Diagnosis and differential diagnosis of progressive lymphoproliferation and malignant lymphoma in persistent active herpesvirus infection

Journal of Virological Methods, 21 (1988) 255-264 Elsevier

255

Diagnosis and differential diagnosis of progressive lymphoproliferation and malignant lymphoma in persistent active herpesvirus infection G.R.F.

Krueger I, D.V. Ablashi2, S.Z. Salahuddin~ and S.F. Josephs2

‘~rnrnuiz~path~log~l Section, ~athoiogy Insi~t~te. ~~~~er‘~it~of Cologne. F. R. G. and 2,~utio~af Cancer Institute, Bethesda, U.S.A.

Summary

Persistent active Epstein-Barr virus (EBV) and human herpesvirus(HHV-6) infections may be accompanied by extensive lymphoproliferative reactions mimicking malignant lymphoma. Such atypical polyclonal lymphoproliferations (APL) can frequently be separated from malignant lymphoma only by detailed immunopathologic and virologic studies. Recommended procedures include immunotyping of lymphoid cells, extensive viral serology, in situ hybridization and Southern blotting for viral DNA, gene rearrangement and DNA ploidy studies. Clear separation of APL from malignant lymphoma is essential for therapeutic planning. Herpesvirus phoma

infection;

Atypical polyclonal

lymphoproliferation;

Malignant lym-

Human herpesviruses (HHV) belong to lymphotropic viruses, thus their effect on the immune system exceeds that of common infectious antigens (Krueger, 1985). Consequently, hyperplastic changes in lymphoid tissues are in excess of the usual response: polyclonal B-cell stimulation causes pronounced lymphoplasmacytoid hyperpiasia of the B-cell system; virus-infected lymphocytes will markedly stimu-

Correspondence fo: G.R.F. Krueger, Cologne, 5000 Cologne 44, F.R.G.

Immunopathology

Section,

Pathology

Institute,

University

of

256

late the T-cell defense with excessive paracortical (T-zone) hyperplasia, and T-cell factors will activate the phagocytic system with reticulohistiocytosis and occasional epithelioid cell granuloma. Classical changes of this kind are seen in infectious mononucleosis (IM) following acute Epstein-Barr virus (EBV) infection in children and young adults. In addition, some members of the Herpesviridae are oncogenic, or may contribute to oncogenesis under certain conditions. Thus, malignant lymphomas may develop in HHV-infected individuals. Best examples are for EBV infection African Burkitt’s lymphoma and other B-cell lymphomas in immunocompromised persons (Purtilo et al.. 1985) as well as, more recently, occasional B-cell lymphomas in individuals infected with the human herpesvirus(HHV-6) (Salahuddin et al., 1986; Josephs et al.. 1988). Classical infectious mononucleosis as response to an acute infection, and Burkitt’s, immunoblastic or follicle cell lymphoma as a late response to persistent and/or reactivated infection do usually not cause diagnostic problems. However, we had to recognize recently that in chronic active HHV infection hyperplastic stages of the lymphoid tissues exist which are still polyclonal, yet clinically hardly to be separated from malignant lymphoma (Krueger et al., 1987; Krueger and Ablashi, 1987). For such changes the term atypical polyclonal lymphoproliferation (APL) is the preferred designation. It apparently constitutes a prelymphomatous lesion. or better, a condition of enhanced susceptibility to malignant transformation. Recognizing APL is thus of interest both scientifically and clinically: scientifically, it further supports George Klein’s concept of successive stages in lymphoma development, and is well in keeping with experimental data (Klein, 1979, 1986); clini-

LATENT

ACUTE

T CELL

01s

CELL

CHRONIC

-MALIGNANT

ACTIVE

CELL

Fig. 1. Histopathological reaction patterns in EBV infection. Acute infection with ‘infectious mononucleosis pattern’ shows increase in EBV+ B lymphocytes and a marked cytotoxic T-cell response. Chronic active EBV induces atypical polyclonal lymphoproliferation (APL) with marked increase in polyclonal B-cells. There may be also certain numbers of ‘atypical’ cells at this stage with signs of aneuploidy and gene rearrangement. The final stage of malignant lymphoma (ML) is characterized by essentially monoclonal proliferation of atypical lymphoid cells.

