[CIS PIDD] Chronic EBV ?

[Elias Akl MD]

Dear all,

Any insights on this patient would be greatly appreciated.

Our patient is a 6 year old Caucasian female with a history of asthma on
Budesonide 80 mcg 2 puffs BID and montelukast 4 mg, history of allergic
rhinitis on Azelastin nasal spray and cetirizine 5 mg daily presenting for
persistent EBV infection. In March of 2013 she was diagnosed with an acute
EBV infection for which she received supporting treatment at home. At the
time she complained of generalized fatigue, malaise and myalgia along with
mild grade fever, headache and occasional abdominal pain. Her symptoms
resolved in around a week time and she went back to her normal daily
activities.

3 months ago, the patient started again complaining of the same symptoms
she had with her EBV infection consisting mainly of daily low grade fevers
of 99-100.8 F at around 4 pm, daily frontal headaches that would get worse
throughout the day and are relieved by acetaminophen. Her HA were not
associated with an aura, were localized and had no accompanying symptoms of
nausea or vomiting. She was not sensitive to light or noise and had no
seizure like activity. Other symptoms included an almost once a week severe
periumbilical pain, stabbing in nature, lasting around 1 hour with no
associated symptoms of nausea or vomiting. Patient had an US of the abdomen
done with no abnormalities noted. She did also admit to petechial-like
spots that would show up once a week on random body parts mainly on her
neck, upper back, arms and stomach, last around couple days and then
resolve. These lesions show up on average once a week.  Over the last 3
weeks, she had been also complaining of increased itching and had an
episode of hives that lasted around 3 days. Other symptoms include general
malaise and fatigue although she slept for 11 or 12 hours a day.

On ROS pt had a dry cough that was worse at night, relieved by albuterol
with NO SOB. No joint pain, no muscle pain, no joint swelling or decreased
range of motion, no lower extremity swelling and no weight loss. Appetite
was at baseline and no other household members had the same symptoms.



Patient also describes recurrent infections:

PNA once or twice a year. Last episode was 2 weeks prior to her symptoms.

Bronchitis once or twice a year.

Several sinus infections. Last one almost 2 months ago.

Has been on antibiotics and prednisone on several occasions.

 Patient was up to date on her vaccinations and her physical exam was
benign with a 2/6 nonradiating systolic murmur on the pulmonary area of
auscultation. She also had petechiae on her neck.

 Labs:

*3/2013:*

EBV Ab VCA IgM POSITIVE

EBV Early Ag Ab, IgG: NEGATIVE

EBV Ab VCA IgG : NEGATIVE

EBV Ab VCA : NEGATIVE

EBV Nuclear Ag Ab IgG: NEGATIVE

*10/2014:*

EBV Ab VCA IgM 87.5 U/mL

EBV Early Ag Ab, IgG < 9 U/mL

EBV Ab VCA IgG 94.4 U/mL

EBV Nuclear Ag Ab IgG 412 U/mL

EBV DNA Quant (serum): UNDETECTABLE

EBV DNA Quant (whole blood): POSTIVE.

 *11/2014:*

IgA 80mg/dL

IgE 79 IU/mL

IgG 648 mg/dL

IgM 75 mg/dL

CRP and ESR Normal

EhrlichChaf IgG/IgM NEGATVE

HGE IgG/IgM NEGATIVE

Toxo and H Influenza NEGATIVE.

LEP within normal limit

CBC with diff WNL

Pneumo titers were positive to only 4/14 and repeat 6 weeks after prevnar
was positive for 13/14

Tetanus IgG Ab < 0.10 IU/mL with repeat 1.80 after vaccination.

*Questions:*
1. Are her symptoms consistent with chronic EBV infection ?
2. What treatment (if any) has worked for this condition?
3. Use of rituximab was thought of as a treatment but she doesn't have
severe enough symptoms to justify use of this medication, with its
associated long term immune suppression ?

-- 
Best Regards,

*Elias Akl MD*

*Allergy and Immunology FellowVirginia Commonwealth University Health
Center*
*Work email: eakl at mcvh-edu.lb <eakl at mcvh-edu.lb>*
*Office: 804-828-8681*
*Cell: 716-904-3649*

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