Primary Epstein–Barr virus infection associated with renal flare-up of HCV-related cryoglobulinaemia

Piero Stratta, Loredana Colla, Andrea Campo, Luca Besso, Silvia Berutti, Caterina Canavese, Anna Barbui1, Ivana Franchi1 and Valeria Ghisetti1

Department of Internal Medicine, Nephrology Section of the University of Torino and 1 Service of Microbiology, S. Giovanni Molinette Hospital, Torino, Italy

Introduction

Epstein–Barr virus (EBV) is a ubiquitous human herpes virus which infects B lymphocytes, epithelial cells and T lymphocytes. More than 90% of adults are infected, and most are asymptomatic. It is associated aetiologically with both benign (infectious mononucleosis) and malignant (African Burkitt's lymphoma, nasopharyngeal carcinoma) disorders. The possibility that EBV infection plays a causal role in the pathogenesis of systemic lupus erythematosus was suggested some time ago. EBV is recognized as being a potent natural B-cell activator which may introduce antigenic material into the body and eventually lead to the formation of antibodies which cross-react with autoantigens of cell nuclear constituents [1,2]. Putative relationships between EBV infection and other autoimmune diseases, including mixed cryoglobulinaemia, have received less attention [3,4]. Cryoglobulins are serum immunoglobulins that precipitate at low temperature. Cryoglobulins are classified as follows: type I, consisting of monoclonal Ig alone (observed during immunoproliferative disorders such as multiple myeloma or Waldenström's disease); and types II and III, consisting of polyclonal Ig with (type II) or without (type III) a monoclonal component. Type II and type III, known as mixed cryoglobulins, are observed in a wide variety of diseases such as immunoproliferative disorders (type II), chronic inflammation, autoimmune disorders and acute or chronic infectious diseases (type II or III). Mixed cryoglobulins occurring without evidence of an underlying disease are considered as essential mixed cryoglobulins. Recently, it has been demonstrated that 50–80% of patients with essential mixed cryoglobulinaemia are in fact infected with hepatitis C virus (HCV) [5].

Here we report on a patient who had a previously undetected HCV-related mixed type II cryoglobulinaemia when a primary EBV infection triggered an acute renal flare-up.

Case

A 62-year-old woman was admitted in July 1997 for evaluation of abdominal pain, macroscopic haematuria, fever and pedal oedema. Her past history disclosed acute hepatitis 37 years before, occasional purpuric lesions on the upper extremities of the legs (putatively attributed to insect bites) and a recent Helicobacter-positive gastritis treated with H2-blocker drugs and antibiotics. As serum creatinine had risen from 1.2 to 2.3 mg/dl over a few days, she was transferred to our unit. On admission, the patient was in poor general condition with fever (37.5–38°C), arthralgia, purpuric lesions and hypertension (170/110 mmHg). Laboratory values included: sedimentation rate 45 mm/h, C-reactive protein 108 mg/l, haemoglobin 10.5 g/dl, leukocytes 17 000/mm3 (85% neutrophils), platelets 291 000/mm3, IgG 237 mg/dl, IgA 50 mg/dl, IgM 165 mg/dl, C3 43 mg/dl, C4<10 mg/dl and a high type II cryoglobulin level (cryocrit 15%) consisting of polyclonal IgG/monoclonal IgMK. Rheumatoid factor, anti-nuclear, anti-DNA, anti-ENA, anti-phospholipid, and anti-neutrophil cytoplasm (C-ANCA and P-ANCA) antibodies were absent. Blood cultures were negative for aerobic and anaerobic infectious agents, as were stool cultures for Clostridium difficilis, Salmonella, Shighella and Campylobacter.

