Continuing Education Activity

Epstein-Barr virus (EBV) positive B-cell lymphoproliferative disorders (LPDs) are a spectrum of diseases that range from self-limiting, localized conditions to aggressive lymphomas. The Epstein-Barr virus is a ubiquitous organism, achieving asymptomatic lifelong carrier status in a large proportion of the world's population. The pathophysiology of this latent infection is due to the interaction of EBV with the memory B cells of a healthy, immunocompetent individual. This activity reviews the pathophysiology of EBV positive mucocutaneous ulcer and highlights the role of the interprofessional team in its management.

Objectives:

• Review the presentation of a patient with EBV positive mucocutaneous ulcer.
• Describe the evaluation of a patient with EBV positive mucocutaneous ulcer.
• Summarize the treatment of EBV positive mucocutaneous ulcer.
• Explain modalities to improve care coordination among interprofessional team members in order to improve outcomes for patients affected by EBV positive mucocutaneous ulcer.

Introduction

Epstein-Barr virus (EBV) positive B-cell lymphoproliferative disorders (LPDs) are a spectrum of diseases that range from self-limiting, localized conditions to aggressive lymphomas. Epstein-Barr virus is a ubiquitous organism, achieving asymptomatic lifelong carrier status in a large proportion of the world's population. The pathophysiology of this latent infection is due to the interaction of EBV with the memory B cells of a healthy, immunocompetent individual. Disruptions in the balance of this interaction are believed to result in the lymphoproliferation of various cell derivatives. EBV positive mucocutaneous ulcer (EBVMCU) is an indolent condition on this spectrum of LPDs, which localizes to the skin and mucosal surfaces. It is a rare lymphoproliferation that gained recognition as a new entity in the 2016 revisions to the World Health Organization classifications.[1][2]

Etiology

Epstein-Barr virus (EBV), also known as human herpesvirus 4, is transmitted via saliva and has a propensity to infect B-cells. The virus can persist in humans asymptomatically throughout their lifetime, however can also result in delayed complications such as lymphoproliferative disorders. One of the most noteworthy risk factors for the development of EBV positive mucocutaneous ulcer is immunosuppression. This condition has been reported in the setting of iatrogenic immunosuppression (56%), advanced age-associated immunosenescence (40%), and primary immunosuppression (4%).[3] Many commonly used immunosuppressive drugs have correlations with the development of EBVMCU, including methotrexate, cyclosporin A, azathioprine, tacrolimus, TNF inhibitors, mycophenolate, and topical steroid treatment.[1] Reports also suggest that immunosenescence is a significant predisposing factor for patients who are also on immunomodulating drugs.[3]

Epidemiology

The incidence of EBV positive mucocutaneous ulcer is likely highly underestimated, given its self-limiting course, in addition to its rarity amongst the spectrum of EBV positive lymphoproliferative disorders with only a limited number of reported cases in the literature. It was first identified in 2010 and is associated with immunosuppression, both iatrogenic, primary, and age-related.[4] A slight female predominance has been reported with a median patient age of 66.4 years.[5] 

Pathophysiology

Although the pathogenesis of EBV positive mucocutaneous ulcer is not fully established, it is thought to correlate with reduced levels of T cells in immunosuppressed patients leading to a reduced ability to target all EBV associated antigens. This suppression results in a proliferation of only restricted clones of EBV specific T cells when encountering the virus. In the immunocompetent individual, the cytotoxic T-cells are able to manage the EBV induced B cell proliferation and keep the virus in the dormant state. In immunosuppressed patients with EBVMCU, the immune system is only able to keep the virus in a dormant state systemically. Thus, exposure to additional immune-modulating factors at a particular site can lead to a localized EBV driven lymphoproliferation.[6][7]

Histopathology

Biopsies of EBV positive mucocutaneous ulcer demonstrate surface ulceration with infiltrates of atypical lymphoid cells. This lymphoid component is variable in appearance and can have a similar histological appearance to that of diffuse large B-cell lymphoma (DLBCL) and classic Hodgkin lymphoma (cHL). There may be a mixed inflammatory infiltrate with lymphocytes, plasma cells, histiocytes, and eosinophils. Often there is a rim of reactive T-cells around the EBV-positive B-cell areas. Immunoblasts have been shown to express markers consistent with B-cell immunophenotypes.[3][8]

