[CIS PIDD] [cis-pidd] Persistent EBV?

[CIS-PIDD]

Jason,

How high is the EBV IgM titers?  The authors of the original paper describing "chronic EBV disease" published a follow-up paper to emphasize that what they meant was a disease with persistently high anti-EBV IgM titers.

Stan

From: CIS-PIDD [mailto:cis-pidd at lists.clinimmsoc.org]
Sent: Friday, October 02, 2015 11:12 AM
To: CIS-PIDD
Subject: [cis-pidd] Persistent EBV?


I would appreciate any comments regarding the patient below.  My questions are as follows:

  1.   Clinical significance of several years or more of persistently elevated EBV titers and one positive (although < 100 copies/mL) PCR during an asymptomatic period?
  2.  To what extent does this patient need additional immunologic evaluation?
  3.  To what extent does this patient need treatment (if at all)?

53 year-old woman who recounts 4 episodes of 'mono-like' illness since her early 20s.

Typical presentation is fever, pharyngitis, cervical lymphadenopathy and fatigue; no rash.  I cannot find documentation of splenomegaly. Each time, EBV serology revealed elevated VCA IgG and IgM; elevated EBNA IgG; elevated EA IgG.  She has NOT had EBV PCR performed during these episodes.  She has not had elevated LFTs or cytopenias.   It takes 3-4 weeks or more for her to recover.  She MAY have had convalescent serology noting negative VCA IgM and EA on one occasion, although I cannot confirm this.

She was started on valacyclovir through primary care several months before presentation to our clinic; reason for treatment and rationale for dose uncertain.

Presently (5 months after her most recent episode, asymptomatic), EBV VCA Ig and IgM are elevated, as are EBNA IgG and EA IgG (similar to previous).  EBV quantitative, whole blood (Lab Corp) PCR- while on valacyclovir 500mg once daily - was 'positive' but at < 100 copies/mL.  I confirmed this with lab tech.  It has not been repeated.

Health history includes recurrent upper respiratory illness in the context of atopy (allergic rhinitis, EIA) and IgE-mediated anaphylaxis to tree nuts.

Between episodes she has NO history of [relapsing-remitting] fever, lymphadenopathy, hepatosplenomegaly or rash; no elevation of liver enzymes; no cytopenias.  She has NOT had invasive bacterial or opportunistic infections.  She has had NO history of malignancy, autoimmunity, interstitial lung disease or CNS disease.

She is adopted; family history is unavailable.

CBC, CMP, quantitative immunoglobulins, post-vaccine tetanus/pneumococcal titers, TBNK cell enumeration, mannose-binding lectin are NORMAL/within reference range/unrevealing.  NO OTHER DIAGNOSTICS HAVE BEEN PERFORMED.

So my questions are:

  1.  In the context of this patient's history, what to make of her persistently elevated EBV serology and single finding of positive (although < 100 copies/mL) PCR during an asymptomatic period (while on valacyclovir)?
  2.  To what extent does this patient need additional immunologic evaluation?
  3.  To what extent does this patient need treatment (if at all)?



Thank you for your thoughts.



-j

Jason Raasch, MD

Midwest Immunology Clinic
15700 37th Ave N, Ste 110
Plymouth, MN 55446

TEL: (763) 577-0008
FAX: (763) 577-0192







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