Successful treatment of Epstein–Barr virus-induced transverse myelitis with ganciclovir and cytomegalovirus hyperimmune globulin following unrelated bone marrow transplantation

Abstract

Summary:We report a patient who developed Epstein-Barr virus (EBV)-induced transverse myelitis 19 months after unrelated bone marrow transplantation (BMT). The disease was diagnosed by physical examination, serologic determinations, EBV-specific polymerase chain reaction in peripheral blood lymphocytes and cerebrospinal fluid, and characteristic magnetic resonance imaging scan of the spine. The patient was treated with ganciclovir and cytomegalovirus (CMV) hyperimmune globulin. He gradually improved and recovered completely within 4 weeks. This case suggests that ganciclovir and CMV hyperimmune globulin appear to be effective for the treatment of EBV-induced transverse myelitis in immunocompromised patients following BMT. Keywords: Epstein-Barr virus; transverse myelitis; bone marrow transplantation Epstein-Barr virus (EBV)-associated lymphoproliferative disorder is a well-recognized infectious complication in patients receiving bone marrow transplantation (BMT), particularly from unrelated donors. 1 Other EBV-induced clinical manifestations are relatively infrequent following BMT. Transverse myelitis, an inflammatory disease of the spinal cord, is one of the rarest presentations of EBV infection. 2 We report a patient who developed acute EBVinduced transverse myelitis 19 months following unrelated BMT. The patient recovered completely with ganciclovir and cytomegalovirus (CMV) hyperimmune globulin treatment. Case reportA 16-year-old male received an allogeneic BMT for acute myeloid leukemia (FAB classification M2) in second partial remission after conditioning with busulphan (4 mg/kg/day ϫ 4 days) and cyclophosphamide (50 mg/kg/day ϫ 4 days). The HLA-matched unrelated donor was seronegative for CMV but had reactivation of EBV at the time of transplantation. Before harvest, the donor's EBV serostatus was positive for viral capsid antigen (VCA) immunoglobulin G (IgG), VCA IgM, early antigen (EA) IgG, and EpsteinBarr nuclear antigen (EBNA) antibodies. The recipient was VCA-IgG positive, VCA-IgM negative and EBNA-antibodies positive. Polymerase chain reaction (PCR) for EBV DNA from buffy coat leukocytes was positive in the donor and negative in the recipient. Acyclovir and CMV hyperimmune globulin (Cytotect; Biotest, Dreieich, Germany) with high titers of EBV antibodies were given as prophylaxis for EBV disease in the early post-transplantation period. Graft-versus-host disease (GVHD) prophylaxis consisted of antithymocyte globulin, cyclosporin A, methotrexate, and prednisolone. The patient developed moderate acute GVHD of the skin and the gastrointestinal tract and received methylprednisolone and FK506 (tacrolimus) instead of cyclosporin A. Because of extensive chronic GVHD with generalized skin and eye involvement he was treated with prednisolone and azathioprine.Nineteen months after BMT, the patient presented with local back pain and bilateral lower extremity sensory loss. There was a clear sensory level at the 10th thoracic dermatome, below which pain, temperature, light touch, position, and vibratory sensatio...

Transverse Myelitis

“…One noteworthy parasite is the pinworm (Enterobius vermicularis), which has been reported to cause TM associated with anti-GM1 antibodies (which are also seen in C jejuni infection) via molecular mimicry. 224 Pathogens associated with parainfectious LETM [167][168][169][170]186,192,193,201,209,212,213,[225][226][227][228][229][230][231][232][233][234][235][236][237][238][239] are listed in Box 3.…”

Prevention and Treatment of Epstein—Barr Virus Associated Lymphoproliferative Disorders in Recipients of Bone Marrow and Solid Organ Transplants

“…Nevertheless, as toxicity of acyclovir therapy is low, treatment with acyclovir is often instituted when EBV-LPD has been diagnosed. Two case reports described the achievement of CR of EBV disease after treatment with ganciclovir or foscarnet (Gruhn et al, 1999;Schneider et al, 2000). Little information is available on the effectiveness of newer antiviral agents regarding prevention or treatment of EBV-LPD.…”

Semiquantitative PCR analysis of Epstein‐Barr virus DNA in clinical samples of patients with EBV‐associated diseases

“…The disease was diagnosed by physical examination and characteristic MRI scan of the spine. Reactivation of EBV was con®rmed by detection of EBV in CSF, increased EBV copy numbers in PBMC, as well as serologic data [Gruhn et al, 1999]. After treatment with ganciclovir and CMV hyperimmune globulin with high anti-EBV antibody titers the patient gradually improved and recovered completely within 4 weeks.…”