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Immunosuppressants/rituximab/valaciclovir S

Epstein-barr virus infection: 2 case reports

In a literature review, 2 girls aged 3 and 5 years were described, out of which, a girl developed epstein-barr virus infection (EBV
infection) following immunosuppressant therapy with sirolimus, tacrolimus and prednisolone for transplant rejection, and also
exhibited a lack of efficacy following treatment with valaciclovir for EBV infection. The other girl developed EBV infection following
immunosuppressant therapy with ciclosporin, prednisone and rituximab for haematopoietic transplant [routes and dosages not
stated].
Case 1: The 3-year-old girl was presented to the hospital due to hepatic fulminant failure, and underwent a liver transplantation
after 1 month. She was initiated on unspecified immunosuppressants [immunosuppressive medication]. She developed a transplant
rejection. Thus, she was initiated on sirolimus [rapamycin], prednisolone and tacrolimus, and underwent a 2nd liver transplant, after
4 months. However, the transplant was complicated due to acute cellular mild rejection and venous portal thrombosis, and
underwent a thrombectomy. However, after 1 year, the EBV infection was noted and the viral load increased from 625 × 103 viral
copies per milliliter to 35 × 106 viral copies per milliliter. Therefore, she was treated with valaciclovir [valacyclovir] for 6 months.
Despite, valaciclovir, the viral load was not reduced (lack of efficacy). She was initiated on rituximab. Later 2 years, she was
presented with pupillary dilation of the left eye, that suggested a third nerve palsy secondary to EBV infection. The MRI with contrast
revealed 2 lesions, 1 lesion into the right temporal pole and other in the left parasellar region, and the imaging features suggested a
meningioma [etiology not stated]. She underwent a bilateral craniotomy and excision of both lesions, and the pathology of the lesion
confirmed and smooth muscle tumour (SMT). The immunohistochemical analysis resulted positive for actin EM, actin SM, vimentin,
desmin, and Ki-67 was at 2%. Thus, she was diagnosed with EBV infection secondary to sirolimus, prednisolone and tacrolimus, and
the diagnosis of SMT was considered secondary to EBV infection. During follow-up, she was initiated on prednisone and
ursodeoxycholic-acid, along with sirolimus [time to reaction onset and outcome not stated].
Case 2: The 5-year-old girl was presented to the hospital due to acute lymphoblastic leukaemia (ALL) that required
haematopoietic cell transplant. She was initiated on ciclosporin [cyclosporine] and prednisone. The IgM and IgG and PCR test
revealed the diagnosis of EBV infection. After 7 months of the transplant, she developed a lymphoproliferative syndrome secondary
to EBV infection. Thus, she was treated with 4 cycles of rituximab. Later 9 months from rituximab initiation, she had a mass in the
neck, was operated and resulted in a polymorphic post-transplant lesion. After 2 years of transplant, the EBV viral load increased.
She underwent a temporal craniotomy and lesion excision. The histology revealed a diagnosis of smooth muscle tumour (SMT)
secondary to EBV infection. The immunohistochemical analysis resulted positive for actin EM, actin SM, and Ki-67 was at 2%. Thus,
she was diagnosed with EBV infection secondary to prednisone, rituximab and ciclosporin [time to reaction onset and outcome not
stated].
Paez-Nova M, et al. Primary intracranial smooth muscle tumor associated with Epstein-Barr virus in immunosuppressed children: two cases report and review of literature.
Childs Nervous System 37: 3923-3932, No. 12, 22 Apr 2021. Available from: URL: http://doi.org/10.1007/s00381-021-05173-0 803786088

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