25-l

tally, since APL requires another therapy than malignant lymphoma (Hoffmann et al., 1988; Berthold et al., 1988). In essence, we must now identify three types of proliferative lymphoid diseases associated with I-II-IV infection (Fig. 1): infectious mononucleosis-type (I&l), pro-

Fig. 2. Histology of atypical polyclonal lymphoproliferation (APL). (A) HBLV+, 3.6year-old boy with severe systemic lymphadenopathy, hyperplastic lymph nodes, and focal replacement by an atypical polymorphous lymphoiimmunoblast proliferation (left: H&E, 120 X; right: Giemsa, 300 x). (B) 52 year old EBV+ male with localized (Hodgkin-like) neck lymphadenopathy. Histology shows excessive polyclonal lymphoproliferation with similarity to infectious mononucleosis and with giant cell formation (left and right H&E, 300 X and 400 x). (C) HBLV+, 35-year-old AIDS patient with severe systemic iymphadenopathy. Histology shows complete destruction of lymphoid structure by diffuse pleomorphic iymphohistiocytic proliferation with giant cells (H&E; 300 x). (D) In situ h~~bridization with HBLV pZVH 14 DNA probe of lymph node from patient A shows foci of positive celts (black).

258

gressive polyclonal lymphoproliferation type APL, and malignant B-cell lymphoma (B-ML), monomorphic or pleomorphic. Occurrence of one or the other of such lymphoid reactions is apparently controlled by the patient’s immune status and by eventual oncogenic mutations (Purtilo et af.. 1985; Krueger, 1988). While IM-type lesions can be induced by several HHVs (Lennert et al., 1981). APL and B-cell malignant lymphoma - to our current knowledge - are preferentially related to EBV and HHV-6 infection. (Corresponding reaction patterns as

Fig. 3. creased ruption (DRC).

Immunotyping of lymph node cells from patient A (Fig. 2). Obvious polyclonality with inT-suppressor (TS), immature T (10) and activated T-cells (TO 1). Follicles show signs of diswith scattering of B-lymphocytes with B7 marker and prominence of dendritic reticular cells T-helper cells (T3) appear somewhat reduced (APAAP method with monoclinal antisera from Ortho and Biotestl.

259

induced by human uncornavirus such as HTLV-1 are not subject of this workshop.) Unequivocal diagnosis of APL in HHV infection and its separation from malignant lymphoma requires the close cooperation of clinician, pathologist, and virologist. Clinical and virologic characteristics of persistent active HHV infection are discussed elsewhere in this volume ~Kornaro~~ l988; Abrashi et al., 1988:;Fox, 19%; Biberfeld, 1988). Patients with APL, like those with malignant lymphomas, frequently have lo-

Fig. 4. Immunotyping with prominbt marked

increase

of lymph node cells from patient B (Fig. 2). Advanced

dendritic

reticular

in immature

cells (DRC)

T-cells

creased (APAAP

(TIO). method

is accompanied Monocytes

by polyclonal

are pr~nliffent

with monoclonal

follicular

disruption

~ymphopr~iiferati~n

(OKM).

yet not markedly

antisera from Ortho).

(B7) with in-

260 TABLE

I

Diagnostic

techniques

for APL

Parhology:

Routine histology optional: electron

Immunoputhology:

Immunotyping of cells in situ hybridization for viral DNA/RNA in situ viral antigen DNA extraction and gene translocation cell culture DNA ploidity studies oncogen expression

Immunovirology:

Serology (complete!) DNA extraction and blotting cell culture: transfection and cytopathic

TABLE

qf

effects

2

APL in chronic No.

and histochemistry microscopy

active

EBV 4

cases

Agelsex

2Mi2F

Clinical

Tumorlikc lymphadenopathy (4) splenomegaly (3) hypergamma globulinemia (3) dermal infiltration (I) blood and hone marrow CML-like

Puthology

(inirial)

2X-58 years

Excessive IM (1) Hodgkin’s_like (1) Castleman disease. CML + lymphoma?

plasmacytoid (I)

(1)

(I)

Immunopatholog?

polyclonal lymphoproliferation with myelocytic infiltration (I)

Virology

EBV EAD&R significantly clevatcd (4) EBNA low to not measurable (2) EBNA moderately clewted (2) IgAiVCA elevated (2) EBV genome in lymphotd cells (3)

COUW

persistence with spontaneous regress (1) progression to malignant lymphoma (I) complete remission after radiotherapy (I) persistence since I year (‘CML-like’ case)

(ref. also to Krueger

et al.. 1987)

(4)

