Infection, Genetics and Evolution 112 (2023) 105443

Contents lists available at ScienceDirect

Infection, Genetics and Evolution

journal homepage: www.elsevier.com/locate/meegid

T cell-mediated immunity during Epstein–Barr virus infections in children

Mengjia Liu a, b, Ran Wang a, b, *, Zhengde Xie a, b, *
a
Beijing Key Laboratory of Pediatric Respiratory Infectious Diseases, Key Laboratory of Major Diseases in Children, Ministry of Education, National Clinical Research
Center for Respiratory Diseases, Laboratory of Infection and Virology, Beijing Pediatric Research Institute, Beijing Children’s Hospital, Capital Medical University,
National Center for Children’s Health, Beijing 100045, China
b
Research Unit of Critical Infection in Children, 2019RU016, Chinese Academy of Medical Sciences, Beijing 100045, China

A R T I C L E I N F O A B S T R A C T

Keywords: Epstein–Barr virus (EBV) infection is extremely common worldwide, with approximately 90% of adults testing
Epstein–Barr virus (EBV) positive for EBV antibodies. Human are susceptible to EBV infection, and primary EBV infection typically occurs
Cellular immunity early in life. EBV infection can cause infectious mononucleosis (IM) as well as some severe non-neoplastic dis­
Infectious mononucleosis (IM)
eases, such as chronic active EBV infection (CAEBV) and EBV-associated hemophagocytic lymphohistiocytosis
Chronic active EBV infection (CAEBV)
EBV-associated hemophagocytic
(EBV-HLH), which can have a heavy disease burden. After primary EBV infection, individuals develop robust
lymphohistiocytosis (EBV-HLH) EBV-specific T cell immune responses, with EBV-specific CD8+ and part of CD4+ T cells functioning as cytotoxic
Vaccine T cells, defending against virus. Different proteins expressed during EBV’s lytic replication and latent prolifer­
ation can cause varying degrees of cellular immune responses. Strong T cell immunity plays a key role in con­
trolling infection by decreasing viral load and eliminating infected cells. However, the virus persists as latent
infection in EBV healthy carriers even with robust T cell immune response. When reactivated, it undergoes lytic
replication and then transmits virions to a new host. Currently, the relationship between the pathogenesis of
lymphoproliferative diseases and the adaptive immune system is still not fully clarified and needs to be explored
in the future. Investigating the T cell immune responses evoked by EBV and utilizing this knowledge to design
promising prophylactic vaccines are urgent issues for future research due to the importance of T cell immunity.

1. Introduction lymphoproliferative disorders (PTLD) (Singavi et al., 2015; Dharnid­

Epstein–Barr virus (EBV) is a ubiquitous and successful virus that
infects a large portion of the population. It is also recognized as the first
virus associated with tumors. The primary mode of transmission for EBV
is through saliva, although it can also spread through blood transfusion
and organ transplantations. Following initial infection, individuals may
experience either asymptomatic infection or infectious mononucleosis
(IM) (Dunmire et al., 2015; Dunmire et al., 2018). After recovering from
primary EBV infection, most individuals enter into a host-virus balance
state and become healthy carriers. However, a small minority of patients
may experience chronic active EBV infection (CAEBV), EBV-associated
hemophagocytic lymphohistiocytosis (EBV-HLH), diffuse large B cell
lymphoma, Hodgkin’s lymphoma (HL), and other EBV-related NK/T
lymphoproliferation-related diseases (Kimura et al., 2012; Fujiwara and
Nakamura, 2020). Additionally, EBV-seronegative recipients who
receive organs from EBV- seropositive donors are at a high risk of
developing post-transplant lymphoma and related post-transplant
harka et al., 2016; Subspecialty Group of Infectious Diseases and Na­
tional Children’s Epstein-Barr Virus Infection Cooperative, 2021). EBV
infection triggers a strong T cell-mediated immunity that plays a crucial
role in the control of infection and maintenance of virus-host balance.
The disease burden caused by EBV infection is significant, as it can
impact both physical and mental health of children. However, prophy­
lactic and therapeutic T cell-mediated vaccines against EBV are still
being researched. By exploring the role of T cell immunity in infection
control and its relationship with EBV protein, we can better understand
the progression of EBV infection and develop more effective immuno­
logical methods. In this review, we summarize T cell immunity in
common EBV -associated diseases in children, including IM, CAEBV and
EBV-HLH.
1.1. Epstein–Barr virus genome
EBV was discovered in 1964 by Michael A. Epstein and Yvonne Barr

* Corresponding authors at: Corresponding authors at: Beijing Children’s Hospital, Capital Medical University, Nan Li Shi Rd 56#, Xi Cheng District, Beijing
100045, China.
E-mail addresses: randall@mail.ccmu.edu.cn (R. Wang), xiezhengde@bch.com.cn (Z. Xie).

https://doi.org/10.1016/j.meegid.2023.105443
Received 31 January 2023; Received in revised form 25 April 2023; Accepted 15 May 2023
Available online 16 May 2023
1567-1348/© 2023 Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
M. Liu et al.
in a cultured lymphoblast line derived from an African Burkitt lym­
phoma patient through electron microscopy (Epstein et al., 1964; Liu
et al., 2020). EBV belongs to the family Herpesviridae, and is one of the
eight known herpesviruses. It is a human lymphotropic herpesvirus that
has been named human γ herpesvirus and is classified under the genus
Lymphocryptovirus (Dunmire et al., 2015). EBV particles have a charac­
teristic three-layer configuration like other herpes viruses and are
around 120 to 180 nm in diameter (Cohen, 2000; Odumade et al., 2011;
Li et al., 2020). The viral double-stranded DNA genome encodes various
proteins necessary for viral DNA replication and the formation of viral
structure (Cruchley et al., 1997; Cohen, 2000; Farrell, 2019). It’s
approximately 172 kb in length and enclosed by the pseudo-icosahedral
nucleocapsid. The material outside the nucleocapsid is proteinaceous
tegument, which contains various viral proteins. The outermost layer of
the proteinaceous tegument is the lipid bilayer membrane containing
glycoproteins like gp350, gB, gH, gL, and gp42. These glycoproteins are
responsible for host recognition and the fusion process between the virus
and host membrane (Odumade et al., 2011; Li et al., 2020). Currently,
there are 130 published EBV genome sequence using EBV genome
sequencing technology (Correia et al., 2017). Based on the differences in
the EBV nuclear antigen (EBNA) loci between EBNA2 and EBNA3, EBV is
isolated into type 1 and type 2. EBV-1 is the dominant type worldwide,
while EBV-2 has a high prevalence in the New Guinea population and
sub-Saharan Africa (Odumade et al., 2011; Farrell, 2015; Correia et al.,
2017).
1.2. The process of Epstein–Barr virus entering host cells
Primary EBV infection generally occurs by coming into contact with
oral secretions from EBV seropositive individuals. The primary target
cells for EBV are epithelial cells and B lymphocytes (Cruchley et al.,
1997; Balfour Jr. et al., 2015). In the oropharyngeal epithelial cells, the
viruses amplified through lytic replication and then infects B cells. EBV
can directly infects resting B cells in tonsil crypts, transforming them
Fig. 1. The process of EBV entering host cells. MHC, major histocompatibility complex; EphA2, Ephrin type A receptor 2.
2
Infection, Genetics and Evolution 112 (2023) 105443
into a latent infection state. Infected B cells then move back to the
oropharynx, occur lytic replication, and circulate in the oropharynx (Bu
et al., 2019). The process of EBV entering host cells requires the syner­
gistic action of numerous glycoproteins (Fig. 1) (Connolly et al., 2021).
Viral attachment occurs by binding the viral envelope glycoprotein
gp350 to the C3d complement receptor CR2 (CD21), which expresses on
the surface of naïve B lymphocytes. On the surface of epithelial cells
without CD21 expression, viral BMRF2 protein binds to integrin and
triggers endocytosis of particles (Cohen, 2000; Molesworth et al., 2000;
Borza and Hutt-Fletcher, 2002; Chen et al., 2018). The penetration and
fusion of the virus particles with the host cell membrane require
glycoprotein heterodimer complex gH-gL, gp42, and viral fusion pro­
teins gB (Wang et al., 1998). During the process of EBV infecting
epithelial cells, the heterodimer gH-gL binds to integrin αVβ5, αVβ6, or
αVβ8 (Chesnokova and Hutt-Fletcher, 2011) and then subsequently
binds to Ephrin type A receptor 2 (EphA2) receptors, resulting in the
activation of the fusion protein gB and promoting the process of virus-
cell membrane fusion (Chen et al., 2018; Bu et al., 2019; Connolly
et al., 2021). During EBV infection of B cells, the heterodimer gH-gL
forms a complex with gp42 glycoprotein. Human Leukocyte Antigen
(HLA)-II molecules, as cofactors for infection of B lymphocytes, bind to
gp42 glycoprotein, and subsequently induce fusion protein gB to
mediate the process by which the virion enters the host cell (Li et al.,
1997; Molesworth et al., 2000; Borza and Hutt-Fletcher, 2002).
1.3. Life cycle of EBV
Infected B cells undergo continuous latent proliferation in the
germinal centers of the tonsils (Dunmire et al., 2018). The EBV releases
the nucleocapsid into the cytoplasm via vesicles. After the dissolution of
the nucleocapsid, the viral genome is transported to the nucleus through
nuclear pore complexes (Lee and Chen, 2021). The expression products
of EBV’s latency genes play an essential role in the maintaining latent
infections of EBV-infected B cells. These gene products include EBV-
M. Liu et al.
encoded microRNAs (miRNAs), BamHI A-encoded transcripts (BARTs),
EBV-encoded small RNAs (EBER1 and EBER2), six Epstein–Barr nuclear
antigen proteins (EBNA1, EBNA2, EBNA3A, EBNA3B, EBNA3C, and
EBNA-LP) and three latent membrane proteins (LMP-1, LMP-2A, and
LMP-2B) (Li et al., 1997; Wang and Hutt-Fletcher, 1998; Tugizov et al.,
2003; Tsurumi et al., 2005; Tsao et al., 2012; Dunmire et al., 2018). EBV
latency patterns can be classified into four stages (Latency stage 0-III)
(Fig. 2) (Bailey, 1994; Tsuchiya, 2002; Odumade et al., 2011). In la­
tency stage III, all latency genes are expressed, including EBNA1,
EBNA2, EBNA3A, EBNA3B, EBNA3C, LMP-1, LMP-2, EBER, miRNAs,
and BARTs. These genes can activate naïve B cells, promote prolifera­
tion, and contribute to the virus transformation. Because EBNA3s are
dominate targets of CD8+ T cell response, a part of the infected cells is
eliminated by cytotoxic T lymphocytes (CTLs) in latency stage III. This
pattern is associated with IM and lymphoproliferative diseases (Cohen,
2000; Speck and Ganem, 2010). In latency stage II, I, and 0, restricted
latency genes are expressed in EBV-infected cells, allowing them to
establish latency infections and evade CD8+ CTLs (Kimura et al., 2008).
In latency stage II, the programmed expression of EBNA1, LMP-1, LMP-
2, EBER, and BARTs can induce the B cells differentiation and establish
the phenotype of memory B cells (Speck and Ganem, 2010; Odumade
et al., 2011). This pattern is characteristic of HL, epithelial tumor
nasopharyngeal carcinoma (NPC), and CAEBV. In latency stage I,
EBNA1/EBER and BARTs are expressed, which can facilitate B cell
survival and can be found in Burkitt lymphoma (Yin et al., 2003; Herbert
and Pimienta, 2016). In latency stage 0, only EBER and BARTs are
expressed, and during this phase, EBV memory B cells are thought to be
silent. Individual in this stage is healthy carrier in a virus-host balance
state (Yin et al., 2003; Minarovits, 2006).
Under the inducement of reactivation signals, some infected resting
B cells and memory B cells undergo viral reactivation. This results in the
lytic replication of infected cells and the generation of progeny virus
particles, as shown in Fig. 2 (Price and Luftig, 2014). Following virus
Fig. 2. Life cycle of EBV and latency types in EBV-associated diseases. EBV, Epstein–Barr virus; EBNA, Epstein–Barr nuclear antigen; miRNAs,EBV-encoded
microRNAs; BARTs, BamHI A-encoded transcripts; LMP, latent membrane proteins; IM, infectious mononucleosis; PTLD, post-transplant lymphoproliferative dis­
eases; CAEBV, chronic active EBV infection.
3
Infection, Genetics and Evolution 112 (2023) 105443
activation, the immediate early trans-activator Zta (BZLF1) and Rta
(BRLF1) genes are preferentially expressed. The genes are transcribed
and cohesively bind to the origin of lytic replication to form the core
replication complex (Murata, 2014; Zhang et al., 2017). Consequently,
lytic virus genes are orderly expressed, producing proteins that are
involved in the formation of daughter virus particles. Early genes are
expressed to produce over 30 early proteins, such as BMLF1, BHRF1,
BALF1, and DNase BGLF5, all of which are essential in the replication of
the EBV genome (McKenzie and El-Guindy, 2015). The episomal form
genome is linearly activated as viral genome replication takes place.
Finally, the late genes are expressed, producing late viral protein capsid
protein VCA/gp350/ gp 220, and among others, which take part in the
formation of daughter viral structural proteins. Once complete viral
particles are formed, they are excreted through exocytosis (Tsurumi
et al., 2005; Ressing et al., 2015; Lee and Chen, 2021).
