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12. Prognostic Factors for Chronic Active Epstein-Barr Virus Infection / Hiroshi Kimura, Tsuneo Morishima, Hirokazu Kanegane [et al.] // The Journal of Infectious Diseases. -2003. - Vol. 187. - P. 527-533.
English version: THE IMPROVEMENT OF DIAGNOSIS OF CHRONIC EPSTEIN-BARR VIRUS INFECTION
Bodnar V.A.
HSEE "Ukrainian Medical Stomatological Academy", Poltava, Ukraine
The long-term outcomes of infectious mononucleosis (IM) in adults is analyzed and diagnostic approaches to chronic Ep-stein-Barr virus (EBV) infection is improved in the article. For this purpose, 111 persons were examined with various forms of EBV-infection and 20 healthy for control. Outcomes of IM were assessed by dynamic observation of 48 convalescents. 83.3% adult immunocompetent patients of IM had recovery, and chronic forms of EBV-infection was formed in 16,7% patients. Chronic subclinical EBV-infection in adults are characterized by subciinical forms with typical signs of IM without signs of generalization process, the intenstty of immune responses (increased content of CD8+, CIC, IgM, LKB and NBT test against decrease in CD3+, CD16+, CD20+, IRI, IgA and IgG), in active EBV-infection - manifest course, polymorphism wtth evidence of generatization of process: subfebritity (94,3%%), tonsillopharyngttis (74,3%%), generatized iymphadenopathy (88,6%), hepato- (88,6%) and splenomegaly (45,7%) expressed asthenovegetative (100,0%), dyspeptic (57,1%) and arthropathic (28,6%) syndromes, changes in laboratory parameters (anemia - 25,7%, leukopenia - 48.5%, thrombocytopenia - 37,1%, lymphocytosis - 68,5%, hypergammaglobulinemia - 68.5%) and organ damage (encephaittis - 42,8%, hepatttis - 28,6%), pronounced imbalance of immune suppression characteristics of cellular and humoral immunity (lymphocyte subpopulations decrease in CD3+, CD4+, CD8+, CD16+, CD20+, IgG and IgA, inhibttion of the functional activity of phagocytosis, increased CIC). According to the resutts of the study and discriminant analysis, a two-stage screening to improve the differential diagnosis of chronic forms of EBV-infection in the prehospttal and hospttal stages is developed.
Keywords: Epstein-Barr virus infection, infectious mononucleosis, diagnostic approaches.
Introduction
One of the most common infections in the world is an infection caused by the Epstein-Barr virus (EBV) [1, 5, 8, 10]. It is known that the outcomes of infectious mononucleosis (IM) (the most studied variants of acute EBV infection) depend on the presence and severity of immune dysfunction, genetic predisposition to certain EBV-associated diseases, as well as external factors that affect the immune system [2, 10, 11]. It is shown that in 3-5 years after IM hematological and other clinical dysfunction of varying degrees of severity can occure [3, 7, 12].
In recent years, the increase in the incidence of IM among adults, because of the deteriorating health of the general population [1, 2, 9]. Due to polymorphism of the clinical signs both acute and chronic forms of EBV-infection, difficulty interpreting specific laboratory tests, at present there are some differences of opinion on the priority of different diagnostic methods to determine the stage of infection [1, 3, 4, 5, 7]. Thus, due to the significant increase in the incidence of IM among adults
and proven contribution to the development of chronic pathology of the immune system, and, consequently, chronic somatic diseases, improving diagnosis of chronic EBV-infection is relevant and necessary as determined the direction of our research .
The research purpose is to analyze of long-term outcomes of IM and improve the diagnosis of chronic EBV-infection in adults.
Material and methods
Total 111 patients with various forms of EBV-infection and 20 healthy were examined. Outcomes of IM were assessed by dynamic observation of 48 convalescents, aged 15 to 39 years (men - 26, women - 22). All patients were observed during the acute period and examined 3-5 years after discharge. IM was diagnosed according to ICD-10 (WHO, 1998) and confirmed the detection of serum IgM to VCA, IgM to EA in the absence of IgG antibodies EBNA EBV by enzyme immunoassay (EIA) and the definition EBV DNA levels in the polymerase chain reaction (PCR).
To cite this English version: Bodnar V.A. The improvement of diagnosis of chronic epstein-barr virus infection // Problemy ekologii ta medytsyny. - 2013. - Vol 17, № 5-6. - P. 12-15.