261

calized or systemic lymphadenopathy mimicking clinically malignant lymphoma. Lymphocytosis, lymphadenopathy and/or splenomegaly can persist for many years (Berthold et al., 1988) or progress rapidly (Hoffmann et al., 1988). The histologic appearance of lymph nodes varies and is influenced by the state of immune competence (e.g. probable pre-existent AIDS or another acquired immune deficiency) and by the infectious agent (EBV or HHV-6). Unless adequate immunopathology and virology studies are done, the final diagnosis of APL will not be reached by classical histopathology. Common pathologic diagnoses in the 16 cases of APL we

Fig. 5. lmmunotyping of lymph node cells from patient C (Fig. 2). Polyclonal lymphoid populations with intense staining for several markers which frequently can hardly be separated from background. M: macrophage: TY: transferrin receptor of activated cells; for other markers see previous figures (APAAP method wirh monoclonal antisera from Ortho).

262

collected so far were: excessive reactive hyperplasia, chronic pseudomalignant lymphoproliferation (Canale-Smith syndrome), angiofollicular hyperplasia with plasmacytosis (Castleman’s disease), angioimmunoblastic lymphadenopathy (AIL), Hodgkin’s disease, pleomorphic immunocytoma or pleomorphic immunoblastic lymphoma, and atypical lymphoid hyperplasia in chronic myelogenous leukemia. The basic lymphoid structure in APL may be effaced to an extent that malignant lymphoma (most frequently of pleomorphic type) is indeed suggested; Fig. 2 shows some examples from our case material. We have applied additional techniques in such cases to prove persistent HHV activity and to confirm the diagnosis of APL: they are summarized in Table 1. Immunotyping showed polyclonality in all APL cases (Figs. 3-5) with especially bizarre reactions of lymphoproliferation in AIDS. Viral genome was shown in lymphoid tissues by in situ hybridization and by Southern blotting. In an occasional case, a low percentage of lymphoid cells may show TABLE

3

APL in chronic

active

Clinical

Puthology

HHV-6

persistent l~rnphocyt~si~ (5) lymphadenopathy (12) intestinal lymphadenopathy (2) splenomegaly (4) SjZjgren’s syndrome (1) hypothyroidism (1) fatigue and depression (4) weight loss (S) AIDS (4) (initial)

Immunopathology

excessive IM (2) ALL or CLL-like (I) SjBgren’s syndrome (1) Castleman-like (plasmacytoid) l~mphop~asmacytoid l~mphonla ‘lymphoma in AIDS‘ (3) polyclonal

lymphoproliferation

( 1) (I 1

(12)

anti HI-IV-6 (HSB2 cells) ahove 1:40 HHV-6 genome in tymphoid cells (12) IgG

Course

(ref. also to Hoffmann

died of AIDS (2) died of malignant lymphoma (2) complctc remission after IFNP (I) spontaneous remission (1) others pcrsibt (since up to I1 years)

et al.. 19X8: Berthold

et al.. 1988: Krueger

et al..

1988).

263

aneuploidy and gene rearrangement without clinical evidence of malignancy (Berthold et al., 1988). The data of our current case material are summarized in Tables 2 and 3. In essence, persistent active infection by EBV and by HHV-6 can induce excessive lymphoid hyperplasia mimicking malignant lymphoma or leukemia. Such reactions are tentatively summarized under the term atypical polyclonal lymphoproliferation (APL). The diagnosis of APL requires specialized immunopathologic and virologic procedures on adequately sampled tissues or blood specimens (fresh unfixed tissue taken under sterile precautions and transferred immediately for immunopathologic and virologic testing). Persistence of active virus and lymphoproliferation are apparently based on nonhomogeneous and partly ill-defined immune defects (Hamblin et al., 1983; Purtilo et al., 1985; Jones and Straus, 1987; Straus et al., 1985; Tosato et al., 1985; Krueger and Ramon, 1988) which need further study. As to our current knowledge, no systemic anti-lymphoma chemotherapy is indicated in cases of APL but attempts to correct for immune deficiency and to inhibit virus replication. One of our cases with HHV-6 induced systemic APL had a complete response after interferon-a2 therapy (Hoffmann et al., 1988). A second case of localized EBV-related APL in the neck finally responded to local radiation (40 Gy) which probably not only caused regression of lymphomas but also sterilization of the adjacent salivary gland shedding the virus (Krueger et al., 1987). Other cases remain in clinical observation without specific treatment.

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