1.4. Pathogenicity of EBV
After primary infection with EBV, individuals may develop asymp­
tomatic infections or present with clinical manifestations of IM. In the
developed country, primary EBV infection usually causes IM in adoles­
cents and young adults, while in infants and younger children, it is
usually asymptomatic or presents with non-specific symptoms (Dunmire
et al., 2018). Conversely, in developing countries such as China, peak
incidence of IM was found in preschoolers, particularly in the 4–6 years
old age group (Hu et al., 2021; Liu et al., 2022). IM is characterized by a
long incubation period before the onset of clinical manifestations
(Dunmire et al., 2015). In children, typical clinical manifestations of IM
include pharyngitis, fever, and lymphadenopathy, sometimes accom­
panied by liver dysfunction, hepatosplenomegaly, and edema of eyelids.
Children with IM usually have IgM and low-affinity IgG antibodies
against viral capsid antigen (VCA), or only low-affinity IgG antibodies
against VCA. Several months later, IgG antibodies against EBNA and
M. Liu et al.
high-affinity IgG antibodies against VCA become detectable, which is
typical of serological tests in healthy carriers of EBV (Subspecialty
Group of Infectious Diseases and National Children’s Epstein-Barr Virus
Infection Cooperative, 2021). There is no specific standard for the
treatment of IM, which is mainly symptomatic and supportive (Womack
and Jimenez, 2015). Most cases of IM have a good prognosis, while some
patients may develop complications such as encephalitis, myocarditis,
or even EBV-HLH (Jenson, 2000; Allen and McClain, 2015; Yao et al.,
2021; Liu et al., 2022). EBV-HLH can occur during different states of
EBV infection and is essentially organ damage caused by excessive
production of inflammatory cytokines (Imashuku et al., 2021). Patients
with EBV-HLH may present with persistent high fever, hep­
atosplenomegaly, lymph node enlargement, anemia, and jaundice
(Subspecialty Group of Infectious Diseases and National Children’s
Epstein-Barr Virus Infection Cooperative, 2021; El-Mallawany et al.,
2022). The main treatments for EBV-HLH are symptomatic treatment,
chemotherapy, and hematopoietic stem cell transplantation (HSCT);
however, the prognosis of EBV-HLH is poor, and mortality rates are high
(Yanagaisawa et al., 2019).
In addition, some patients exhibit persistent or recurring IM-like
symptoms for over three months (Kimura and Cohen, 2017; Shafiee
et al., 2022), which is referred as a lymphoproliferative disorder called
CAEBV. The clinical manifestations of CAEBV are diverse including
fever, hepatosplenomegaly, liver dysfunction, lymphadenopathy,
thrombocytopenia, and hypersensitivity to mosquito bites, excluding
known immunodeficiency diseases (Arai, 2021). Depending on the
infected cell types of clonal proliferation, CAEBV can be divided into
NK/T cell type and B cell type. The T cell type CAEBV can be further
divided into CD4+ T cell type, CD8+ T cell type, γδ T cell type, and other
T cell types (Kimura and Cohen, 2017). CAEBV characterized by EBV-
infected NK/T cell clone proliferation is more common in children in
Asia, particularly in East Asia, while EBV-infected B-cell-related CAEBV
is more prevalent in western country (Kimura et al., 2012; Bollard and
Cohen, 2018). The etiology of CAEBV is not clearly understood (Fuji­
wara and Nakamura, 2020). Additionally, there is still no satisfactory
therapy for CAEBV, and the most effective treatment is HSCT (Subspe­
cialty Group of Infectious Diseases and National Children’s Epstein-Barr
Virus Infection Cooperative, 2021).
2. T cell-mediated immune responses during EBV infection
After primary infection with EBV, both humoral and cellular immune
responses are triggered in the infected individual. B cells produce anti­
bodies to participate in controlling EBV infection. IgG antibody titers
against lytic cycle antigens such as the VCA complex peak after primary
EBV infection and subsequently decline to stable levels. The production
of antibodies by B cells requires T helper cells. Antigen-specific helper T
cells interact with antigen-specific B cells via the “antigen-bridge” and
eventually produce specific antibodies that are involved in controlling
infection (Lanzavecchia, 1985; Tomita et al., 1998; Zhong et al., 2022).
During primary EBV infection, EBV usually infects naïve B cells and
leads to latent infection (Shafiee et al., 2022). These latent infected B
cells induce T cell immunity, which plays a critical role in maintaining
the balance between the host immune system and virus. After initial
exposure to EBV, robust EBV-specific T cell immune responses are
induced in the host, and these responses decrease in magnitude over
time, forming memory immunity that persists throughout life of the
host. CD8+ and CD4+ T cells specifically target infected cells that express
a wide range of EBV proteins during the latent and lytic stages of viral
infection. CD8+ T cells exert effector function of cytotoxicity and control
virus infection by recognizing the short peptide derived from the
endocellular breakdown of EBV protein and combining with major
histocompatibility complex (MHC)-I molecular on the infected cell
surface. CD4+ T cells that bind to MHC-II molecules expressed on the cell
surface can be categorized as helper T lymphocytes (Th), CTLs, and
regulatory T cells (Treg), which function in the immune response to viral
4
Infection, Genetics and Evolution 112 (2023) 105443
infection. EBV-specific CD4+ T cells identified as helper T cells partici­
pate in high-affinity antibody production, initiate and maintain CTL
function and are highly activated, producing cytotoxic substance such as
Granzyme B and perforin, to control EBV infection (Landais et al., 2004;
Martorelli et al., 2010; Meckiff et al., 2019; Dowell et al., 2021).
EBV-specific memory T cells act as immune surveillance to maintain the
virus-host balance in the infected host. Understanding T cell-mediated
cellular immunity during EBV infection will contribute to providing
data support for the development of EBV vaccine.
2.1. Asymptomatic infection
It is well-known that primary EBV infection in infants and toddlers is
almost always asymptomatic (Silins et al., 2001), though asymptomatic
individuals are occasionally discovered through EBV-specific antibody
spectrum contemporary assays. This makes it challenging for clinicians
to identify asymptomatic EBV infections in a timely manner (Subspe­
cialty Group of Infectious Diseases and National Children’s Epstein-Barr
Virus Infection Cooperative, 2021). Consequently, there are a limited
number of studies on asymptomatic infection. Silins et al. reported that
individuals with asymptomatic infection maintain a diverse T cell re­
ceptor (TCR) repertoire. Interestingly, the TCR repertoires remain stable
throughout the process of disease recovery without amplification or
narrowing (Silins et al., 2001). Jayasooriya et al. found that asymp­
tomatic African children aged 14–18 months had higher levels of plasma
EBV-DNA load, similar to IM, which decreased over time. Moreover,
EBV-specific CD8+ T cells were activated, and the response to one in­
dividual epitope accounted for roughly 15% of the total CD8+ T cells.
Highly activated EBV-specific CD8+ T cells express activation markers
HLA-DR and CD38. Strikingly, despite observing such changes, the study
found no significant expansion of CD8+ T lymphocytes and CD8+ T
compartment (Fig. 3A), which is different from what is usually seen in
children with primary EBV infection with clinical manifestations
(Jayasooriya et al., 2015). Similarly, Abbott et al. reported that
asymptomatic adolescents displayed the same level of EBV-DNA as IM
patients but a lower magnitude cell-mediated immune response (Abbott
et al., 2017).Tamaki et al. found that CTL lines from children aged
20–35 months recognized at least one EBV latent gene expression
products, with almost all the children showing CTLs response against
EBNA3s (EBNA3A, 3B, 3C), of which EBNA3C was observed most
frequently (Tamaki et al., 1995). These results suggest that asymptom­
atic EBV infection in children causes high viral load with a decreasing
process while inducing an EBV-specific CD8+ T cells response that can
control EBV infection without excessive amplification of CD8+ T cells.
This provides support for the notion that IM is an immunopathological
disease. Lam et al. observed an increase in PBMC and plasma viral load at
the same level in asymptomatic and IM children. During the convales­
cent phase, both PBMC and plasma viral loads continued to decrease.
Furthermore, both latent and lytic antigen-specific CD4+ and CD8+ T
cells displayed polyfunctionality (Lam et al., 2018). Detection of EBV-
specific CD8+ T cells markers found that the expression of the cell
proliferation marker Ki-67 was increased and anti-apoptotic protein Bcl-
2 was decreased, indicating that the cells were in the sensitive phase of
proliferation and apoptosis (Jayasooriya et al., 2015; Abbott et al.,
2017).
2.2. Infectious mononucleosis
2.2.1. Relation between viral load and T cell-mediated immune response
Primary EBV infection typically presents as IM in older children,
including elementary and adolescent students (Subspecialty Group of
Infectious Diseases and National Children’s Epstein-Barr Virus Infection
Cooperative, 2021). To investigate the cellular immune response to
primary EBV infection, researchers typically examine the peripheral
blood of IM patients. The period between viral infection and the onset of
clinical symptoms is approximately 42 days, and infection may have
M. Liu et al. Infection, Genetics and Evolution 112 (2023) 105443

Fig. 3. T cell-mediated immune response in EBV-associated diseases. T cell-mediated immune response in the asymptomatic, IM and healthy carriers (A), CAEBV (B),
EBV-HLH (C). IM, infectious mononucleosis; CAEBV, chronic active EBV infection; EBV-HLH, EBV-associated hemophagocytic lymphohistiocytosis.

developed 3–6 weeks prior to sample collection (Dunmire et al., 2018).
It is difficult to capture immune response samples during the incubation
period.
During the acute phase of IM, there is a high level of EBV-DNA load
which decreased rapidly during the convalescent phase. This decrease is
consistent with the decrease in the ratio of EBV-specific CD8+ T cells
participating in the elimination of EBV (Fig. 3A) (Hoshino et al., 2011).
CD8+ T cells in children with IM expressed inhibitory receptors and
differentiation markers, and an increased EBV viral load appears to be
related to increased frequencies of PD-1 and KLRG1 positive CD8+ T
cells (Chatterjee et al., 2019).
Antigen-driven EBV-specific CD4+ T cell responses decrease in par­
allel with viral load (Precopio et al., 2003), and the ratio of circulating
follicular help T cells (cTfh) to circulating follicular regulatory T cells
(cTfr) is positively correlated with EBV-DNA load (Qian et al., 2020).
Both CD4+ and CD8+ T cells are involved in the control of viral load in
vivo, and T cell immune responses play an important function in the
control of infection.
The oropharyngeal viral load is higher during the acute period of IM,
after while it decreases slightly after this phase, it remains high for many
months following IM (Hislop et al., 2005). The viral load is inversely
correlated with the number of EBV-specific CD8+ T cells expressing T-
bet, which perhaps participate in the control of infection (Barros et al.,
2019).
2.2.2. Immunophenotype of T cell subsets
2.2.2.1. CD8+ T cells. IM is an immunopathological disease in which an
increased proportion and number of lymphocytes and atypical lym­
phocytes are detected in peripheral blood. Further studies have shown

5
M. Liu et al.
that the increased lymphocytes are confirmed to be high expansion of
CD8+ T lymphocytes, and the atypical lymphocytes are activated CD8+
T lymphocytes (Dunmire et al., 2015). The largely amplified CD8+ T
cells are associated with the clinical manifestations of IM (Jayasooriya
et al., 2015). Additionally, the high expansion of CD8+ T cells is due to
antigen-driven responses, and these CD8+ T cells are mostly EBV-
specific (Callan et al., 1998; Hoshino et al., 1999). Highly expanded
CD8+ T cells can serve as an important indicator of assisted diagnosis of
IM based on the above characteristics. Flow cytometry with HLA-I
tetramer staining makes it possible to study the phenotype of highly
expanded CD8+ T cells (Silins et al., 2001). In children with IM, the
percentages of naïve CD8+ T cells (CCR7+CD45RA+) and effector CD8+
T cells (CCR7− CD45RA+) are decreased in peripheral blood lymphocyte
subsets, accompanied by an increase in the percentage of CD8+ T
effector memory cells (CCR7− CD45RA− ) and CD8+ T central memory
cells (CCR7+CD45RA− ) (Wang et al., 2021). Chatterjee et al. detected
expansion of PD-1 positive CD8+ T cells and high-frequency expression
of TIM-3, 2B4, and KLRG1 in children with IM. Blocking the PD-1 axis
could compromise EBV-specific immune control (Chatterjee et al.,
2019), suggesting that PD-1 expression marks functional CD8+ T cells
from the IM phase to convalescence.
The co-expression of CD38 and HLA-DR on the surface of EBV-
specific CD8+ T cells indicates an activated state, with an increased
ratio of TCR-αβ and TCR-γδ suggesting their function as CTLs. The
activated cells are primarily of a classical CD8+CD27+HLA-DR+
immunophenotype (Callan et al., 1998; Fedyanina et al., 2021; Wang
et al., 2021). While some EBV-specific CD8+ T cells express the CD45RO
isoform, markers for homing molecule CCR7 and CD62L are rare (Cat­
alina et al., 2002). Furthermore, EBV-specific CD8+ T cells demonstrate
a lower expression of the anti-apoptotic protein Bcl-2, indicating high
apoptotic sensitivity in vivo (Soares et al., 2004). The presence of the cell
surface degranulation marker CD107a, as a surrogate for cytotoxicity, is
predominantly observed in CD8+ T cells during IM and involved in
infection control (Lam et al., 2018; Chatterjee et al., 2019). Interest­
ingly, while CD8+ T cells undergo substantial expansion of in peripheral
blood during EBV infection, a predomination of expended CD8+ T cell is
not observed in tonsil, probably due to their inability to enter B-cell
lymphoid follicles and germinal centers to eliminate infected B cells via
a lack of lymphocyte homing receptors (Chen et al., 2001; Montesoro
et al., 2006; MacArthur et al., 2007). In tonsil, EBV-specific CD8+ T cells
show less differentiation and a higher expression level of co-stimulatory
molecule CD28 than those in peripheral blood (Soares et al., 2004).
