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Clinical and Diagnostic Laboratory Immunology, September 2001, p. 993-996, Vol. 8, No. 5
Departamento Virología, Instituto
Nacional de Enfermedades Infecciosas
Received 2 January 2001/Returned for modification 13 March
2001/Accepted 14 June 2001
Human herpesvirus 8 (HHV-8), or Kaposi's sarcoma-associated
herpesvirus, is a gammaherpesvirus first detected in Kaposi's sarcoma
tumor cells and subsequently in primary effusion lymphoma (PEL) tumor
cells and peripheral blood mononuclear cells from PEL patients. PEL has
been recognized as an individual nosologic entity based on its
distinctive features and consistent association with HHV-8
infection. PEL is an unusual form of body cavity-based B-cell
lymphoma (BCBL). It occurs predominantly in human immunodeficiency virus (HIV)-positive patients but occasionally also in elderly HIV-negative patients. We describe a case of PEL, with ascites, bilateral pleural effusions, and a small axillary lymphadenopathy, in a
72-year-old HIV-negative man. PCR performed on a lymph node specimen and in liquid effusion was positive for HHV-8 and negative for
Epstein-Barr virus. The immunophenotype of the neoplastic cells was B
CD19+ CD20+ CD22+ with coexpression
of CD10 and CD23 and with clonal kappa light chain
rearrangement. The patient was treated with Rituximab, a chimeric (human-mouse) anti-CD20 monoclonal antibody. Thirteen months
later, the patient continued in clinical remission. This is the
first report of an HHV-8-associated BCBL in an HIV-negative patient in Argentina.
In 1994 Chang et al.
(10) identified a new herpesvirus sequence in human
immunodeficiency virus (HIV)-positive Kaposi's sarcoma dermopathy
patients, named Kaposi's sarcoma-associated herpesvirus, or human
herpesvirus type 8 (HHV-8). Later reports associated HHV-8 with
a nonmalignant disease, Castleman's disease (19, 36), and
with body cavity-based lymphoma (BCBL), also called primary effusion
lymphoma (PEL) (7, 18, 31, 33). Since 1989 (15) most malignant effusion lymphomas reported have occurred in HIV-positive males (7, 31). PEL is a B-cell
neoplasm characterized by infection of the tumor clone with HHV-8 and
by liquid-filled body spaces without significant adenopathy. Although other lymphomas may develop cavity effusions, PEL is the only HHV-8-associated body cavity effusion lymphoma (11, 37).
Recently, several PEL cases have been reported for HIV-negative
individuals (5, 6, 9, 32, 34). PEL cells are usually
coinfected with HHV-8 and Epstein-Barr virus (EBV) (7, 8,
31). However, there are cases of PEL cells infected with HHV-8
only (6, 9, 33). Because PEL is a malignant lymphoma, the
treatment used for the past 15 years has been the standard treatment
for non-Hodgkin lymphoma (NHL): cyclophosphamide, hydroxydoxorubicin,
oncovin or vincristine, and prednisone (CHOP) in cyclic
administration (22). If relapse or resistance to
CHOP treatment occurs in cases of NHL, monoclonal-antibody therapy may
be used (12). Satisfactory remissions of low-grade NHL
have been obtained with monoclonal-antibody therapy (12,
13). There is no standard polychemotherapy for BCBL or PEL
because of its very low incidence. Rituximab is a chimeric
(human-mouse) monoclonal antibody that binds to the transmembrane antigen of the CD20+ B cell, inducing apoptosis
and complement-mediated cytotoxicity (17). In this work we
report, for the first time in Argentina, a rare case of an
HHV-8-associated BCBL with a B-cell phenotype in an HIV-negative male,
in clinical remission after anti-CD20 treatment.
A 72-year-old man was referred to the Hematology Service at the
Santojanni Hospital for investigation of pericardial and bilateral pleural effusions, plus ascites and chronic itching. Two years earlier he had presented with a lymphoproliferative disease, and
biopsy of a 13-mm-diameter lymph node specimen showed a B CD19+ CD20+
CD22+ immunophenotype with coexpression of CD10
and CD23 and with clonal kappa light chain rearrangement. After eight
cycles of CHOP chemotherapy he was in clinical remission for 16 months, but prurigo remained. On examination, the patient was
mildly dyspneic, with ascites and massive bilateral effusions,
requiring several drainages. Lesions from scratching could be seen, but
neither hepatosplenomegaly nor significant adenopathy was present.