Serologies for HBV and HIV were negative, while serology for HCV was positive (ELISA and RIBA 2): polymerase chain reaction (PCR) documented HCV RNA (genotype 2a/2c), and the branched DNA technique showed a high level of viraemia (>120 MEq/ml). Serology for Amoeba, Rickettsiae, Mycoplasma (IgM) parvovirus B19 (IgM), Mycobacterium tuberculosis (IgM and IgG), Aspergillus, Coxsackie virus, Chlamydia, Trachomatis (IgG and IgA), Borrelia, Leptospira (IgM), Echinococcus, Legionella, Candida albicans, Cryptococcus and cytomegalovirus (IgM) were negative, while there were detectable levels of IgG antibodies against cytomegalovirus (CMV), parvovirus B19 (PV-B19), herpes simplex virus and varicella zoster virus. Serology for EBV disclosed a IgG-negative/IgM-positive pattern with a positive agglutination test with heterophile antibodies. The specificity of IgM against different antigenic constituents of EBV was confirmed by western blotting. The serial evaluations of blood samples showed that IgM to EBV early antigen (EA) and EBV nuclear antigen (EBNA) vanished progressively with the persistence of IgM to EBV viral capsidic antigens (VCAs) and the late appearance of IgM to EBV VCA 200–180. At the time of the second sample when EBV VCA IgG was still undetectable in the serum, cryoprecipitates disclosed detectable amounts of EBV VCA IgG, but not IgM. PCR for EBV DNA was performed in peripheral lymphocytes and tested positive (Table 1Go).


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Table 1. Longitudinal evolution of markers of EBV infection and renal parameters

 
An acute nephritic syndrome (>100 erythrocytes, many hyaline, granular and cellular casts and 10–20 leukocytes in the urine; proteinuria 2–4 g/24 h) with a rapidly progressive evolution required haemodialysis (serum creatinine 4 mg/dl, oliguria, anasarca). Renal biopsy showed cryoglobulinaemic glomerulonephritis: diffuse endocapillary proliferation with intraluminal PAS+thrombi, splitting and reduplication of the basal membrane with mesangial interposition and diffuse finely granular IgG(+++), IgM(+++), C3(++) and C1q(+) deposits along the basal membrane (subendothelial and intramembranous sites) with heavy localization at the site of endoluminal thrombi.

Treatment consisted of intravenous methylprednisolone pulses (four pulses of 500 mg each), followed by oral steroid (0.5 mg/kg/day), antibiotics (teicoplanine, azthreonam, methronidazole and fluconazole) and three plasma exchange sessions with subsequent pulses of cyclophosphamide i.v. (200 mg/each). Co-trimoxazole ‘bed therapy’ was given contemporaneously to prevent opportunistic infection, and a 3-week course of gancyclovir (125 mg i.v./day) was administered because of CMV reactivation (25 cells positive for early antigen on August 12). Both clinical features and renal parameters rapidly improved and haemodialysis was discontinued. The patient was discharged 20 days later (serum creatinine 2.5 mg/dl, creatinine clearance 30 ml/min) on steroid and cyclophosphamide therapy.

After 9 months of follow-up, Crs was 1.2 mg/dl, sedimentation rate 4 mm/h and cryoglobulins were only detectable in trace amounts. HCV RNA was still detectable with a viraemia of 27 MEq/ml, while there was no evidence of EBV DNA in peripheral lymphocytes. EBV serology showed that IgMs against different EBV antigenic determinants were absent, as was the positive result with heterophile antibody (Table 1Go). Cryoprecipitates still revealed a detectable amount of anti-EBV VCA IgG.

Comment

In the present case, several factors suggest that the positive EBV serology was unlikely to have been brought about by cross-reactivity of antibodies produced in the course of a disease characterized by expansion of immunocompetent cell activity. (i) EBV infection was confirmed by PCR showing viral replication in peripheral lymphocytes; (ii) rheumatoid factor, which might be associated with false antibodies, was negative; (iii) the search for IgM against many other viruses and bacteria was negative; (iv) the pattern detected by EBV IgM western blot coupled with monotest was specific for primary infection; and (v) EBV serology converted, as is usually the case after a primary infection [15], independently of the cryocrit which ranged from 10 to 20% during the conversion period.

The reasons why EBV infection might be associated with renal flare-up in mixed cryoglobulinaemia remain to be clarified. EBV has a remarkable ability to interfere with immunocompetent cells, and this may link EBV infection to the kidney. EBV-induced B cell activation in patients with ongoing autoimmune diseases seems to be shaped by antigen-driven responses, rather than merely reflecting a polyreactive response [6,16]. This could modify some cryoglobulin characteristics, eventually leading to an impaired processing by renal macrophages [17,18]. EBV-transformed B-cell lines derived from patients with autoimmune diseases produce a nephritic factor of the classic complement pathway [19] and EBV infection has been associated with tubulointerstitial damage and immune complex-mediated glomerulonephritis [20]. Thus, the induction of polyspecific IgG production (all potential ligands for the cryo-IgM component) and/or impaired clearance by the reticular–endothelial system could increase renal cryo-complex deposition. Yet, the increase in some nephrotoxic antibodies could amplify cryo-complex/cryoglobulin glomerular damage.