Additionally, the number of CD8+ T cells expressing cytotoxic markers
TIA1 and Granzyme B is higher than that of CD8+ T cells expressing
FoxP, indicating a domination of the cytotoxic signature rather than
regulatory T cells phenotype in tonsil (Barros et al., 2019).
2.2.2.2. CD4+ T cells. Contrary to the extensive proliferation observed
in CD8+ T cells, no expansion of CD4+ T cells nor an increase in their
absolute numbers are observed in children with IM (Balfour Jr. et al.,
2013). Analysis of peripheral blood lymphocyte subsets in IM children
indicates a decreased proportion of naïve CD4+ T cells
(CCR7+CD45RA+) accompanied by an increase in the percentage of
CD4+ T effector memory T cells (CCR7− CD45RA− ). In addition, a
reduced percentage of Tregs (CD4+CD25+CD127low) correlates with the
lower cTfh (FoxP3+CXCR5+PD-1+CD4+)/cTfr (FoxP3− CXCR5+PD-
1+CD4+) ratio in primary EBV infections than in healthy carrier
resulting from a remarkable increase in cTfr, a marker of ongoing hu­
moral activity. This imbalance in cTfr and cTfh cells is involved in the
immune control of children with IM (Qian et al., 2020).
CD38 and HLA-DR co-expression is detected on the surface of EBV-
specific CD4+ T cells, indicating the activation. In contrast to the ratio
of TCR-αβ, that of TCR-γδ is higher among EBV-specific CD4+ T cells
(Wang et al., 2021). Similarly, a proportion of EBV-specific CD4+ T cells
function as effector CD4+ T cells and can survive until the persistent
6
Infection, Genetics and Evolution 112 (2023) 105443
stage of EBV infection for an extended period (Amyes et al., 2003).
Primary EBV infection results in oligoclonal populations of cytotoxic
EBV-specific CD4+ T cells, that secrete Granzyme B and perforin in
response to direct in vitro to challenge with EBV-infected B cells (Meckiff
et al., 2019; Tamura et al., 2022). During convalescence, the number of
cytotoxic EBV-specific CD4+ T cells gradually decreases to undetectable
levels (Appay et al., 2002; Takeuchi and Saito, 2017; Meckiff et al.,
2019). Activated EBV-specific CD4+ T cells produce one or more of IL-2,
TNF-α, IFN-γ, CD107a, and cytokine polyfunctionality, contributing to
the decrease of EBV-DNA load in the blood to control infection (Lam
et al., 2018). Meckiff et al. reported that T-bet expression was common
among EBV-specific CD4+ T cells in IM patients and significantly higher
than in EBV-specific memory CD4+ T cells in healthy EBV carriers
(Meckiff et al., 2019). In the tonsil microenvironment, Th2-like
(CD4+CMAF+) CD4+ T cells constitute the most significant subset, fol­
lowed by Tregs (CD4+FoxP3+) and Th1-like (CD4+Tbet+) cells (Chai
et al., 2011; Barros et al., 2019). The proportion and number of Tregs
(CD4+FoxP3+) remain stable, and Th1-like (CD4+Tbet+) cells retain
cytotoxicity for a lifetime following primary EBV infection (Wingate
et al., 2009; Barros et al., 2019).
2.2.3. Lytic and latent antigens targeted by T cell immune responses
2.2.3.1. CD8+ T cells. During the acute phase of IM, EBV-specific CD8+
T cell responses are directed toward lytic proteins (Callan et al., 1998;
Adem et al., 2002). Steven et al. screened antigenic epitopes from pe­
ripheral blood mononuclear cells (PBMCs) of IM patients and found that
individual responses to the lytic antigens mainly focus on the epitopes of
the BZLF1/BRLF1, as well as BMLF1 and BMRF1 induced by BZLF1/
BRLF1 (Steven et al., 1997). This conclusion was consistent with other
studies which found that EBV-specific CD8+ T cells are more responsive
to BZLF1 and BMLF1 epitopes (Precopio et al., 2003). CD8+ T cell re­
sponses to the late lytic antigens are subdominant and at low levels, and
they are rarely detected during primary EBV infection (Abbott et al.,
2013). However, BMLF1-specific CD8+ T cell clones could recognize and
eliminate EBV-lytically replicating autologous lymphoblastoid cell lines
(LCLs) in vitro, demonstrating the effector function of cytotoxicity of
specific CD8+ T cell in vivo (Antsiferova et al., 2014). Furthermore,
BMLF1-specific CD8+ T cells expressing PD-1 and Ki-67 were observed,
suggesting that despite the presence of inhibitory receptors, CD8+ T cells
can still proliferate vigorously (Chatterjee et al., 2019). Brooks et al.
reported that BHRF1, as the “first wave antigens” expressed after EBV
infection of B cells, induced strong T cell imunity in some individuals,
making it a promising candidate in the devolpoment of prophylactic
vaccines (Brooks et al., 2016). Additionally, Rühl et al. found that lytic
antigen-specific CD8+ T cells have specific
PD1+TIM− 3+KLRG1+CXCR5+TCF-1+ and BATF3+ phenotypes that may
relate to their ability to control EBV-infected B cells within the germinal
center (Ruhl et al., 2020). To prevent CD8+ T cells from targeting EBV-
infected cells, the lytic genes of EBV downregulate the expression of
HLA-I molecules, inhibiting antigen recognition and presentation. Early
protein product DNA exonuclease BGLF5 plays a crucial role in inhib­
iting antigen recognition and presentation by downregulating HLA-I
molecules mRNA expression (van Gent et al., 2015).
Compared to the lytic-specific CD8+ T cell response, CD8+ T cells
exhibit a lower frequency of responding to latent infected cells (Munz,
2020). CTL responses mainly target the major latent antigen epitopes
that are derived from the EBNA3 proteins, and such epitopes show much
promise in the design of an EBV prophylactic vaccine (Steven et al.,
1996). Subdominant epitopes like EBNA2 and LMP2 can also elicit a
strong CD8+ T cell immune response in some populations (Chen et al.,
2009). Brooks et al. reported that EBNA2-specific CD8+ T cells can
recognize infected B cells within the first day of infection and effectively
inhibit the growth of EBV-transformed B cell lines in vitro. They sug­
gested that the EBNA2 protein may serve as a new target antigen for
M. Liu et al.
prophylactic vaccines (Brooks et al., 2016). The EBNA1 protein has a
glycine-alanine (Gly-Ala) repeat domain consisting solely of repeated
glycine and alanine residues, which impede the proteasome degradation
process that breaks down viral proteins into short peptides that can be
recognized by antigen-presenting cells (APC). This interference in the
presentation of the virus antigen to CD8+ T cells leads to the failure of
the EBNA1 epitope to be recognized by such T cells (Levitskaya et al.,
1997; Apcher et al., 2009; Farrell, 2019). The presence of this repeat
domain guarantees a sufficient supply of EBNA1 to maintain the
episomal form of the EBV genome in infected cells, thereby preventing
attacks by cytotoxic cells (Valentine et al., 2010).
2.2.3.2. CD4+ T cells. The CD4+ T cell responses of individuals epitopes
are less frequent than CD8+ T responses (Landais et al., 2004). T cell
clone analysis suggests that CD4+ T cells responses to immediate early
protein (IE), early protein (E), and late protein (L) are at the same level.
The results of peptide stimulation in vitro indicate that frequency of
BZLF1-specific CD4+ T cell responses increase rapidly in the acute phase
of IM, peak, and decline in the convalescent phase (Precopio et al., 2003;
Calarota et al., 2013). Dowell et al. found that structural protein BORF1-
specific CD4+ T cells express Granzyme B and perforin in IM patients,
and the expression levels persist in healthy carriers. (Dowell et al.,
2021). During the acute stage of primary EBV infection, the response
frequency of CD4+ T cells to the lytic epitope is high, and gradually
decreases in the convalescent phase. Since most of the lytic proteins are
involved in the formation of EBV genome replication and structural
proteins into complete EBV particles, it is possible that CD4+ T cells
participate in the control of viral infection in vivo by interfering with the
replication of virus particles. BZLF2 binds to HLA-II-peptide complexes,
resulting in a novel complex that contributes to the binding process of
MHC-II and TCR on the surface of CD4+ Th cells. This interferes with the
antigen recognition ability of Th cells and constrains cellular immunity
(Ressing et al., 2003).
Unlike CD8+ T cells, CD4+ T cells have a lower response frequency to
an individual epitope and the target epitopes that are widely distributed
in EBNAs (Leen et al., 2001; Hislop et al., 2007). Precopio et al. noted
that the response of EBV latency-specific CD4+ T cells was the highest
within three weeks of initial exposure to EBV antigen, but then rapidly
decreased (Precopio et al., 2003). During the acute stage of IM, CD4+ T
cells have a strong response of to the EBNA2 epitope, but the response to
the EBNA1 epitope is substantially delayed, which parallels the late
emergence of EBNA1 IgG antibody (Yang et al., 2011; Long et al., 2013;
Meckiff et al., 2019). Thus, the delayed appearance of EBNA1 IgG
antibody may be related to the immune response of CD4+ T cells.
Meckiff et al. found that under EBNA2 peptide pool stimulation, CD4+ T
cells expressing Granzyme B and perforin were closely associated with
cellular activation, and these responsive CD4+ T cells usually overex­
pressed CD38 (Meckiff et al., 2019). Lam et al. observed a dramatic in­
crease in CD4+ T cell immune response against EBNA3B from primary
EBV infection to the period of long-term carrier (Lam et al., 2018).
Intriguingly, the EBNA3 protein family epitope is located in a 992-
amino-acids (aa) fragment that can induce maximal proliferation of
CD4+ T cells in vitro. Furthermore, 13-aa repeat region of EBNA3C
(aa741 to 779) was previously reported to an immunodominant target
for antibody response and contained numerous overlapping and mixed
CD4+ T antigen epitopes (Rajnavolgyi et al., 2000), making it a prom­
ising vaccine target (Cirac et al., 2018; Cirac et al., 2021). Regarding the
response of CD4+ T cell to latent membrane proteins, LMP1 epitopes
appear to induce a stronger immune response than LMP2 epitopes.
Marshall et al. reported that CD4+ T cells were involved in controlling
CTLs activities and responded to LMP1 during the acute phase of pri­
mary EBV infection, resembling a Th-1-like role; however, over time,
they seem to switch to a regulatory IL-10-like role during convalescence
(Marshall et al., 2007; Morales et al., 2012). Chen et al. demonstrated
that Th-1 like cells predominantly dominated the LMP2A-specific CD4+
7
Infection, Genetics and Evolution 112 (2023) 105443
T cell-mediated immune response (Chen et al., 2009).
2.3. Healthy carrier
2.3.1. T cell-mediated immune response in EBV-host homeostasis
After recovering from primary EBV infection, the patients develop a
virus-host balance and become long-term healthy carriers. The level of
EBV-DNA load in plasma drops sharply during the convalescence stage
and is undetectable during the healthy carrier stage. However, the level
of EBV-DNA load in PBMCs may plateau 4–6 months after infection,
declines sharply to a lower level from 6 to 12 months after infection, and
then reaches equilibrium. This phenomenon may be related to the in­
crease in the proportion of polyfunctional T cells, which can simulta­
neously secrete two or more types of cytokines to participate in infection
control (Lam et al., 2018). Additionally, the level of EBV-DNA load in
the tonsil is much lower than during the acute phase (Hislop et al.,
2005). In long-term healthy carriers, infected B cells are often charac­
terized by latent infection status in a dormant state, and activated to
undergo lytic replication under the stimulation of certain factors. EBV is
reactivated in vivo and viral load is temporarily elevated, but most in­
dividuals do not develop clinical symptoms, which is related to the
involvement of EBV-specific memory T cells in controlling the infection.
2.3.2. Immunophenotype of T cell subsets
2.3.2.1. CD8+ T cells. HLA-I tetramer staining of memory CD8+ T cells
has shown that the resting T cells are present and can activate again
upon stimulation by antigen, leading to the development of CTLs that
secret cytokines to control infection (Fig. 3A) (Hislop et al., 2001). EBV-
specific CD8+ T cells exhibit stable phenotype, functional characteris­
tics, and TCR clone composition over time (Lelic et al., 2012). A subset of
latent antigen-specific CD8+ T cells that express high levels of CCR7 and
CD62L circulate in lymphatic tissue and upregulate expression of anti-
apoptotic protein Bcl-2, a feature of central memory T cells (Dunne
et al., 2002).
2.3.2.2. CD4+ T cells. Analysis of CD4+ T cell phenotypes suggests an
equitable distribution between central memory T cells and effector
memory T cells (Long et al., 2013). Central memory T cells express
CD45RO and CD27simultaneously, while effector memory T cells ex­
press CD45RO. In patients with IM, responsive CD4+ T cells secrete IFN-
γ, which is the dominant cytokine (Meckiff et al., 2019). However, in
healthy carriers, EBV-specific CD4+ memory T cells secrete TNF-α, with
decreased secretion of IFN-γ and CD107a (Lam et al., 2018), indicating
an increase in cytokine polyfunctionality but a decrease in cytotoxic
activity (Meckiff et al., 2019).