Laboratory tests showed eosinophilia (16%), a hemoglobin level of 115 g/liter, a white blood cell count of 5.7 × 109/liter, and a platelet count of 350 × 109/liter. Levels of markers for lymphoma
evolution were increased as follows: lactic dehydrogenase, 740 IU (from
460); A chest computed-tomography scan showed bilateral pleural effusions; a
computed-tomography scan of the abdomen revealed ascites with no
hepatosplenomegaly and retroperitoneal adenopathies with diameters of
less than 1.5 mm. A new lymph axillary node biopsy specimen was
studied, and cytopathology was found, as was the case 2 years
earlier. The immunophenotypic profile was 61% B lymphocytes and
34% T lymphocytes (Fig. 1A); the B-cell
population expressed CD19 (Fig. 1B), CD20 (Fig 1C), and CD22 (Fig 1D),
with coexpression of CD10 and CD23 antigens (Fig. 1B and C) and
kappa light chain restriction (Fig. 1E). The T-cell population
consisted of 21% CD4+ cells and 12%
CD8+ cells (Fig. 1G). Bone marrow was not
infiltrated by lymphoma cells. PCR was positive for HHV-8 (Fig.
2) and negative for EBV in both a lymph
node biopsy specimen and liquid effusion. The patient underwent a
four-cycle, 1-month Rituximab anti-CD20 treatment at the recommended
dosage (26, 29). One month after the end of treatment, all
effusions disappeared; itching and eosinophilia were also resolved.
Seven months later, while in clinical remission, the patient was
serologically tested by indirect immunofluorescence assay for HHV-8
(serum titer, 1/10) and EBV (serum titer, 1/40); nested PCR of
peripheral blood mononuclear cells was positive for both HHV-8 and EBV.
Thirteen months later, the patient continued in clinical remission.
1071-412X/01/$04.00+0 DOI: 10.1128/CDLI.8.5.993-996.2001
Copyright © 2001, American Society for Microbiology. All rights reserved.
Anti-CD20 Monoclonal Antibody Treatment of Human Herpesvirus
8-Associated, Body Cavity-Based Lymphoma with an Unusual
Phenotype in a Human Immunodeficiency Virus-Negative
Patient
ANLIS "Dr. Carlos G. Malbrán,"1 and Servicio de
Hematología, Hospital Santojanni, Gobierno de la Ciudad de
Buenos Aires,2 Buenos Aires, Argentina
ABSTRACT
Top
Abstract
Introduction
Case Report
Materials and Methods
Results and Discussion
References
INTRODUCTION
Top
Abstract
Introduction
Case Report
Materials and Methods
Results and Discussion
References
CASE REPORT
Top
Abstract
Introduction
Case Report
Materials and Methods
Results and Discussion
References
2-microglobulin, 55 g/liter (from a range of 11 to 30).
Results of additional studies, including serum protein electrophoresis
and routine serum biochemistry (glucose, urea, albumin, cholesterol,
glutamic-pyruvic transaminase, glutamic-oxalacetic transaminase,
alkaline phosphatase, and creatinine), were normal. Results of
enzyme-linked immunosorbent assay serology for HIV, HTLV 1 and
2, hepatitis B virus surface antigen, and hepatitis C virus were negative.
View larger version (30K):
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FIG. 1.
Contour plots showing flow cytometry profile. (A)
CD20+ B-cell population (21%) and CD3+ T-cell
population (34%); (B) coexpression of CD19 and CD10; (C) coexpression
of CD20 and CD23; (D) CD22 and FMC7 expression; (E) kappa light chain
restriction; (F) normal expression of lambda chain; (G) T-cell
population (21% CD4-12% CD8). FITC, fluorescein isothiocyanate; PE,
phycoerythrin.
View larger version (102K):
[in a new window]
FIG. 2.
PCR for HHV-8 (233 bp). Lanes: L1, molecular weight
marker; L2, negative control (Raji cells positive for EBV and negative
for HHV-8); L3, H2O; L4, lymph node DNA; L5, pleural
effusion DNA; L6, positive control (BCBL-1 cells [National Institutes
of Health AIDS Research Program] positive for HHV-8 and negative for
EBV).
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MATERIALS AND METHODS |
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Top
Abstract
Introduction
Case Report
Materials and Methods
Results and Discussion
References
|
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Cytological studies were performed on formalin fixed, paraffin-embedded lymph node specimens for hematoxylin-eosin staining. The immunophenotypic profile was determined by FACSscan flow cytometry (Becton Dickinson Immunocytometry Systems) with fluorescein isothiocyanate- and phycoerythrin-conjugated monoclonal antibodies (Becton Dickinson) on the specimen obtained by aspiration biopsy.
