[CIS-PAGID] Puzzling Patient #1

[Church, Joseph]

Thank you, Terry.  We use whole blood PCR for EBV.  The patient is indeed a puzzle.  JC

From: pagid-bounces at list.clinimmsoc.org [mailto:pagid-bounces at list.clinimmsoc.org] On Behalf Of Harville, Terry O
Sent: Thursday, May 03, 2012 1:51 PM
To: pagid at list.clinimmsoc.org
Subject: Re: [CIS-PAGID] Puzzling Patient #1

Joe,

The PCR may be explained depending on whether the lab uses "plasma" or "whole blood".  PCR of the plasma can be negative, if there is not active viral replication and release of viral particles.  Whereas, whole blood should pick up latent virus in circulating B lymphocytes.

The sero-conversion is a different issue, that I cannot fully explain.

I have seen necrotizing cervical adenitis (Kikuchi-like) with strong EBER staining, yet no circulating evidence of EBV.  I cannot remember for sure, but I think the VCA-IgG and EBNA were positive, as expected, and VCA-IgM and EA were negative.  This was before routine PCR for EBV.

Terry Harville MD PhD
-Medical Director, Special Immunology Laboratory
-Medical Director, Histocompatibility Laboratory
-Medical Director, Immunogenetics and Transplantation Laboratory
-Specialist in Pediatric Immunology and Rheumatology
Departments of Pathology and Laboratory Services and Pediatrics
University of Arkansas for Medical Sciences
4301 West Markham
Mail Slot #502
Little Rock, AR  72205-7199

Work Phone 1.....................................................................501.686.7257
Work Phone 2.....................................................................501.526.7511
Work Phone 3.....................................................................501.686.7556
Work Phone 4.....................................................................501.364.1885
Work Fax 1..........................................................................501.686.7443
Work Fax 2..........................................................................501.526.4621

Email..............................................................harvilleterryo at uams.edu

Special Immunology Laboratory......................................501.364.1804
Histocompatibility Laboratory..........................................501.686.7257
Immunogenetics and Transplantation Laboratory.........501.686.7374

From: pagid-bounces at list.clinimmsoc.org [mailto:pagid-bounces at list.clinimmsoc.org] On Behalf Of Church, Joseph
Sent: Wednesday, May 02, 2012 8:48 PM
To: pagid at list.clinimmsoc.org
Subject: [CIS-PAGID] Puzzling Patient #1

This 18yo girl had persistent anterior cervical adenitis complicating severe purulent tonsillitis.  Throat culture was negative for bacterial pathogens.  Routine serology for EBV and CMV were negative.  There was no organomegaly or adenopathy other than that described.

Eventually she came to biopsy that showed necrotizing adenitis with strong histochemical staining for EBV.  Histologic and histochemical features were not consistent with neoplasm.

EBV serology 1 month after the procedure showed only +EBV VCA IgM; 3 months after the procedure the serologic picture was the same.

Blood PCR for EBV was negative x2.

The following immune functions were normal:
            T-, B-, NK cell numbers.
            Ig levels
            Antibody responses to Pneumovax
            Mitogen and antigen-specific LPAs
            CTL function (Cincinnati Children's Lab)
            NK cell function (Cincinnati Cildren's Lab)
            X-inactivation - random (looking for potential for XLP)

Have any of you seen 4+ EBV in a lymph node with negative VCA IgG and EBNA and negative blood EBV PCR?

What am I missing?

Joe Church
Children's Hospital Los Angeles

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