2.3.3. Lytic and latent antigens targeted by T cell immune responses
T cell immune responses can target both lytic and latent EBV anti­
gens. The distinction between the two types of antigens is significant, as
lytic antigens are expressed during active viral replication and can be
targeted, while latent antigens are expressed in the absence of replica­
tion and are less accessible to the immune system. The interplay be­
tween CD4+ and CD8+ T cells in targeting different types of EBV
antigens remains an area of active research.
2.3.3.1. CD8+ T cells. As long as individuals undergo primary infection,
whether they develop IM or not, EBV-specific T cell responses targeting
lytic and latent epitopes can be detected in healthy carriers, albeit with
reduced frequency and specificity. The hierarchy of immunodominance
for EBV-specific CD8+ T cells specific to EBV lytic cycle proteins is well-
established, with IE>E>L rank system maintained, which is possibly
determined during primary EBV infection and matched in efficiency for
epitope recognition with CD8+ T cells (de Bleser and Poeck, 1985; Long
et al., 2011; Forrest et al., 2018). For EBV-specific CD8+ T cells specific
M. Liu et al.
to EBV latency antigen, a certain degree of immunodominance hierarchy
is maintained, with the immune response size to latent antigens, rep­
resented by EBNA3A/EBNA3B/EBNA3C > LMP2 > EBNA1 > EBNA2/
EBNA-LP > LMP1 hierarchy (Ning et al., 2011; Munz, 2020). The im­
mune response of EBV-specific CD8+ memory T cell is mainly focused on
the latent epitopes EBNA3s, whereas the response to the lytic epitope is
slightly decreased compared with the acute IM phase (Wang et al.,
2014a).
2.3.3.2. CD4+ T cells. The hierarchy of immunodominance for EBV-
specific CD4+ T cells responses to lytic epitopes is not well-
established, unlike the EBV-specific CD8+ T cells responses (Long
et al., 2011; Munz, 2020). Dowell et al. reported that structural antigen-
specific CD4+ T cells in primary EBV infection exhibit cytotoxic poten­
tial, an ability maintained in structural antigen-specific memory CD4+ T
cells in healthy carriers (Dowell et al., 2021). Similarly, Adhikary et al.
observed the detection of cytotoxic potential of BNRF1-specific CD4+ T
cells in healthy carriers and surmise that BNRF1 may be a common
target of responsive CD4+ T cells (Adhikary et al., 2020). These findings
imply that structural antigens may serve as target antigens in inducing
CD4+ T cells to rapidly eliminate virus-infected cells, thereby presenting
novel possible antigen targets and supporting data for rophylactic vac­
cine devolopment.
Furthermore, the hierarchy of immunodominance for EBV-specific
CD4+ T memory cells response differs from the EBV-specific CD8+ T
memory cells’ targeting of latent epitopes; the EBV-specific CD4+ T
memory cells’ response presents an EBNA1 > EBNA3A/EBNA3B/
EBNA3C > LMP2 > LMP1 hierarchy (Calarota et al., 2013). EBNA1
epitope could elicit a strong CD4+ T cell immune response in some
healthy carriers (Munz et al., 2000). Mullen et al. reported that CD4+
memory T lymphocytes targeting EBNA1 or EBNA3C epitopes appear to
secrete different cytokines upon in vitro antigen stimulation. EBNA1-
specific CD4+ memory T cells are considered Th0-like effector T cells
that could simultaneously produce type I cytokines (IFN-γ) and type II
cytokines (IL-5 and IL-13), whereas EBNA3-specific CD4+ memory T
cells appeared to produce only type I cytokines (Steigerwald-Mullen
et al., 2000).
2.4. Chronic active EBV infection
CAEBV is a lymphoproliferative disease characterized by signifi­
cantly elevated levels of EBV-DNA load in the blood and invasion of
organs by EBV-positive lymphocytes (Kimura and Cohen, 2017). Typi­
cally, the EBV-DNA load of PBMCs in CAEBV patients is higher than in
IM patients, and this characteristic is used for the diagnosis of CAEBV.
According to diagnostic criteria, the diagnostic cut-off EBV-DNA load for
CAEBV approximately is 102.5 copies/μg DNA (Okano et al., 2005;
Subspecialty Group of Infectious Diseases and National Children’s
Epstein-Barr Virus Infection Cooperative, 2021). Decreased numbers of
EBV-specific T cells and increased viral loads in PBMCs are observed in
CAEBV patients, which may be associated with the impaired ability of
EBV-specific T cells to control infection (Tsuge et al., 2001). Addition­
ally, the latent type II pattern in CAEBV patients contributes to the
emergence of high viral loads. This is because infected cells maintain
latent infection by expressing a limited number of latent proteins that
are not easily recognized by the immune system.
The pathogenesis of CAEBV is not yet fully understood, but potential
reasons include dysfunction of EBV-specific CD8+ T cells, which are
unable to eliminate infected cells (Kimura et al., 2005; Xing et al., 2013).
In chronic infections, antigen-specific CD8+ T cells may display
decreased effector function, cytotoxicity, proliferation, and upregula­
tion of coinhibitory receptors, known as “T cell exhaustion”. This phe­
nomenon is not beneficial in disease control and may lead to recurrent
infection (Chatterjee et al., 2019; Busselaar et al., 2020). Several studies
have reported that some patients with CAEBV have mutation in their
8
Infection, Genetics and Evolution 112 (2023) 105443
perforin genes that impairs the function of CTLs. As a result, these in­
dividuals may be unable to control chronic infections, which can prog­
ress to CAEBV (Katano et al., 2004; Collins et al., 2021). Kimura et al.
reported that transformed lymphocytes from patients with CAEBV tested
positive for EBER but negative for Granzyme B, a potent killer factor in
the immune effect of CTL-mediated granulocyte exocytosis (Kimura
et al., 2012). In addition, myeloid-derived suppressor cells (MDSCs) that
develop during chronic infections can suppress host cellular immunity
and cause defective antiviral T cell function, leading to persistent
chronic infection (Gabrilovich and Nagaraj, 2009). Collins et al. found
that patients with CAEBV had a large number of MDSCs that suppressed
the function of effector T cells, resulting in persistent uncontrolled EBV
infection (Collins et al., 2021).
On possible reason for immune suppression is host gene mutation,
with CD27 or CD70 deficiency being common (Guan et al., 2021). In
CAEBV patients, the interaction between CD27 and CD70 is crucial as it
induces protective EBV-specific T cell immunity and immune surveil­
lance of infected-B cells, which is due to the expansion of EBV- specific T
cells (Izawa et al., 2017; Kruger et al., 2020). CD27 is especially vital in
the expansion of lytic EBV antigen-specific CD8+ T cells, and blocking
the CD27-CD70 pathway compromises EBV-specific immune control
(Deng et al., 2021). Izawa et al. pointed out that the deficiency of CD27
and CD70 leads to impaired proliferation and insufficient accumulation
of activated T cells during EBV infection. CD70, which is expressed on
the surface of B cells, provides the necessary co-stimulatory signal for
TCR-mediated proliferation. CD70-dependent proliferating T cells ex­
press high levels of CD27, CD25, and CD45RO but not CD70 and CD62L,
and are able to secrete IFN-γ and TNF-α. This indicates that the preser­
vation of memory T cell immunity shows that CD70-CD27 interactions
affect the proliferation of activated T cells without affecting cytotoxicity,
production of IFN-γ, and differentiation (Izawa et al., 2017).
In patients with CAEBV, pro-inflammatory cytokines are secreted by
activated T cells (Fig. 3B), which can induce hemophagocytic syndrome.
TNF-α plays a dominate role in this process. Murakami et al. found that
the serum TNF-α concentration was ten times higher in CAEBV patients
than in the healthy carrier group. CAEBV patients also exhibited IFNGR1
gene overexpression, with expression levels of IFN-γ at 3.8 times higher
than the control group. In addition, CAEBV patients showed up-
regulated IL-10, IL-2, and INHBA gene expression by about 10 times
higher than the control group (Murakami et al., 2014). Ohga et al.
investigated the relationship between viral load and cytokine gene
expression in activated T cells in CAEBV patients. Results showed that
activated T cells with the surface molecular marker CD3+HLA-DR+ had
higher EBV-DNA copies and increased levels of IL-10, IL-2, and INF- γ
than those with CD3+HLA-DR− (Ohga et al., 2001). Th1 cells secrete IL-
2, TNF-α, and INF-γ, while Th2 cells secrete IL-10. These cytokines may
be produced by activated T cells in CAEBV, contributing to the induction
of clinical symptoms (Ohga et al., 2004; Solomon et al., 2014).
2.5. EBV-associated hemophagocytic lymphohistiocytosis
EBV-induced HLH is the most common subtype of secondary virus-
associated HLH during childhood, and is characterized by uncon­
trolled activation of T lymphocytes and macrophages. This leads to
excessive production of inflammatory cytokines, ultimately causing
extensive tissue damage (Ishii, 2016). Patients with EBV-HLH typically
have a high viral load of EBV and a high number of cells containing
EBERs in their peripheral blood or tissues (Wang et al., 2014b; Ai and
Xie, 2018). Active EBV-HLH develops rapidly and is associated with a
poor prognosis, with a high fatality rate of over 50%. Children with IM
complicated by HLH is most likely to have a primary immunodeficiency
disease (PID), such as X-linked lymphoproliferative disease (XLP) and
CD27 deficiency (Qiang et al., 2012). In patients with EBV-HLH and
XLP, a typical mutation in SH2D1A, which encodes the signaling
lymphocyte activator molecule (SLAM) associated protein (SAP), in­
activates an important cytolytic activating receptor, NKG2D. This
M. Liu et al.
receptor is expressed on the surface of CD8+ T cells, and its inactivation
results in impaired cytotoxic function of CD8+ T cells and disabled
function of controlling infection (Latour and Fischer, 2019).
The study of T cell response in patients with EBV-HLH is limited.
Analysis of PBMCs in some EBV-HLH patients showed that activated T
cell subsets are usually hyperactivated CD8+ T cells that expresses CD38,
whereas the number of CD4+ T cells are decrease (Kasahara et al., 2001;
Yang et al., 2017). The imbalance of immune regulation of CTLs leads to
the production of large amount of inflammatory cytokines, (Fig. 3C),
resulting in severe tissue damage (Kasahara et al., 2001). In EBV-HLH
patients, the secretion of many pro-inflammatory cytokines, such as
IFN-γ and TNF-α, is elevated, while IL-10, which plays a role in immu­
nosuppressive to maintain the balance of inflammation in the immune
system, is also significantly increased. A previous report suggests that
the high level of IL-10 in EBV-HLH patients might be related to HLH
itself (Wada et al., 2013). Interestingly, CD4+ T cells spontaneously
function and complete differentiation process in EBV-HLH patients;
therefore, the function of CD8+ CTLs may be impaired during molecular
immune control processes in patients with EBV-HLH, while the function
of CD4+ T cells is not affected.
3. Prophylactic vaccine and biologics
Prophylactic vaccination can make the population less prone to EBV
infection and contribute to a decrease in severe cases, thus providing
some level of protection in host-virus interaction. However, there are
ongoing investigations into the effectiveness of EBV-related prophylac­
tic vaccines in mitigating the burden of EBV-associated diseases in
general population. As such, the development of a prophylactic vaccine
against EBV remains an urgent concern.
Previous research on prophylactic EBV vaccines has focused on
blocking EBV infection in target cells, primarily through the induction of
neutralizing antibodies. The first clinical trial of a prophylactic vaccine
involved the use of anti-gp350 prophylactic vaccines. Gu et al. observed
high levels of neutralizing antibody against EBV in vaccinated children,
with only three individuals being infected (Gu et al., 1995). Other
promising prophylactic vaccine targets include the proteins gp350, gH,
gL, and gp42, which have shown potential in eliciting higher neutral­
izing antibody titers, although there are currently no clinical trials that
can confirm complete protection against EBV infection (Reynolds, 2013;
Cui et al., 2016; Cohen, 2018; Bu et al., 2019). Recent studies have
focused on the development of novel prophylactic vaccines against EBV.
Kanekiyo et al. developed a ferritin nanoparticle vaccine (ferritin-gp350)
with the target antigen of gp350 and found a 10- to 100-fold increase in
neutralization in a mouse model (Kanekiyo et al., 2015). Heeke et al.
developed a glucopyranosyl lipid A incorporated into the stable emul­
sion (GLA/ SE)-gp350 vaccine targeting gp350 with GLA/SE as an
adjuvant, and detected high neutralizing antibody titers and robust
polyfunctional CD4+ T cell response against gp350 in mice and rabbits
(Heeke et al., 2016). Currently, phase I clinical trials of the Modena
mRNA vaccine (mRNA-1189) containing four antigens, gH, gL, gp42,
and gp220, are underway (Zhong et al., 2022). Epitope vaccines,
antigen-armed antibodies (AgAbs), and virus-like particles (VLP) are
popular vaccine categories that elicit cellular immunity. It is hoped that
these advancements will aid in the development of more effective pro­
phylactic vaccines against EBV.
3.1. Epitope-based vaccine
The simplest vaccine system is EBNA3A epitope peptide-based vac­
cine. This vaccine is made by mixing EBNA3A epitope peptides with
tetanus toxin, which serve as a source of CD4+ T cell, in a water-in-oil
adjuvant. Clinical trial results have shown that inoculation with
EBNA3A epitope peptide successfully induces CD8+ T cell response in
most of subjects. However, although subjects are mostly asymptomatic
after EBV infection, the vaccine fails to prevent EBV infection (Elliott
9
Infection, Genetics and Evolution 112 (2023) 105443
et al., 2008). Chen et al. reported that gB-specific CD8+ T cells obstruct
B-cell transformation in vitro, which facilitates immune surveillance and
the development of the gB subunit vaccine. gB is considered to be a
valuable T cell epitope due to its precise localization and epitopes con­
servation. Therefore, it may be a promising epitope for the development
of subunit vaccines (Chen et al., 2021).