Furthermore, it is well known that infection may change the natural course of diseases. Our patient was suffering from a chronic HCV infection, had a recent Helicobacter infection and currently had EBV infection followed by CMV infection, all of which occurred in the context of cryoglobulinaemia.

One may doubt the utility of diagnosing a viral infection at a time when appropriate antiviral treatment is not yet available. We believe that analysing the natural history of a disease in an attempt to provide new elements for basic research, and possibly subsequent improvements in treatment is important. It is possible that a viral infection vanishes after inducing irreversible changes in the immune-competent system responsive only to traditional protocol schedules such as steroids and other immunosuppressants. However, it cannot be excluded that antiviral drugs employed in the early stages of such a disease might eventually contribute to a favourable change in its natural course.

Thus in autoimmune diseases such as cryoglobulinaemia, disease flare-up and viral infection frequently present a problem of differential diagnosis. The possibility of an infectious cause should be considered before the diagnosis of an acute immunologic flare-up is made. Furthermore, another lesson to be learned from our report is that, in the case of mixed cryoglobulinaemia, what one is looking for in the serum might be simply absent because it is in the cryoprecipitate, as was the case in our patient with IgG against EBV VCA.

Notes

Correspondence and offprint requests to: Piero Stratta, Department of Internal Medicine, Nephrology Section of the University of Torino, S. Giovanni Molinette Hospital, Corso Bramante 88, 10126 Torino, Italy. Back

References

  1. Incaprera M, Rindi L, Bazzichi A, Garzelli C. Potential role of the Epstein–Barr virus in systemic lupus erythematosus autoimmunity. Clin Exp Rheumatol1998; 16: 289–304[ISI][Medline]
  2. Marchini B, Dolcher MP, Sabbatini A, Klein G, Migliorini P. Immune response to different sequence of the EBNA-I molecule in Epstein–Barr-related disorders and in autoimmune diseases. J Autoimmun1994; 7: 179–191[ISI][Medline]
  3. Vrbikova J, Janatkova I, Zamrazil V, Tomiska F, Fucikova T. Epstein–Barr virus serology in patients with autoimmune thyroiditis. Exp Clin Endocrinol Diabet1996; 104: 89–92[ISI][Medline]
  4. Fiorini GF, Sinico RA, Winearls C, Custode P, De Giuli-Morghen C, D'Amico G. Persistent Epstein–Barr virus infection in patients with type II essential mixed cryoglobulinemia. Clin Immunol Immunopathol1988; 47: 262–269[ISI][Medline]
  5. Fornasieri A, D'Amico G. Type II mixed cryoglobulinaemia, hepatitis C virus infection, and glomerulonephritis. Nephrol Dial Transplant1996; 11 [Suppl] 4: 25–30[ISI][Medline]
  6. Henle W, Henle GE, Horwitz CA. Epstein–Barr virus specific diagnostic tests in infectious mononucleosis. Hum Pathol1974; 5: 551–565[ISI][Medline]
  7. Roccatello D, Morsica G, Picciotto G et al. Impaired hepatosplenic elimination of circulating cryoglobulins in patients with essential mixed cryoglobulinaemia and hepatitis C virus (HCV) infection. Clin Exp Immunol1997; 110: 9–14[ISI][Medline]
  8. Caligaris-Cappio F, De Leo AM, Bertero MT. Autoimmune phenomena and hepatitis C virus in lymphoproliferative and connective tissue disorders. Leuk Lymphoma1997; 28: 57–63[ISI][Medline]
  9. Hiramatsu M, Tsokos Gc. Epstein–Barr virus transformed B cell lines derived from patients with systemic lupus erythematosus produce a nephritic factor of the classical component pathway. Clin Immunol Immunopathol1988; 46: 91–99[ISI][Medline]
  10. Ioh K, Kanetsuna Y, Ishikawa Y, et al. Epstein–Barr virus genome-positive tubulointerstitial nephritis associated with immune-complex-mediated glomerulonephritis in chronic active EB virus infection. Virchows Arch1998; 432: 567–573[Medline]
Received for publication: 15.11.99
Revision received 6. 3.00.



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