antigen immunoglobulin G and early antigen immunoglobulin G were elevated. EBV was thought to have been reactivated as a result of the immunosuppressive condition occurring after transplantation. A physical examination revealed small, palpable cervical lymph nodes. Cervical lymph nodes were enlarged;, however, abdominal computed tomography did not reveal swelling of the intra-abdominal lymph nodes. A histological examination of skin biopsies showed a diffuse lymphohistiocytic infiltrate having a slight admixture of neutrophils and eosinophils in septa and lobules. Vasculitis was found in the paraseptal and septal blood vessels. A perivascular dermal infiltrate was also noted. Immunohistochemistry showed predominantly CD8ϩ T-cell infiltration (80%) with an angiocentric pattern (Fig. 2B). Approximately 15% were CD4ϩ T-cells, and CD20ϩ B-cells were scattered. In situ hybridization for the presence of EBV-encoded RNA transcripts (EBV-encoded small RNA) on a paraffin section of a formalin-fixed biopsy specimen obtained from the skin revealed occasional EBV-encoded small RNA signals in the lymphocytes (1%-2%) compatible with an activated EBV infection (Fig. 2C). The patient was treated by a reduction of immunosuppression (trough levels: 2-3 ng/mL) and with an antiviral agent (acyclovir, 60 mg/ kg/day). After treatment for 3 months, the EBV polymerase chain reaction decreased to 1/10, and the erythema improved transiently. The skin lesion did not resolve completely, despite a decrease in the EBV DNA level, but it did gradually disappear after a switch from tacrolimus to cyclosporine A (trough levels: 25-50 ng/ mL).

Early Detection of Epstein-Barr Virus as a Risk Factor for Chronic High Epstein-Barr Viral Load Carriage at a Living-donor–dominant Pediatric Liver Transplantation Center

“…However, 2 PTLD cases were identified during the study period; both were excluded because of the second LT following severe rejection and PTLD developed only after the second LT. Similarly, only a few EBVassociated diseases were diagnosed in the entire cohort, 0 of 184 (0%) in low, 3 of 149 (2%) in high, and 2 of 61 (3%) in CHL, respectively, 17,23,24 and this difference did not reach statistical significance (P = 0.08) (Table 2).…”

Gianotti-Crosti Syndrome and Erythema Nodosum: Two Distinct Entities or Two Manifestations of the Same Infection?

“…Gianotti-Crosti syndrome and erythema nodosum are 2 skin conditions that can be caused by bacterial and viral infections. [1][2][3] To the best of our knowledge, their simultaneous presentation has not been reported previously. Both conditions may be immunologic manifestations of EBV infection, with a mechanism of delayed hypersensitivity.…”

UZLOVATAYa ERITEMA: SOVREMENNYE ASPEKTY

“…Данный микроб характе-ризуется повышенным тропизмом к сосудистому эндоте-лию и после попадания в кровоток может длительно пер-систировать и размножаться в гладкомышечных и эндоте-лиальных клетках сосудов, моноцитах/макрофагах и в из-мененных тканях. В этом же плане рассматриваются Helicobacter pylori, а также некоторые представители семей-ства герпесвирусов: вирус простого герпеса человека 1-го типа -Herpes simplex virus, 4-го типа -вирус Эпштейна-Барр, 5-го типа -Cytomegalovirus, -которые путем геном-ных изменений могут вызвать клональную экспансию по-пуляций интимальных гладкомышечных клеток [42]. Из-вестно, что различные группы вирусов могут годами суще-ствовать в клетках тканей и органов (в том числе в эндоте-О Б З О Р Ы НАУЧНО-ПРАКТИЧЕСКАЯ РЕВМАТОЛОГИЯ, 2010, № 4, 66-72 лии сосудов, миокарде, эндокарде), вызывая полиорган-ную патологию [42,43].…”