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Chronic EBV-infection was diagnosed according to the classification by S.A.Kramarev et al. (2007): latent, subclinical reactivation, chronic subclinical and chronic active forms [3]. The diagnosis is verified defined serum IgM serologic profiles VCA / IgG EA / IgG EBNA and EBV DNA detection in blood by PCR. Latent form was determined in the absence of clinical and laboratory signs of chronic infection, EBV DNA in the blood and the presence of serological profile ( - / - / +) serological reactivation - in the absence of clinical and laboratory signs of chronic process, EBV DNA in the blood and the presence of serological reactivation profiles ( + / + / + , + / - / + - / + / +); chronic subclinical - if periodic subfebrility, as-thenovegetative, lymphoproliferative syndromes, myalgia, arthralgia, clinical signs of secondary immunodeficiency stratification of infections, chronic active - with a combination of the above syndromes with signs of organ lesions of the nervous system and internal organs are longer than 6 months, the serological profiles (+ / + / + , + / - / + - / + / +) and EBV DNA in blood. 63 patients with chronic forms of EBV-infection were examined, 16 of them - with subclinical chronic (men - 10, women - 6, aged 19 to 44 years), 27 - chronic active (men - 14, women - 13, at the age of 20 to 47 years), 20 - latent (men - 9 women - 11, from 18 to 34 years). Patients did not have viral hepatitis, HIV and other forms of replicative herpesvirus infections: HSV 1/2, VVZ, CMV, HSV 6.
All patients received a complete comprehensive general clinical and laboratory (including immunological) examination after obtaining informed written consent.
Statistical analysis of the results was carried out by standard methods of variation statistics: the t-Student's test, nonparametric methods: Mann-Whitney's Wilkson's and discriminant analysis. The difference was considered reliable at p<0.05.
Results and discussion
A comprehensive survey of convalescents of IM based on serological profiles and EBV DNA detection in blood showed that the vast majority of the patients (n=40, 83,3%) had recovery, and in 8 (16,7%) for the totality of the clinical and laboratory features and specific markers could not exclude chronic EBV-infection: in 5 (10,41%) -subclinical in 3 (6,25% ) - active.
In order to find important diagnostic signs of chronic EBV-infection, given the immunosuppressive effect virus, it is appropriate to characterize the complex clinical and laboratory parameters of patients with different forms of EBV-infection.
Studies have shown that a latent form of EBV-infection has changes in physical status requiring examination to exclude the possible forms of chronic EBV-infection: in 18,2% - a syndrome of autonomic dysfunction, in 27,6% - lymphadenopathy due to increased submandibular lymph nodes, which was combined with signs of tonsillitis, of which 13,6% -pharyngitis. In the analysis of blood parameters as general clinical and biochemical, significant changes were detected. In the immune status of the majority of the patients with latent form of EBV-infection immune parameters were recorded as level indicators of healthy, but the individual analysis of some of them turned out to change that showed the system voltage antiviral defense. Thus, multidirectional changes in CD4+ and CD8+ lymphocytes resulted in increasing the immunoregulatory index (IRI) SD4/CD8 in 60,0%, in 40,0% it decline as compared with the control group, the ratio of CD3/CD20
was within reference values healthy group only 20,0 % of the patients, in the others - determined above (40,0%) or below (40,0%). No significant differences in the average performance of the phagocytic activity of neutrophils is not found, however, when comparing the performance of individual activity, NBT-test was reduced in 70% of the patients, higher - 20%. Humoral immunity is usually determined at the level of the control group, and only in rare cases varied in different directions: the content of IgA, IgG and IgM in serum were above - in 30,0%, 20,0% and 20,0%, below - in 10,0%, 20,0% and 40,0%, respectively. Thus, the study of the immune status of persons with latent form of EBV-infection showed changes that could be due to the presence of comorbidities. We can also assume that in these patients is the risk of EBV reactivation in the amplification of immune suppression.
Chronic EBV-infection in patients had subclinical or active form.
