[CIS-PAGID] EBV with persistent lymphopenia and chronic thrombosis

[Terri Tarrant]

I would appreciate any thoughtful input on the following case as to whether
you believe this to be chronic EBV and if further immune and/or infectious
disease work up should be pursued.  The patient has been referred to us by
Hematology/Oncology who is following him closely for resolving
pancytopenia, resolving lymphadenopathy, and chronic vascular thrombosis of
unclear etiology with no demonstration to date of lymphoma or malignancy.

The patient is a 30 yo WM who had previously been in good health until 5/11
when he was admitted for several weeks of cachexia, fevers, weight loss,
lymphadenopathy, pancytopenia, low B12, and splenomegaly.  He had been
drinking heavily due to depression, and was found to have EBV+
proliferation seen on lymph node biopsy and +EBV viral load. HLH was not
noted.  EBV IgG was positive and IgM was negative at the time of hospital
admission.  There was no evidence of lymphoma on biopsy, and the patient's
adenopathy and fevers have abated over the last 9 months.  He also has
increased weight gain and is no longer drinking excessive EtOH.  HIV was
negative, and he has since had quantitative immunoglobulins (IgG=1283,
IgA=161, and IgM=32), which are normal.  His CBC has almost normalized now
(Hct=49, Plts=175, WBC total=4.0 with normal percent neutrophils but
persistent lymphopenia).  Dedicated flow cytometry shows normal NK cells,
reduced CD3+ T cells (492 cells/ul) normal CD8+ T cells (286 cells/ul),
reduced CD4+ T cells (206 cells/ul), and reduced CD19+ B cells (46
cells/ul).  He has never had recurrent infections and denies any trouble
with any type of viral, fungal, or bacterial infection except for this
recent presumed EBV infection in the last year.  PPD is negative, and AFB
and fungal cultures from the lymph node biopsy are also negative.  There is
no personal or family history of autoimmunity or immunodeficiency.

In 9/11, he was admitted for symptoms of LE claudication and was found to
have a chronic aortic thrombosis as well as a right popliteal thrombosis
(also thought to be chronic).  The most recent CT angiogram demonstrated
mural thrombus throughout the abdominal aorta with no extension.  The
patient also had splenomegaly of 13.6 cm.  The celiac axis, SMA, renal
arteries and IMA were patent.  The hypercoagulability work up has largely
been negative with a slightly elevated IgG anticardiolipin that is now
negative, IgM anticardiolipin antibody negative, negative lupus inhibitor,
and IgG, IgA, and IgM anti-beta 2 GP1 antibodies negative.  Homocysteine
level was not elevated, but this was drawn in September, and the B12
deficiency was being treated at this time and the malnutrition and EtOH had
resolved.

-- 
Terri Tarrant, MD
Assistant Professor of Medicine
Thurston Arthritis Research Center
Lineberger Cancer Center Member
CB # 7280, 3300 Manning Dr.
Chapel Hill, NC 27599
(919) 843-4727
http://tarc.med.unc.edu/tarrant_welcome.php
-------------- next part --------------
An HTML attachment was scrubbed...
URL: <http://seven.pairlist.net/mailman/private/pagid/attachments/20120207/d68714ac/attachment.htm>