3.2. Antigen-armed antibodies
Another candidate for a vaccine is based on AgAbs, which stimulate
immune response by fusing the antigen to endocytic receptor DEC-205, a
monoclonal antibody against dendritic cells, to deliver the antigen
specifically to antigen-presenting cells (Iberg and Hawiger, 2019;
Padilla-Quirarte et al., 2019). However, laboratory experiments have
shown that DEC-205 tends to process antigens to MHC-II molecules.
Furthermore, presenting DEC-205-targeted antigens to MHC-II mole­
cules elicit an amplified T cell immune response (Leung et al., 2013; Yu
et al., 2015). Recombinant AgAbs vaccines of αDEC-205 equipped with
EBNA1 or LMP1 induce T cell responses, primarily EBNA1-specific CD4+
T cell response and less frequently EBNA1-specific CD8+ T cell immune
responses, resulting in the amplification of specific memory CTLs (Leung
et al., 2013). Further studies have demonstrated that the combination of
recombinant AgAbs vaccines targeting DEC-205 and adenovirus
possibly protect mice from T cell lymphoma challenge. This suggests
that heterologous prime-boost and antigen-antibody conjugates ap­
proaches should be considered to elicit T cell-mediated immune control
against EBV (Gurer et al., 2008; Ruhl et al., 2019). The AgAbs of αDEC-
205 equipped with BZLF1 elicit strong EBV-specific cellular responses in
humanized mice and lead to a remarkable expansion of EBV-specific
memory CTLs, which is a promising vaccine category (Ahmed et al.,
2021).
3.3. Virus-like particles
VLP have been utilized in the development of EBV vaccines. These
VLPs are structurally similar to EBV particles but lack EBV DNA due to
knockout of certain genes. A cell line for EBV-derived VLPs was created
by deleting terminal repeat (TR) involved in DNA packaging and po­
tential EBV oncogenes BZLF1, EBNA2, EBNA3A, 3B, 3C, and LMP1.
Inoculated BALB/c mice showed EBV-specific humoral and cellular
immune responses (Ruiss et al., 2011). Subsequent research discovered
that latent antigen fused with envelope protein could enhance the
antigenic spectrum of EBV VLP. These VLPs containing latent antigens
could stimulate CD8+and CD4+ T cell responses specific to latent pro­
teins, thereby contributing to immune protection against EBV infection
in humanized mice (van Zyl et al., 2018). Therefore, the antigenic cargo
in EBV VLP can be fine-tuned to induce an immune response by
immunodominant latent antigen. A new vaccine platform was devel­
oped by Perez et al. to incorporating gH/gL-EBNA1 or gB-LMP2 with
VLPs. This vaccine candidate was stably produced in CHO cells and
induced neutralizing antibodies in inoculated BALB/c mice, as well as
EBNA1- or LMP2-specific T cell responses (Perez et al., 2017). This
approach provides a viable and effective vaccine system.
4. Conclusions
EBV is a prevalent virus that can cause a significant disease burden.
Understanding T cell immune function controls infection and how it
contributes to disease is essential. However, the mechanisms by which T
cells responses control infection are still not fully understood, and
further investigation is needed, including the immune response in
asymptomatic individuals versus IM patients, the role of cellular im­
munity in CAEBV, and which antigen epitope triggers the strongest EBV-
specific T cell responses. Ultimately, designing an effective prophylactic
vaccine is crucial for mitigating clinical manifestations even if it cannot
prevent primary EBV infection.
M. Liu et al.
Credit author statement
Mengjia Liu wrote the first draft. Ran Wang and Zhengde Xie revised
the manuscript.
Data statement
None.
Ethical statement
This review does not involve the ethical issues.
Declaration of Competing Interest
The authors have declared no conflict of interest.
Data availability
No data was used for the research described in the article.
Acknowledgments
R.W. was supported by the Beijing Natural Science Foundation
(7222059), National Natural Science Foundation of China (82002130).
ZD.X. was supported by the CAMS Innovation Fund for Medical Sciences
(2019-I2M-5-026).
References
Abbott, R.J., Quinn, L.L., Leese, A.M., Scholes, H.M., Pachnio, A., Rickinson, A.B., 2013.
CD8+ T cell responses to lytic EBV infection: late antigen specificities as
subdominant components of the total response. J. Immunol. 191, 5398–5409.
Abbott, R.J., Pachnio, A., Pedroza-Pacheco, I., Leese, A.M., Begum, J., Long, H.M.,
Croom-Carter, D., Stacey, A., Moss, P.A.H., Hislop, A.D., Borrow, P., Rickinson, A.B.,
Bell, A.I., 2017. Asymptomatic primary infection with Epstein-Barr virus:
observations on young adult cases. J. Virol. 91.
Adem, C., Sebo, T.J., Riehle, D.L., Lohse, C.M., Nascimento, A.G., 2002. Recurrent and
non-recurrent pigmented villonodular synovitis 1. Ann. Pathol. 22, 448–452.
Adhikary, D., Damaschke, J., Mautner, J., Behrends, U., 2020. The Epstein-Barr virus
major tegument protein BNRF1 is a common target of cytotoxic CD4(+) T cells.
J. Virol. 94.
Ahmed, E.H., Brooks, E., Sloan, S., Schlotter, S., Jeney, F., Hale, C., Mao, C., Zhang, X.,
McLaughlin, E., Shindiapina, P., Shire, S., Das, M., Prouty, A., Lozanski, G.,
Mamuye, A.T., Abebe, T., Alinari, L., Caligiuri, M.A., Baiocchi, R.A., 2021. Targeted
delivery of BZLF1 to DEC205 drives EBV-protective immunity in a spontaneous
model of EBV-driven lymphoproliferative disease. Vaccines (Basel) 9.
Ai, J., Xie, Z., 2018. Epstein-Barr virus-positive T/NK-cell lymphoproliferative diseases in
Chinese Mainland. Front. Pediatr. 6, 289.
Allen, C.E., McClain, K.L., 2015. Pathophysiology and epidemiology of hemophagocytic
lymphohistiocytosis. Hematol. Am. Soc. Hematol. Educ. Program. 2015, 177–182.
Amyes, E., Hatton, C., Montamat-Sicotte, D., Gudgeon, N., Rickinson, A.B.,
McMichael, A.J., Callan, M.F., 2003. Characterization of the CD4+ T cell response to
Epstein-Barr virus during primary and persistent infection. J. Exp. Med. 198,
903–911.
Antsiferova, O., Muller, A., Ramer, P.C., Chijioke, O., Chatterjee, B., Raykova, A.,
Planas, R., Sospedra, M., Shumilov, A., Tsai, M.H., Delecluse, H.J., Munz, C., 2014.
Adoptive transfer of EBV specific CD8+ T cell clones can transiently control EBV
infection in humanized mice. PLoS Pathog. 10, e1004333.
Apcher, S., Komarova, A., Daskalogianni, C., Yin, Y., Malbert-Colas, L., Fahraeus, R.,
2009. mRNA translation regulation by the Gly-Ala repeat of Epstein-Barr virus
nuclear antigen 1. J. Virol. 83, 1289–1298.
Appay, V., Zaunders, J.J., Papagno, L., Sutton, J., Jaramillo, A., Waters, A.,
Easterbrook, P., Grey, P., Smith, D., McMichael, A.J., Cooper, D.A., Rowland-
Jones, S.L., Kelleher, A.D., 2002. Characterization of CD4(+) CTLs ex vivo.
J. Immunol. 168, 5954–5958.
Arai, A., 2021. Chronic active Epstein-Barr virus infection: the elucidation of the
pathophysiology and the development of therapeutic methods. Microorganisms 9.
Bailey, R.E., 1994. Diagnosis and treatment of infectious mononucleosis. Am. Fam.
Physician 49, 879–888.
Balfour Jr., H.H., Odumade, O.A., Schmeling, D.O., Mullan, B.D., Ed, J.A., Knight, J.A.,
Vezina, H.E., Thomas, W., Hogquist, K.A., 2013. Behavioral, virologic, and
immunologic factors associated with acquisition and severity of primary Epstein-
Barr virus infection in university students. J. Infect. Dis. 207, 80–88.
Balfour Jr., H.H., Dunmire, S.K., Hogquist, K.A., 2015. Infectious mononucleosis. Clin.
Transl. Immunol. 4, e33.
10
Infection, Genetics and Evolution 112 (2023) 105443
Barros, M.H.M., Vera-Lozada, G., Segges, P., Hassan, R., Niedobitek, G., 2019. Revisiting
the tissue microenvironment of infectious mononucleosis: identification of EBV
infection in T cells and deep characterization of immune profiles. Front. Immunol.
10, 146.
Bollard, C.M., Cohen, J.I., 2018. How I treat T-cell chronic active Epstein-Barr virus
disease. Blood 131, 2899–2905.
Borza, C.M., Hutt-Fletcher, L.M., 2002. Alternate replication in B cells and epithelial cells
switches tropism of Epstein-Barr virus. Nat. Med. 8, 594–599.
Brooks, J.M., Long, H.M., Tierney, R.J., Shannon-Lowe, C., Leese, A.M., Fitzpatrick, M.,
Taylor, G.S., Rickinson, A.B., 2016. Early T cell recognition of B cells following
Epstein-Barr virus infection: identifying potential targets for prophylactic
vaccination. PLoS Pathog. 12, e1005549.
Bu, W., Joyce, M.G., Nguyen, H., Banh, D.V., Aguilar, F., Tariq, Z., Yap, M.L.,
Tsujimura, Y., Gillespie, R.A., Tsybovsky, Y., Andrews, S.F., Narpala, S.R.,
McDermott, A.B., Rossmann, M.G., Yasutomi, Y., Nabel, G.J., Kanekiyo, M.,
Cohen, J.I., 2019. Immunization with components of the viral fusion apparatus
elicits antibodies that neutralize Epstein-Barr virus in B cells and epithelial cells.
Immunity 50, 1305–1316 e1306.
Busselaar, J., Tian, S., van Eenennaam, H., Borst, J., 2020. Helpless priming sends CD8(
+) T cells on the road to exhaustion. Front. Immunol. 11, 592569.
Calarota, S.A., Chiesa, A., Zelini, P., Comolli, G., Minoli, L., Baldanti, F., 2013. Detection
of Epstein-Barr virus-specific memory CD4+ T cells using a peptide-based cultured
enzyme-linked immunospot assay. Immunology 139, 533–544.
Callan, M.F., Tan, L., Annels, N., Ogg, G.S., Wilson, J.D., O’Callaghan, C.A., Steven, N.,
McMichael, A.J., Rickinson, A.B., 1998. Direct visualization of antigen-specific CD8
+ T cells during the primary immune response to Epstein-Barr virus in vivo. J. Exp.
Med. 187, 1395–1402.
Catalina, M.D., Sullivan, J.L., Brody, R.M., Luzuriaga, K., 2002. Phenotypic and
functional heterogeneity of EBV epitope-specific CD8+ T cells. J. Immunol. 168,
4184–4191.
Chai, L., Ge, X., Biswas, M.K., Deng, X., 2011. Molecular analysis and expression of a
floral organ-relative F-box gene isolated from ‘Zigui shatian’ pummelo (Citrus
grandis Osbeck). Mol. Biol. Rep. 38, 4429–4436.
Chatterjee, B., Deng, Y., Holler, A., Nunez, N., Azzi, T., Vanoaica, L.D., Muller, A.,
Zdimerova, H., Antsiferova, O., Zbinden, A., Capaul, R., Dreyer, J.H., Nadal, D.,
Becher, B., Robinson, M.D., Stauss, H., Munz, C., 2019. CD8+ T cells retain
protective functions despite sustained inhibitory receptor expression during Epstein-
Barr virus infection in vivo. PLoS Pathog. 15, e1007748.
Chen, G., Shankar, P., Lange, C., Valdez, H., Skolnik, P.R., Wu, L., Manjunath, N.,
Lieberman, J., 2001. CD8 T cells specific for human immunodeficiency virus,
Epstein-Barr virus, and cytomegalovirus lack molecules for homing to lymphoid sites
of infection. Blood 98, 156–164.
Chen, Y., Sun, H., Liu, G., Wang, B., Wang, F., Sun, B., Yao, K., 2009. EBV LMP2A-specific
T cell immune responses elicited by dendritic cells loaded with LMP2A protein. Cell.
Mol. Immunol. 6, 269–276.
Chen, J., Sathiyamoorthy, K., Zhang, X., Schaller, S., Perez White, B.E., Jardetzky, T.S.,
Longnecker, R., 2018. Ephrin receptor A2 is a functional entry receptor for Epstein-
Barr virus. Nat. Microbiol. 3, 172–180.
Chen, H., Zhang, X., Zhang, S., Duan, X., Xiang, T., Zhou, X., Zhang, W., Zhang, X.,
Feng, Q., Kang, Y., Li, J., Deng, L., Wang, L., Lv, X., Zeng, M., Zeng, Y.X., Xu, M.,
2021. T cell epitope screening of Epstein-Barr virus fusion protein gB. J. Virol.
https://doi.org/10.1128/JVI.00081-21.