Chronic subclinical form characterized of typical syndromes of IM without evidence of generalization process: subfebrility (25,9%), tonsillopharyngitis (92,9%), lymphadenopathy (92,6%), hepato-, splenomegaly and (37,0%), moderate asthenovegetative syndrome (40,7%), the change in laboratory parameters (lymphocytosis - 51,8% hypergammaglobulinemia - 77,8%). The immune status of patients with chronic subclinical forms of EBV-infection differed from the healthy and the patients with latent. Changes of immunological parameters were characterized by a decrease in the total number of white blood cells, the absolute number of lymphocytes, CD3+, CD4+, SD16+, IRI, IgA and IgG, increase - the absolute and relative number of CD8+, IgM, CIC, indicators NBT-test and LKB. In general, changes in immune status in patients with subclinical form of chronic EBV-infection showed a weakening of cellular immunity and system voltage antiviral defense.
Chronic active form characterized of manifest course, polymorphism with evidence of generalization of process: subfebrility (94,3%), tonsillopharyngitis (74,3%), generalized lymphadenopathy (51,6%), hepato- (88,6%) and splenomegaly (45,7% ), expressed asthenovegetative (100.0%), dyspeptic (57,1%) and arthropathic (28,6 %) syndromes, changes in laboratory parameters (anemia -25,7%, leukopenia - 48,5%, thrombocytopenia - 37,1%, lymphocytosis - 68,5%, hypergammaglobulinemia - 68.5%), organ damage (encephalitis - 42,8%, hepatitis - 28,6 %). In the analysis of immune parameters in the active form of chronic EBV-infection there were the most significant changes in comparison with the control group and patients with latent and subclinical forms: lower absolute and relative content of all subpopulations of lymphocytes, IRI, IgA, IgG, inhibition of phagocytic activity on indicators LKB-and NBT-tests, reduction of CIC compared to subclinical forms and increase - compared to the latent form and the control group, indicating immunosuppression of both cellular and humoral immunity. In general, studies have shown that the immune status can be used as an additional diagnostic criterion for differential diagnosis of various forms of EBV-infection.
Given nonspecific and polymorphism of clinical manifestations, a significant value of specific serological, molecular markers and immunological tests, diagnosis of chronic EBV-infection is a big challenge for physician practice health care. Therefore, an important and feasible is finding a set of clinical and laboratory signs, which can
diagnose chronic forms of EBV- infection in the prehospital and hospital phases. In order to find the most important diagnostic criteria for us was used discriminant analysis, according to which the two-stage screening is designed to improve the differential diagnosis of chronic EBV-infection. In the prehospital phase the frequency of general clinical and biochemical signs were compared, in the hospital - specific markers and immune parameters.
When comparing the indicators defined in the prehospital phase in patients with active compared to the subclinical form, the highest discriminant features were: fever (F=52,37; p<0.000002), asthenic syndrome (F=43,53; p <0.000001) encephalitis (F=18,82; p<0.000004), hepatitis (F=10,66; p<0.000032), monocytosis (F=9,05; p<0.000056), vegatative dysfunction syndrome (F=5,72; p<0.000056), thrombocytopenia (F=4,28; p<0.001389), generalized lymphadenopathy (F= 4,1; p<0.000322), myocarditis (F= 4,12; p<0.008791) tonsillopharyngitis (F=4,12; p<0.005511), lymphocytosis (F=4,12; p<0.008791 ), leukopenia (F=4, 11, p<0.000142).
Thus, according to discriminant analysis, these signs may be the basis for the differential diagnosis between active and subclinical forms of chronic EBV-infection in the hospital phase.
Based on the data using multiple discriminant analysis we have a system of equations that can diagnose subclinical and the active form of chronic EBVinfection:
С1 = 3,393 * A - 0, 387 * B + 1,417 * С +1,024 * D + 1,861 * E - 2,726 * G - 1,254 * I + 3,285 * K + 1,232 * L + 1,417 * M - 1,255 * N - 1,313 * O - 3,148;
С2 = 7,201 * A - 0,673 * B + 6,215 * С + 5,137 * D + 3,719 * E - 3,396 * G - 0,919 * I + 6,779 * K + 4,005 * L - 0,464 * M - 1,611 * N + 3,193 * O - 11,492;
where: A - asthenic syndrome, B - vegatative dysfunction syndrome, C - encephalitis, D - fewer, E -generalized lymphadenopathy, G - myocarditis, I -hepatitis, K - pharyngitis, L - leukopenia, M -lymphocytosis, N - monocytosis, O - thrombocytopenia.