PCR for HHV-8 was carried out on DNA extracted from 250 µl of fresh pleural effusion and from a paraffin-embedded lymph node specimen. PCR amplified the 233 bp of the KS 330 Bam region described by Chang et al. (10). PCR for EBV amplified the repeat segment in the BamH-IW region, as previously described (35). Nested PCR for the same fragment of HHV-8 was carried out in peripheral lymphocytes as described elsewhere (25).
Ambulatory treatment with Rituximab was given at the recommended dose of 375 mg/m2 of body surface in weekly infusions for 4 weeks (26, 27, 29) Sixty minutes before the treatment, a vial of acetaminophen was administered. Vital signs were monitored. The initial infusion of 50 mg/h was raised to 100 mg/h for 6 h in the 1st week. Subsequent administrations were reduced to 5 h.
Neither intolerance nor side effects were recorded.
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RESULTS AND DISCUSSION |
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Top
Abstract
Introduction
Case Report
Materials and Methods
Results and Discussion
References
|
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PEL was first described in 1989 by Knowles et al.
(24), who observed major lymphomatous effusions in body
cavities, usually growing in the absence of an identifiable tumor mass.
Other investigators subsequently confirmed this observation (23,
38). In 1995, Cesarman et al. (7) reported the
presence of HHV-8 in AIDS-related BCBL. Then the term PEL was suggested
for AIDS-related and non-AIDS-related BCBLs that are characterized by
effusions in body cavities without lymphadenopathy, tumor masses, or
bone marrow involvement and are typically associated with HHV-8
(2, 3, 6, 9, 31). The main manifestations of
lymphoma in the case reported in this paper were pleural effusions and
ascites. The volume and locations of these effusions prompted us
to review the case and to look for HHV-8 in effusions and lymph
node specimens. Reports describing early lymph node involvement of
HHV-8 DNA in an HIV-negative PEL patient (1), small
intra-abdominal solid tumors detected by imaging in a few cases
(30), and HHV-8 DNA in fluid effusions (7, 21,
31) support the possibility that HHV-8 may play a role in PEL
pathogenesis. Some cases of PEL in HIV-negative patients have been
reported previously (1, 5, 9, 14, 21, 32). The average age
of these patients was 72 years, coincident with the age of our patient.
Although other investigators have reported that the main features of
PEL are large, anaplastic CD19
CD20 cells (9, 16, 23, 31,
38), there are CD20+ (33) and
CD19/20+ PELs (6, 9, 20), and some
cases with an intermediate lymphocytic cytomorphology have been
described (9). Moreover, on the basis of immunoglobulin VH
gene mutational analysis, it has been suggested that PEL may not be
restricted to one stage of B-cell differentiation but may represent
transformation of B cells at different stages of ontogeny
(28). In an animal model, mice injected with lymphoma
cells from a PEL patient developed small intra-abdominal tumors
(4). It has also been proposed that the clinical spectrum
of manifestations at presentation of PEL may be wider than initially
described (1). On the basis of the reports cited and the
clinical and molecular results obtained, the diagnosis for this patient
was PEL. Because of its very low incidence, there is no standard
polychemotherapy for BCBL or PEL. Most PEL patients do not respond to
CHOP therapy (1). Recently, a PEL with a B-cell phenotype
successfully treated with prednisone was reported
(20), but the patient died 15 months after PEL diagnosis.
There are reports of satisfactory remissions in low-grade NHL
(12, 13) and in bone marrow transplant purging
following treatment with anti-B-cell monoclonal antibodies. Rituximab
is a chimeric (human-mouse) monoclonal antibody that binds to the CD20
B cell's transmembrane antigen, inducing apoptosis and
complement-dependent cytotoxicity (17). We chose Rituximab
therapy for this case based on previous CHOP treatment failure and the
CD20+ immunophenotype.
We report here a case of a patient with an HHV-8-associated BCBL, with a B-cell phenotype, treated with an anti-CD20 monoclonal antibody. In view of the poor results of present schemes, monoclonal therapy may be another modality of treatment for PEL patients.
| |
FOOTNOTES |
|---|
*
Corresponding author. Mailing address: Instituto
Nacional de Enfermedades InfecciosasANLIS "Dr. Carlos G. Malbrán," Departamento Virología, Av. Vélez
Sásrsfield 563 (1281), Buenos Aires, Argentina. Phone:
54-11-4301-7428. Fax: 54-11-4302-5064. E-mail:
olaudanno{at}intramed.net.ar; Cperez{at}anlis.gov.ar.
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Results and Discussion
References
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