Chesnokova, L.S., Hutt-Fletcher, L.M., 2011. Fusion of Epstein-Barr virus with epithelial
cells can be triggered by alphavbeta5 in addition to alphavbeta6 and alphavbeta8,
and integrin binding triggers a conformational change in glycoproteins gHgL.
J. Virol. 85, 13214–13223.
Cirac, A., Stutzle, S., Dieckmeyer, M., Adhikary, D., Moosmann, A., Korber, N., Bauer, T.,
Witter, K., Delecluse, H.J., Behrends, U., Mautner, J., 2018. Epstein-Barr virus strain
heterogeneity impairs human T-cell immunity. Cancer Immunol. Immunother. 67,
663–674.
Cirac, A., Poirey, R., Dieckmeyer, M., Witter, K., Delecluse, H.J., Behrends, U.,
Mautner, J., 2021. Immunoinformatic analysis reveals antigenic heterogeneity of
Epstein-Barr virus is immune-driven. Front. Immunol. 12, 796379.
Cohen, J.I., 2000. Epstein-Barr virus infection. N. Engl. J. Med. 343, 481–492.
Cohen, J.I., 2018. Vaccine development for Epstein-Barr virus. Adv. Exp. Med. Biol.
1045, 477–493.
Collins, P.J., Fox, C.P., George, L., Pearce, H., Ryan, G., De Santo, C., Mussai, F.,
Lewis, D., Long, H., Shannon-Lowe, C., 2021. Characterizing EBV-associated
lymphoproliferative diseases and the role of myeloid-derived suppressor cells. Blood
137, 203–215.
Connolly, S.A., Jardetzky, T.S., Longnecker, R., 2021. The structural basis of herpesvirus
entry. Nat. Rev. Microbiol. 19, 110–121.
Correia, S., Palser, A., Elgueta Karstegl, C., Middeldorp, J.M., Ramayanti, O., Cohen, J.I.,
Hildesheim, A., Fellner, M.D., Wiels, J., White, R.E., Kellam, P., Farrell, P.J., 2017.
Natural variation of Epstein-Barr virus genes, proteins, and primary MicroRNA.
J. Virol. 91.
Cruchley, A.T., Williams, D.M., Niedobitek, G., Young, L.S., 1997. Epstein-Barr virus:
biology and disease. Oral Dis. 3 (Suppl. 1), S156–S163.
Cui, X., Cao, Z., Chen, Q., Arjunaraja, S., Snow, A.L., Snapper, C.M., 2016. Rabbits
immunized with Epstein-Barr virus gH/gL or gB recombinant proteins elicit higher
serum virus neutralizing activity than gp350. Vaccine 34, 4050–4055.
de Bleser, R., Poeck, K., 1985. Analysis of prosody in the spontaneous speech of patients
with CV-recurring utterances. Cortex 21, 405–415.
Deng, Y., Chatterjee, B., Zens, K., Zdimerova, H., Muller, A., Schuhmachers, P., Ligeon, L.
A., Bongiovanni, A., Capaul, R., Zbinden, A., Holler, A., Stauss, H.,
M. Liu et al.
Hammerschmidt, W., Munz, C., 2021. CD27 is required for protective lytic EBV
antigen-specific CD8+ T-cell expansion. Blood 137, 3225–3236.
Dharnidharka, V.R., Webster, A.C., Martinez, O.M., Preiksaitis, J.K., Leblond, V.,
Choquet, S., 2016. Post-transplant lymphoproliferative disorders. Nat. Rev. Dis.
Primers 2, 15088.
Dowell, A.C., Haigh, T.A., Ryan, G.B., Turner, J.E., Long, H.M., Taylor, G.S., 2021.
Cytotoxic CD4+ T-cells specific for EBV capsid antigen BORF1 are maintained in
long-term latently infected healthy donors. PLoS Pathog. 17, e1010137.
Dunmire, S.K., Hogquist, K.A., Balfour, H.H., 2015. Infectious mononucleosis. Curr. Top.
Microbiol. Immunol. 390, 211–240.
Dunmire, S.K., Verghese, P.S., Balfour Jr., H.H., 2018. Primary Epstein-Barr virus
infection. J. Clin. Virol. 102, 84–92.
Dunne, P.J., Faint, J.M., Gudgeon, N.H., Fletcher, J.M., Plunkett, F.J., Soares, M.V.,
Hislop, A.D., Annels, N.E., Rickinson, A.B., Salmon, M., Akbar, A.N., 2002. Epstein-
Barr virus-specific CD8(+) T cells that re-express CD45RA are apoptosis-resistant
memory cells that retain replicative potential. Blood 100, 933–940.
Elliott, S.L., Suhrbier, A., Miles, J.J., Lawrence, G., Pye, S.J., Le, T.T., Rosenstengel, A.,
Nguyen, T., Allworth, A., Burrows, S.R., Cox, J., Pye, D., Moss, D.J., Bharadwaj, M.,
2008. Phase I trial of a CD8+ T-cell peptide epitope-based vaccine for infectious
mononucleosis. J. Virol. 82, 1448–1457.
El-Mallawany, N.K., Curry, C.V., Allen, C.E., 2022. Haemophagocytic
lymphohistiocytosis and Epstein-Barr virus: a complex relationship with diverse
origins, expression and outcomes. Br. J. Haematol. 196, 31–44.
Epstein, M.A., Achong, B.G., Barr, Y.M., 1964. Virus particles in cultured lymphoblasts
from Burkitt’s lymphoma. Lancet 1, 702–703.
Farrell, P.J., 2015. Epstein-Barr Virus Strain Variation. Curr. Top. Microbiol. Immunol.
390, 45–69.
Farrell, P.J., 2019. Epstein-Barr virus and cancer. Annu. Rev. Pathol. 14, 29–53.
Fedyanina, O.S., Filippova, A.E., Demina, O.I., Zhuliabina, O.A., Tikhomirov, D.S.,
Filatov, A.V., Chebotareva, T.A., Kuznetsova, S.A., 2021. The nature and clinical
significance of atypical mononuclear cells in infectious mononucleosis caused by the
Epstein-Barr virus in children. J. Infect. Dis. 223, 1699–1706.
Forrest, C., Hislop, A.D., Rickinson, A.B., Zuo, J., 2018. Proteome-wide analysis of CD8+
T cell responses to EBV reveals differences between primary and persistent infection.
PLoS Pathog. 14, e1007110.
Fujiwara, S., Nakamura, H., 2020. Chronic active Epstein-Barr virus infection: is it
immunodeficiency, malignancy, or both? Cancers (Basel) 12.
Gabrilovich, D.I., Nagaraj, S., 2009. Myeloid-derived suppressor cells as regulators of the
immune system. Nat. Rev. Immunol. 9, 162–174.
Gu, S.Y., Huang, T.M., Ruan, L., Miao, Y.H., Lu, H., Chu, C.M., Motz, M., Wolf, H., 1995.
First EBV vaccine trial in humans using recombinant vaccinia virus expressing the
major membrane antigen. Dev. Biol. Stand. 84, 171–177.
Guan, Y.Q., Shen, K.F., Yang, L., Cai, H.D., Zhang, M.L., Wang, J.C., Long, X.L., Xiong, J.,
Gu, J., Zhang, P.L., Xiao, M., Zhang, W., Zhou, J.F., 2021. Inherited genetic
susceptibility to nonimmunosuppressed Epstein-Barr virus-associated T/NK-cell
lymphoproliferative diseases in Chinese patients. Curr. Med. Sci. 41, 482–490.
Gurer, C., Strowig, T., Brilot, F., Pack, M., Trumpfheller, C., Arrey, F., Park, C.G.,
Steinman, R.M., Munz, C., 2008. Targeting the nuclear antigen 1 of Epstein-Barr
virus to the human endocytic receptor DEC-205 stimulates protective T-cell
responses. Blood 112, 1231–1239.
Heeke, D.S., Lin, R., Rao, E., Woo, J.C., McCarthy, M.P., Marshall, J.D., 2016.
Identification of GLA/SE as an effective adjuvant for the induction of robust humoral
and cell-mediated immune responses to EBV-gp350 in mice and rabbits. Vaccine 34,
2562–2569.
Herbert, K.M., Pimienta, G., 2016. Consideration of Epstein-Barr virus-encoded
noncoding RNAs EBER1 and EBER2 as a functional backup of viral oncoprotein
latent membrane protein 1. mBio 7 e01926–01915.
Hislop, A.D., Gudgeon, N.H., Callan, M.F., Fazou, C., Hasegawa, H., Salmon, M.,
Rickinson, A.B., 2001. EBV-specific CD8+ T cell memory: relationships between
epitope specificity, cell phenotype, and immediate effector function. J. Immunol.
167, 2019–2029.
Hislop, A.D., Kuo, M., Drake-Lee, A.B., Akbar, A.N., Bergler, W., Hammerschmitt, N.,
Khan, N., Palendira, U., Leese, A.M., Timms, J.M., Bell, A.I., Buckley, C.D.,
Rickinson, A.B., 2005. Tonsillar homing of Epstein-Barr virus-specific CD8+ T cells
and the virus-host balance. J. Clin. Invest. 115, 2546–2555.
Hislop, A.D., Taylor, G.S., Sauce, D., Rickinson, A.B., 2007. Cellular responses to viral
infection in humans: lessons from Epstein-Barr virus. Annu. Rev. Immunol. 25,
587–617.
Hoshino, Y., Morishima, T., Kimura, H., Nishikawa, K., Tsurumi, T., Kuzushima, K.,
1999. Antigen-driven expansion and contraction of CD8+-activated T cells in
primary EBV infection. J. Immunol. 163, 5735–5740.
Hoshino, Y., Nishikawa, K., Ito, Y., Kuzushima, K., Kimura, H., 2011. Kinetics of Epstein-
Barr virus load and virus-specific CD8+ T cells in acute infectious mononucleosis.
J. Clin. Virol. 50, 244–246.
Hu, H., Deng, H., Bi, J., Xu, Y., Li, S., Xie, Y., Sun, X., Wang, D., Li, X., Ouyang, W.,
Hu, B., Zhang, Y., Tang, H., Fang, C., Zhang, H., Guo, L., Wang, C., Wang, T.,
Yang, F., Jiang, T., Xie, Z., Liu, G., 2021. Clinical characteristics and effectiveness of
antiviral agents in hospitalized children with infectious mononucleosis in China: a
multicenter retrospective study. Pediatr. Investig. 5, 188–194.
Iberg, C.A., Hawiger, D., 2019. Advancing immunomodulation by in vivo antigen
delivery to DEC-205 and other cell surface molecules using recombinant chimeric
antibodies. Int. Immunopharmacol. 73, 575–580.
Imashuku, S., Morimoto, A., Ishii, E., 2021. Virus-triggered secondary hemophagocytic
lymphohistiocytosis. Acta Paediatr. 110, 2729–2736.
Ishii, E., 2016. Hemophagocytic lymphohistiocytosis in children: pathogenesis and
treatment. Front. Pediatr. 4, 47.
11
Infection, Genetics and Evolution 112 (2023) 105443
Izawa, K., Martin, E., Soudais, C., Bruneau, J., Boutboul, D., Rodriguez, R., Lenoir, C.,
Hislop, A.D., Besson, C., Touzot, F., Picard, C., Callebaut, I., de Villartay, J.P.,
Moshous, D., Fischer, A., Latour, S., 2017. Inherited CD70 deficiency in humans
reveals a critical role for the CD70-CD27 pathway in immunity to Epstein-Barr virus
infection. J. Exp. Med. 214, 73–89.
Jayasooriya, S., de Silva, T.I., Njie-jobe, J., Sanyang, C., Leese, A.M., Bell, A.I.,
McAulay, K.A., Yanchun, P., Long, H.M., Dong, T., Whittle, H.C., Rickinson, A.B.,
Rowland-Jones, S.L., Hislop, A.D., Flanagan, K.L., 2015. Early virological and
immunological events in asymptomatic Epstein-Barr virus infection in African
children. PLoS Pathog. 11, e1004746.
Jenson, H.B., 2000. Acute complications of Epstein-Barr virus infectious mononucleosis.
Curr. Opin. Pediatr. 12, 263–268.
Kanekiyo, M., Bu, W., Joyce, M.G., Meng, G., Whittle, J.R., Baxa, U., Yamamoto, T.,
Narpala, S., Todd, J.P., Rao, S.S., McDermott, A.B., Koup, R.A., Rossmann, M.G.,
Mascola, J.R., Graham, B.S., Cohen, J.I., Nabel, G.J., 2015. Rational design of an
Epstein-Barr virus vaccine targeting the receptor-binding site. Cell 162, 1090–1100.
Kasahara, Y., Yachie, A., Takei, K., Kanegane, C., Okada, K., Ohta, K., Seki, H.,
Igarashi, N., Maruhashi, K., Katayama, K., Katoh, E., Terao, G., Sakiyama, Y.,
Koizumi, S., 2001. Differential cellular targets of Epstein-Barr virus (EBV) infection
between acute EBV-associated hemophagocytic lymphohistiocytosis and chronic
active EBV infection. Blood 98, 1882–1888.
Katano, H., Ali, M.A., Patera, A.C., Catalfamo, M., Jaffe, E.S., Kimura, H., Dale, J.K.,
Straus, S.E., Cohen, J.I., 2004. Chronic active Epstein-Barr virus infection associated
with mutations in perforin that impair its maturation. Blood 103, 1244–1252.
Kimura, H., Cohen, J.I., 2017. Chronic active Epstein-Barr virus disease. Front. Immunol.
8, 1867.