If this feature is available, a factor "1" is entered into the equation, in the absence - "0". In excess of C1 over C2 confirms that patient has active form of EBV-infection, C1 over C2 - subclinical.
At the hospital stage screening was performed on the basis of special examination methods: ELISA, PCR and immunological status. Studies have shown that the active form was significantly different from subclinical by the following specific criteria: PCR (F=6,02; p<0,0001), CD8,% (F=10,45; p<0.003), NBT (F=6.77, p<0,016), CD3,% (F=5,66; p<0.025), EBNA titer over 100 (F = 5,43; p<0.029).
On these grounds by method of multiple discriminant analysis of the system of equations we can differentiate subclinical and the active form of chronic EBV-infection:
К1 = -9,632 * A - 14,261 * B + 0,593 * С +1,504 * D + 23,683 * E - 66,796;
К2 = -6,578 * A + 17,578 * B + 0,429 * С + 0,962 * D + 20,313 * E - 41,898;
where: A - titre EBNA over 100, B - the presence of EBV DNA in blood by PCR, C - CD3,%, D - CD8,%, E -NBT.
In excess of K2 over K1 patient has the active form of chronic EBV-infection, K1 over K2 - subclinical.
Using a two-stage screening system based on a combined assessment of clinical, laboratory, and special techniques we can improve the diagnosis of chronic
EBV-infection differentially in the prehospital and hospital phases.
Conclusions
1. According to the Poltava Regional Clinical Infectious Hospital 83.3% adult immunocompetent patients of IM had recovery, and chronic forms of EBV-infection were formed in 16,7 % patients.
2. Chronic subclinical EBV-infection in adults characterized by subclinical forms with typical signs of IM without signs of generalization process: subfebrility (25,9%), tonsillopharyngitis (92,6%), lymphadenopathy (92,6%), hepato- and splenomegaly (37,0%), moderate asthenovegetative syndrome (40,7%) and changes in laboratory parameters (lymphocytosis - 51,8%, hypergammaglobulinemia - 77,8%), active EBV-infection - manifest course, polymorphism with evidence of generalization of process: subfebrilitety (94,3%), tonsillo-pharyngitis (74,3%), generalized lymphadenopathy (88,6%), hepato- (88,6%) and splenomegaly (45,7%) expressed asthenovegetative (100,0%), abdominal pain, dyspeptic (57,1%) and arthropathic (28,6%) syndromes, changes in laboratory parameters (anemia - 25,7 %, leukopenia - 48.5%, thrombocytopenia - 37,1%, lymphocytosis - 68,5% hypergammaglobulinemia -68.5%) and organ damage (encephalitis - 42,8%, hepatitis - 28,6 %).
3. Patients with chronic EBV-infection have changes of immune parameters, which were characterized: in subclinical forms - the intensity of immune responses (increased content of CD8+, CIC, IgM, LKB- and NBT-test against decrease in CD3+, CD16+, CD20+, IRI, IgA and IgG), in active forms - pronounced imbalance of immune suppression characteristics of cellular and humoral immunity (lymphocyte subpopulations decrease in CD3+, CD4+, CD8+, CD16+, CD20+, IgG and IgA, inhibition of the functional activity of phagocytosis, increased CIC).
4. Clinical and medical history (presence of recurrent inflammatory diseases of the airways, asthenovegetative syndrome, fever, lymphadenopathy, hepato- and splenomegaly, organ damage (primarily encephalitis, hepatitis unspecified etiology), laboratory findings (leukopenia, thrombocytopenia, atypical mononuclear cells, lymphocytosis, monocytosis, hypergamma-globulinemia) in combination or alone constitute grounds for exception chronic form of EBV-infection using an algorithm for diagnosis verification by the system of discriminant equations.
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1. Kawa K. Epstein-Barr virus-associated diseases in humans/ K.Kawa // Inf. J. Hematol. - 2000. - № 71. - Р. 108-117.
2. Maia D.M. Chronic, active Epstein-Barr virus infection / D.M.Maia, A.L.Peace-Brewer // Current opinion in hema-tology. - 2000. - № 7. - C. 59-63.
3. Prognostic Factors for Chronic Active Epstein-Barr Virus Infection / Hiroshi Kimura, Tsuneo Morishima, Hirokazu Kanegane [et al.] // The Journal of Infectious Diseases. -2003. - Vol. 187. - P. 527-533.
Матерiал надйшов до редакци 3.12.2013