Kimura, H., Hoshino, Y., Hara, S., Sugaya, N., Kawada, J., Shibata, Y., Kojima, S.,
Nagasaka, T., Kuzushima, K., Morishima, T., 2005. Differences between T cell-type
and natural killer cell-type chronic active Epstein-Barr virus infection. J. Infect. Dis.
191, 531–539.
Kimura, H., Ito, Y., Suzuki, R., Nishiyama, Y., 2008. Measuring Epstein-Barr virus (EBV)
load: the significance and application for each EBV-associated disease. Rev. Med.
Virol. 18, 305–319.
Kimura, H., Ito, Y., Kawabe, S., Gotoh, K., Takahashi, Y., Kojima, S., Naoe, T., Esaki, S.,
Kikuta, A., Sawada, A., Kawa, K., Ohshima, K., Nakamura, S., 2012. EBV-associated
T/NK-cell lymphoproliferative diseases in nonimmunocompromised hosts:
prospective analysis of 108 cases. Blood 119, 673–686.
Kruger, R., Martin, E., Dmytrus, J., Feiterna-Sperling, C., Meisel, C., Unterwalder, N.,
Kolsch, U., Wahn, V., Hofmann, J., Korn, P., Latour, S., Boztug, K., von Bernuth, H.,
2020. CD70 deficiency associated with chronic Epstein-Barr virus infection,
recurrent airway infections and severe gingivitis in a 24-year-old woman. Front.
Immunol. 11, 1593.
Lam, J.K.P., Hui, K.F., Ning, R.J., Xu, X.Q., Chan, K.H., Chiang, A.K.S., 2018. Emergence
of CD4+ and CD8+ polyfunctional T cell responses against immunodominant lytic
and latent EBV antigens in children with primary EBV infection. Front. Microbiol. 9,
416.
Landais, E., Saulquin, X., Scotet, E., Trautmann, L., Peyrat, M.A., Yates, J.L., Kwok, W.
W., Bonneville, M., Houssaint, E., 2004. Direct killing of Epstein-Barr virus (EBV)-
infected B cells by CD4 T cells directed against the EBV lytic protein BHRF1. Blood
103, 1408–1416.
Lanzavecchia, A., 1985 Apr 11-17. Antigen-specific interaction between T and B cells.
Nature 314 (6011), 537–539. https://doi.org/10.1038/314537a0.
Latour, S., Fischer, A., 2019. Signaling pathways involved in the T-cell-mediated
immunity against Epstein-Barr virus: lessons from genetic diseases. Immunol. Rev.
291, 174–189.
Lee, C.P., Chen, M.R., 2021. Conquering the nuclear envelope barriers by EBV lytic
replication. Viruses 13.
Leen, A., Meij, P., Redchenko, I., Middeldorp, J., Bloemena, E., Rickinson, A., Blake, N.,
2001. Differential immunogenicity of Epstein-Barr virus latent-cycle proteins for
human CD4(+) T-helper 1 responses. J. Virol. 75, 8649–8659.
Lelic, A., Verschoor, C.P., Ventresca, M., Parsons, R., Evelegh, C., Bowdish, D., Betts, M.
R., Loeb, M.B., Bramson, J.L., 2012. The polyfunctionality of human memory CD8+
T cells elicited by acute and chronic virus infections is not influenced by age. PLoS
Pathog. 8, e1003076.
Leung, C.S., Maurer, M.A., Meixlsperger, S., Lippmann, A., Cheong, C., Zuo, J., Haigh, T.
A., Taylor, G.S., Munz, C., 2013. Robust T-cell stimulation by Epstein-Barr virus-
transformed B cells after antigen targeting to DEC-205. Blood 121, 1584–1594.
Levitskaya, J., Sharipo, A., Leonchiks, A., Ciechanover, A., Masucci, M.G., 1997.
Inhibition of ubiquitin/proteasome-dependent protein degradation by the Gly-Ala
repeat domain of the Epstein-Barr virus nuclear antigen 1. Proc. Natl. Acad. Sci. U. S.
A. 94, 12616–12621.
Li, Q., Spriggs, M.K., Kovats, S., Turk, S.M., Comeau, M.R., Nepom, B., Hutt-Fletcher, L.
M., 1997. Epstein-Barr virus uses HLA class II as a cofactor for infection of B
lymphocytes. J. Virol. 71, 4657–4662.
Li, Z., Zhang, X., Dong, L., Pang, J., Xu, M., Zhong, Q., Zeng, M.S., Yu, X., 2020. CryoEM
structure of the tegumented capsid of Epstein-Barr virus. Cell Res. 30, 873–884.
Liu, W., Cui, Y., Wang, C., Li, Z., Gong, D., Dai, X., Bi, G.Q., Sun, R., Zhou, Z.H., 2020.
Structures of capsid and capsid-associated tegument complex inside the Epstein-Barr
virus. Nat. Microbiol. 5, 1285–1298.
Liu, M., Wang, X., Zhang, L., Feng, G., Zeng, Y., Wang, R., Xie, Z., 2022. Epidemiological
characteristics and disease burden of infectious mononucleosis in hospitalized
children in China: a nationwide retrospective study. Virol. Sin. https://doi.org/
10.1016/j.virs.2022.07.007.
Long, H.M., Leese, A.M., Chagoury, O.L., Connerty, S.R., Quarcoopome, J., Quinn, L.L.,
Shannon-Lowe, C., Rickinson, A.B., 2011. Cytotoxic CD4+ T cell responses to EBV
M. Liu et al.
contrast with CD8 responses in breadth of lytic cycle antigen choice and in lytic cycle
recognition. J. Immunol. 187, 92–101.
Long, H.M., Chagoury, O.L., Leese, A.M., Ryan, G.B., James, E., Morton, L.T., Abbott, R.
J., Sabbah, S., Kwok, W., Rickinson, A.B., 2013. MHC II tetramers visualize human
CD4+ T cell responses to Epstein-Barr virus infection and demonstrate atypical
kinetics of the nuclear antigen EBNA1 response. J. Exp. Med. 210, 933–949.
MacArthur, G.J., Wilson, A.D., Birchall, M.A., Morgan, A.J., 2007. Primary CD4+ T-cell
responses provide both helper and cytotoxic functions during Epstein-Barr virus
infection and transformation of fetal cord blood B cells. J. Virol. 81, 4766–4775.
Marshall, N.A., Culligan, D.J., Johnston, P.W., Millar, C., Barker, R.N., Vickers, M.A.,
2007. CD4(+) T-cell responses to Epstein-Barr virus (EBV) latent membrane protein
1 in infectious mononucleosis and EBV-associated non-Hodgkin lymphoma: Th1 in
active disease but Tr1 in remission. Br. J. Haematol. 139, 81–89.
Martorelli, D., Muraro, E., Merlo, A., Turrini, R., Rosato, A., Dolcetti, R., 2010. Role of
CD4+ cytotoxic T lymphocytes in the control of viral diseases and cancer. Int. Rev.
Immunol. 29, 371–402.
McKenzie, J., El-Guindy, A., 2015. Epstein-Barr virus lytic cycle reactivation. Curr. Top.
Microbiol. Immunol. 391, 237–261.
Meckiff, B.J., Ladell, K., McLaren, J.E., Ryan, G.B., Leese, A.M., James, E.A., Price, D.A.,
Long, H.M., 2019. Primary EBV infection induces an acute wave of activated
antigen-specific cytotoxic CD4(+) T cells. J. Immunol. 203, 1276–1287.
Minarovits, J., 2006. Epigenotypes of latent herpesvirus genomes. Curr. Top. Microbiol.
Immunol. 310, 61–80.
Molesworth, S.J., Lake, C.M., Borza, C.M., Turk, S.M., Hutt-Fletcher, L.M., 2000. Epstein-
Barr virus gH is essential for penetration of B cells but also plays a role in attachment
of virus to epithelial cells. J. Virol. 74, 6324–6332.
Montesoro, E., Castelli, G., Morsilli, O., Nisini, R., Stafsnes, M.H., Care, A., Peschle, C.,
Chelucci, C., 2006. Unilineage monocytopoiesis in hematopoietic progenitor culture:
switching cytokine treatment at all Mo developmental stages induces differentiation
into dendritic cells. Cell Death Differ. 13, 250–259.
Morales, O., Depil, S., Mrizak, D., Martin, N., Ndour, P.A., Dufosse, F., Miroux, C.,
Coll, J., de Launoit, Y., Auriault, C., Pancre, V., Delhem, N., 2012. EBV latency II-
derived peptides induce a specific CD4+ cytotoxic T-cell activity and not a CD4+
regulatory T-cell response. J. Immunother. 35, 254–266.
Munz, C., 2020. Redirecting T cells against Epstein-Barr virus infection and associated
oncogenesis. Cells 9.
Munz, C., Bickham, K.L., Subklewe, M., Tsang, M.L., Chahroudi, A., Kurilla, M.G.,
Zhang, D., O’Donnell, M., Steinman, R.M., 2000. Human CD4(+) T lymphocytes
consistently respond to the latent Epstein-Barr virus nuclear antigen EBNA1. J. Exp.
Med. 191, 1649–1660.
Murakami, M., Hashida, Y., Imajoh, M., Maeda, A., Kamioka, M., Senda, Y., Sato, T.,
Fujieda, M., Wakiguchi, H., Daibata, M., 2014. PCR array analysis of gene expression
profiles in chronic active Epstein-Barr virus infection. Microbes Infect. 16, 581–586.
Murata, T., 2014. Regulation of Epstein-Barr virus reactivation from latency. Microbiol.
Immunol. 58, 307–317.
Ning, R.J., Xu, X.Q., Chan, K.H., Chiang, A.K., 2011. Long-term carriers generate Epstein-
Barr virus (EBV)-specific CD4(+) and CD8(+) polyfunctional T-cell responses which
show immunodominance hierarchies of EBV proteins. Immunology 134, 161–171.
Odumade, O.A., Hogquist, K.A., Balfour Jr., H.H., 2011. Progress and problems in
understanding and managing primary Epstein-Barr virus infections. Clin. Microbiol.
Rev. 24, 193–209.
Ohga, S., Nomura, A., Takada, H., Ihara, K., Kawakami, K., Yanai, F., Takahata, Y.,
Tanaka, T., Kasuga, N., Hara, T., 2001. Epstein-Barr virus (EBV) load and cytokine
gene expression in activated T cells of chronic active EBV infection. J. Infect. Dis.
183, 1–7.
Ohga, S., Nomura, A., Takada, H., Tanaka, T., Furuno, K., Takahata, Y., Kinukawa, N.,
Fukushima, N., Imai, S., Hara, T., 2004. Dominant expression of interleukin-10 and
transforming growth factor-beta genes in activated T-cells of chronic active Epstein-
Barr virus infection. J. Med. Virol. 74, 449–458.
Okano, M., Kawa, K., Kimura, H., Yachie, A., Wakiguchi, H., Maeda, A., Imai, S.,
Ohga, S., Kanegane, H., Tsuchiya, S., Morio, T., Mori, M., Yokota, S., Imashuku, S.,
2005. Proposed guidelines for diagnosing chronic active Epstein-Barr virus infection.
Am. J. Hematol. 80, 64–69.
Padilla-Quirarte, H.O., Badillo-Godinez, O., Gutierrez-Xicotencatl, L., Acevedo-
Betancur, Y., Luna-Andon, J.D., Montiel-Hernandez, J.L., Lopez-Guerrero, D.V.,
Esquivel-Guadarrama, F., 2019. Targeting M2e to DEC-205 induces an enhanced
serum antibody-dependent heterosubtypic protection against influenza A virus
infection. Vaccine 37, 2624–2633.
Perez, E.M., Foley, J., Tison, T., Silva, R., Ogembo, J.G., 2017. Novel Epstein-Barr virus-
like particles incorporating gH/gL-EBNA1 or gB-LMP2 induce high neutralizing
antibody titers and EBV-specific T-cell responses in immunized mice. Oncotarget 8,
19255–19273.
Precopio, M.L., Sullivan, J.L., Willard, C., Somasundaran, M., Luzuriaga, K., 2003.
Differential kinetics and specificity of EBV-specific CD4+ and CD8+ T cells during
primary infection. J. Immunol. 170, 2590–2598.
Price, A.M., Luftig, M.A., 2014. Dynamic Epstein-Barr virus gene expression on the path
to B-cell transformation. Adv. Virus Res. 88, 279–313.
Qian, J., Yu, Q., Chen, G., Wang, M., Zhao, Z., Zhang, Y., Qiu, L., 2020. Altered ratio of
circulating follicular regulatory T cells and follicular helper T cells during primary
EBV infection. Clin. Exp. Med. 20, 373–380.
Qiang, Q., Zhengde, X., Shuang, Y., Kunling, S., 2012. Prevalence of coinfection in
children with Epstein-Barr virus-associated hemophagocytic lymphohistiocytosis.
J. Pediatr. Hematol. Oncol. 34, e45–e48.
Rajnavolgyi, E., Nagy, N., Thuresson, B., Dosztanyi, Z., Simon, A., Simon, I., Karr, R.W.,
Ernberg, I., Klein, E., Falk, K.I., 2000. A repetitive sequence of Epstein-Barr virus
12
Infection, Genetics and Evolution 112 (2023) 105443
nuclear antigen 6 comprises overlapping T cell epitopes which induce HLA-DR-
restricted CD4(+) T lymphocytes. Int. Immunol. 12, 281–293.
Ressing, M.E., van Leeuwen, D., Verreck, F.A., Gomez, R., Heemskerk, B., Toebes, M.,
Mullen, M.M., Jardetzky, T.S., Longnecker, R., Schilham, M.W., Ottenhoff, T.H.,
Neefjes, J., Schumacher, T.N., Hutt-Fletcher, L.M., Wiertz, E.J., 2003. Interference
with T cell receptor-HLA-DR interactions by Epstein-Barr virus gp42 results in
reduced T helper cell recognition. Proc. Natl. Acad. Sci. U. S. A. 100, 11583–11588.
Ressing, M.E., van Gent, M., Gram, A.M., Hooykaas, M.J., Piersma, S.J., Wiertz, E.J.,
2015. Immune evasion by Epstein-Barr virus. Curr. Top. Microbiol. Immunol. 391,
355–381.
Reynolds, A.M., 2013. Selection pressures give composite correlated random walks Levy
walk characteristics. J. Theor. Biol. 332, 117–122.
Ruhl, J., Citterio, C., Engelmann, C., Haigh, T., Dzionek, A., Dreyer, J., Khanna, R.,
Taylor, G.S., Wilson, J.B., Leung, C.S., Munz, C., 2019. Heterologous prime-boost
vaccination protects against EBV antigen-expressing lymphomas. J. Clin. Invest. 129,
2071–2087.
Ruhl, J., Leung, C.S., Munz, C., 2020. Vaccination against the Epstein-Barr virus. Cell.
Mol. Life Sci. 77, 4315–4324.
Ruiss, R., Jochum, S., Wanner, G., Reisbach, G., Hammerschmidt, W., Zeidler, R., 2011.
A virus-like particle-based Epstein-Barr virus vaccine. J. Virol. 85, 13105–13113.
Shafiee, A., Shamsi, S., Kohandel Gargari, O., Beiky, M., Allahkarami, M.M., Miyanaji, A.
B., Aghajanian, S., Mozhgani, S.H., 2022. EBV associated T- and NK-cell
lymphoproliferative diseases: a comprehensive overview of clinical manifestations
and novel therapeutic insights. Rev. Med. Virol. 32, e2328.
Silins, S.L., Sherritt, M.A., Silleri, J.M., Cross, S.M., Elliott, S.L., Bharadwaj, M., Le, T.T.,
Morrison, L.E., Khanna, R., Moss, D.J., Suhrbier, A., Misko, I.S., 2001. Asymptomatic
primary Epstein-Barr virus infection occurs in the absence of blood T-cell repertoire
perturbations despite high levels of systemic viral load. Blood 98, 3739–3744.
Singavi, A.K., Harrington, A.M., Fenske, T.S., 2015. Post-transplant lymphoproliferative
disorders. Cancer Treat. Res. 165, 305–327.
Soares, M.V., Plunkett, F.J., Verbeke, C.S., Cook, J.E., Faint, J.M., Belaramani, L.L.,
Fletcher, J.M., Hammerschmitt, N., Rustin, M., Bergler, W., Beverley, P.C.,
Salmon, M., Akbar, A.N., 2004. Integration of apoptosis and telomere erosion in
virus-specific CD8+ T cells from blood and tonsils during primary infection. Blood
103, 162–167.
Solomon, S.R., Sizemore, C.A., Zhang, X., Brown, S., Holland, H.K., Morris, L.E.,
Bashey, A., 2014. Preemptive DLI without withdrawal of immunosuppression to
promote complete donor T-cell chimerism results in favorable outcomes for high-risk
older recipients of alemtuzumab-containing reduced-intensity unrelated donor
allogeneic transplant: a prospective phase II trial. Bone Marrow Transplant. 49,
616–621.
Speck, S.H., Ganem, D., 2010. Viral latency and its regulation: lessons from the gamma-
herpesviruses. Cell Host Microbe 8, 100–115.
Steigerwald-Mullen, P., Kurilla, M.G., Braciale, T.J., 2000. Type 2 cytokines predominate
in the human CD4(+) T-lymphocyte response to Epstein-Barr virus nuclear antigen
1. J. Virol. 74, 6748–6759.
Steven, N.M., Leese, A.M., Annels, N.E., Lee, S.P., Rickinson, A.B., 1996. Epitope focusing
in the primary cytotoxic T cell response to Epstein-Barr virus and its relationship to T
cell memory. J. Exp. Med. 184, 1801–1813.
Steven, N.M., Annels, N.E., Kumar, A., Leese, A.M., Kurilla, M.G., Rickinson, A.B., 1997.
Immediate early and early lytic cycle proteins are frequent targets of the Epstein-
Barr virus-induced cytotoxic T cell response. J. Exp. Med. 185, 1605–1617.
Subspecialty Group of Infectious Diseases and National Children’s Epstein-Barr Virus
Infection Cooperative G, 2021. Experts consensus on diagnosis and treatment of
Epstein-Barr virus infection-related diseases in children. Zhonghua Er Ke Za Zhi 59,
905–911.
Takeuchi, A., Saito, T., 2017. CD4 CTL, a cytotoxic subset of CD4(+) T cells, their
differentiation and function. Front. Immunol. 8, 194.
Tamaki, H., Beaulieu, B.L., Somasundaran, M., Sullivan, J.L., 1995. Major
histocompatibility complex class I-restricted cytotoxic T lymphocyte responses to
Epstein-Barr virus in children. J. Infect. Dis. 172, 739–746.
Tamura, Y., Yamane, K., Kawano, Y., Bullinger, L., Wirtz, T., Weber, T., Sander, S.,
Ohki, S., Kitajima, Y., Okada, S., Rajewsky, K., Yasuda, T., 2022. Concomitant
cytotoxic effector differentiation of CD4(+) and CD8(+) T cells in response to EBV-
infected B cells. Cancers (Basel) 14.
Tomita, Y., Avila-Cariño, J., Yamamoto, K., Mellstedt, H., Klein, E., 1998. Recognition of
B-CLL cells experimentally infected with EBV by autologous T lymphocytes.
Immunology. letters 60 (2–3), 73–79. https://doi.org/10.1016/s0165-2478(97)
00142-9.
Tsao, S.W., Tsang, C.M., Pang, P.S., Zhang, G., Chen, H., Lo, K.W., 2012. The biology of
EBV infection in human epithelial cells. Semin. Cancer Biol. 22, 137–143.
Tsuchiya, S., 2002. Diagnosis of Epstein-Barr virus-associated diseases. Crit. Rev. Oncol.
Hematol. 44, 227–238.
Tsuge, I., Morishima, T., Kimura, H., Kuzushima, K., Matsuoka, H., 2001. Impaired
cytotoxic T lymphocyte response to Epstein-Barr virus-infected NK cells in patients
with severe chronic active EBV infection. J. Med. Virol. 64, 141–148.
Tsurumi, T., Fujita, M., Kudoh, A., 2005. Latent and lytic Epstein-Barr virus replication
strategies. Rev. Med. Virol. 15, 3–15.
Tugizov, S.M., Berline, J.W., Palefsky, J.M., 2003. Epstein-Barr virus infection of
polarized tongue and nasopharyngeal epithelial cells. Nat. Med. 9, 307–314.
Valentine, R., Dawson, C.W., Hu, C., Shah, K.M., Owen, T.J., Date, K.L., Maia, S.P.,
Shao, J., Arrand, J.R., Young, L.S., O’Neil, J.D., 2010. Epstein-Barr virus-encoded
EBNA1 inhibits the canonical NF-kappaB pathway in carcinoma cells by inhibiting
IKK phosphorylation. Mol. Cancer 9, 1.
van Gent, M., Gram, A.M., Boer, I.G.J., Geerdink, R.J., Lindenbergh, M.F.S., Lebbink, R.
J., Wiertz, E.J., Ressing, M.E., 2015. Silencing the shutoff protein of Epstein-Barr
M. Liu et al.
virus in productively infected B cells points to (innate) targets for immune evasion.
J. Gen. Virol. 96, 858–865.
van Zyl, D.G., Tsai, M.H., Shumilov, A., Schneidt, V., Poirey, R., Schlehe, B., Fluhr, H.,
Mautner, J., Delecluse, H.J., 2018. Immunogenic particles with a broad antigenic
spectrum stimulate cytolytic T cells and offer increased protection against EBV
infection ex vivo and in mice. PLoS Pathog. 14, e1007464.
Wada, T., Muraoka, M., Yokoyama, T., Toma, T., Kanegane, H., Yachie, A., 2013.
Cytokine profiles in children with primary Epstein-Barr virus infection. Pediatr.
Blood Cancer 60, E46–E48.
Wang, X., Hutt-Fletcher, L.M., 1998. Epstein-Barr virus lacking glycoprotein gp42 can
bind to B cells but is not able to infect. J. Virol. 72, 158–163.
Wang, X., Kenyon, W.J., Li, Q., Mullberg, J., Hutt-Fletcher, L.M., 1998. Epstein-Barr virus
uses different complexes of glycoproteins gH and gL to infect B lymphocytes and
epithelial cells. J. Virol. 72, 5552–5558.
Wang, Y., Aissi-Rothe, L., Virion, J.M., De Carvalho, Bittencourt M., Ulas, N.,
Audonnet, S., Salmon, A., Clement, L., Venard, V., Jeulin, H., Stoltz, J.F., Decot, V.,
Bensoussan, D., 2014a. Combination of Epstein-Barr virus nuclear antigen 1, 3 and
lytic antigen BZLF1 peptide pools allows fast and efficient stimulation of Epstein-
Barr virus-specific T cells for adoptive immunotherapy. Cytotherapy 16, 122–134.
Wang, R.C., Chang, S.T., Hsieh, Y.C., Huang, W.T., Hsu, J.D., Tseng, C.E., Wang, M.C.,
Hwang, W.S., Wang, J., Chuang, S.S., 2014b. Spectrum of Epstein-Barr virus-
associated T-cell lymphoproliferative disorder in adolescents and young adults in
Taiwan. Int. J. Clin. Exp. Pathol. 7, 2430–2437.
Wang, Y., Luo, Y., Tang, G., Ouyang, R., Zhang, M., Jiang, Y., Wang, T., Zhang, X.,
Yin, B., Huang, J., Wei, W., Huang, M., Wang, F., Wu, S., Hou, H., 2021. HLA-DR
expression level in CD8(+) T cells correlates with the severity of children with acute
infectious mononucleosis. Front. Immunol. 12, 753290.
Wingate, P.J., McAulay, K.A., Anthony, I.C., Crawford, D.H., 2009. Regulatory T cell
activity in primary and persistent Epstein-Barr virus infection. J. Med. Virol. 81,
870–877.
Womack, J., Jimenez, M., 2015. Common questions about infectious mononucleosis. Am.
Fam. Physician 91, 372–376.
13
Infection, Genetics and Evolution 112 (2023) 105443
Xing, Y., Song, H.M., Wei, M., Liu, Y., Zhang, Y.H., Gao, L., 2013. Clinical significance of
variations in levels of Epstein-Barr virus (EBV) antigen and adaptive immune
response during chronic active EBV infection in children. J. Immunotoxicol. 10,
387–392.
Yanagaisawa, R., Matsuda, K., Ohga, S., Kanegane, H., Morimoto, A., Okamoto, Y.,
Ohara, A., Fukushima, K., Sotomatsu, M., Nomura, K., Saito, A.M., Horibe, K.,
Ishii, E., Nakazawa, Y., 2019. Factors predicting the recurrence of Epstein-Barr virus-
associated hemophagocytic lymphohistiocytosis in children after treatment using the
HLH-2004 protocol. Int. J. Hematol. 109, 612–617.
Yang, D., Shao, Q., Sun, H., Mu, X., Gao, Y., Jiang, R., Hou, J., Yao, K., Chen, Y., Sun, B.,
2011. Evaluation of Epstein-Barr virus latent membrane protein 2 specific T-cell
receptors driven by T-cell specific promoters using lentiviral vector. Clin. Dev.
Immunol. 2011, 716926.
Yang, C., Zhu, X., Zhang, T., Ye, Q., 2017. EBV-HLH children with reductions in CD4+ T
cells and excessive activation of CD8+ T cells. Pediatr. Res. 82, 952–957.
Yao, S., Wang, Y., Sun, Y., Liu, L., Zhang, R., Fang, J., Jin, R., Yu, J., Li, F., Bai, J.,
Zeng, Y., Zhang, C., Tan, H., Zhou, F., Chen, Y., Zhang, Q., Wang, Z., 2021.
Epidemiological investigation of hemophagocytic lymphohistiocytosis in China.
Orphanet J. Rare Dis. 16, 342.
Yin, Y., Manoury, B., Fahraeus, R., 2003. Self-inhibition of synthesis and antigen
presentation by Epstein-Barr virus-encoded EBNA1. Science 301, 1371–1374.
Yu, X., Ilecka, M., Bartlett, E.J., Schneidt, V., Bhat, R., Mautner, J., Feederle, R.,
Delecluse, H.J., 2015. Antigen-armed antibodies targeting B lymphoma cells
effectively activate antigen-specific CD4+ T cells. Blood 125, 1601–1610.
Zhang, S., Yin, J., Zhong, J., 2017. Chaetocin reactivates the lytic replication of Epstein-
Barr virus from latency via reactive oxygen species. Sci. China Life Sci. 60, 66–71.
Zhong, L., Krummenacher, C., Zhang, W., Hong, J., Feng, Q., Chen, Y., Zhao, Q., Zeng, M.
S., Zeng, Y.X., Xu, M., Zhang, X., 2022. Urgency and necessity of Epstein-Barr virus
prophylactic vaccines. NPJ Vaccines 7, 159. https://doi.org/10.1038/s41541-022-
00587-6.