History and Physical

EBV positive mucocutaneous ulcer typically presents with isolated, sharply well-circumscribed ulcerations on the oropharyngeal mucosa (52%), on the skin (29%), or the in the gastrointestinal tract (19%). Symptoms are typically directly related to the ulcer, and include weight loss secondary to odynophagia and can even result in abdominal emergencies. Patients typically lack systemic symptoms, lymphadenopathy, organomegaly, or bone marrow involvement.[3] The propensity for localization to the oropharynx and gastrointestinal tract is thought to be related to the initial site of viral inoculation and the subsequent persistence of latent EBV in associated lymphoid tissues (i.e., Waldeyer’s ring and gut-associated lymphoid tissue). Patients may have a waxing and waning clinical course, with worsening of lesion-associated tissue damage when maintaining or increasing iatrogenic immunosuppression.[1]

Evaluation

Diagnostic challenges of EBV positive mucocutaneous ulcer included distinguishing it from other lymphoproliferative disorders, which may be EBV related such as diffuse large B-cell lymphoma, post-transplant lymphoproliferative disorder, or classic Hodgkin lymphoma. EBVMCU typically is a localized condition and does not involve the bone marrow, lymph nodes, liver, or spleen and is not associated with EBV viremia. Work up of this condition typically involves histologic evaluation with immunohistochemistry.  Imaging with or without bone marrow biopsy may be performed to rule out systemic involvement.[4]

Treatment / Management

Most cases of EBV positive mucocutaneous ulcers have a benign course and respond well to conservative management. In these cases, the patients are reported to have complete remission either spontaneously or in response to the reduction of their immunosuppressive therapies. However, there are reports of more persistent and debilitating cases that required more aggressive treatment. Some case reports have indicated excellent response to CD20 or CD30 directed antibody therapy, local radiation, surgical excision, chemotherapy, or a combination of these treatments.[3][9]

Differential Diagnosis

The differential diagnosis for EBV positive mucocutaneous ulcer includes the following:

• EBV positive diffuse large B-cell lymphoma (DLBCL)
• Classic Hodgkin lymphoma (cHL)
• Plasmablastic lymphoma
• Post-transplant lymphoproliferative disorder (PTLD)
• Anaplastic large cell lymphoma

The clinical features of EBVMCU, specifically the localized nature and absence of a mass lesion, are integral in distinguishing it from DLBCL. These entities share an almost indistinguishable cytologic composition and phenotype. The presence of sharp circumscription and a band of small T cells at the base of the ulcer can differentiate EBVMCU from the more infiltrative patterns of DLBCL. EBV positive mucocutaneous ulcer also shares morphologic and phenotypic characteristics with cHL, specifically the presence of CD30/CD15 positive Reed-Sternberg like cells, though, cHL rarely presents as extranodal disease.[6][10][11]  Finding EBV positivity in a variety of cell sizes favors EBVMCU or PTLD. When DLBCL or cHL is EBV related, typically only the large cells are EBER positive. Anaplastic large cell lymphoma may resemble EBVMCU histologically, however, this entity is a CD30 positive T-cell lymphoma and will not be positive for EBER. 

Prognosis

EBV positive mucocutaneous ulcer has a favorable prognosis. Most cases regress spontaneously or with a reduction of immunosuppressive therapy. Some case reports have described a relapsing and remitting course without progression. Persistent cases have been reported to resolve with radiation, chemotherapy, or other localized treatments.[6] 

Complications

The sequelae of EBV positive mucocutaneous ulcer is mostly dependent on the location and severity of the ulcers as they can be extensively destructive to the affected tissue. Persistent, painful ulcerations localized to the oropharynx have been reported to lead to odynophagia and subsequent weight loss. There have been reports of aspiration pneumonia and subsequent sepsis secondary to odynophagia as well. Furthermore, ulcers can appear in any part of the gastrointestinal tract causing abdominal emergencies.[3][4]

Deterrence and Patient Education

Although many cases of EBV positive mucocutaneous ulcers are generally self-limiting and can resolve without treatment, it is important to seek medical care if you develop a mucocutaneous ulcer as it can be secondary to multiple diagnoses, thus additional work-up should be pursued. Furthermore, with an increasing number of cases of EBVMCUs being reported, there have been reports of more aggressive or persistent cases that require additional treatment. 

Pearls and Other Issues

• EBVMCU is a B-cell lymphoproliferative disorder with a wide variety of appearances that may resemble DLBCL and/or cHL.
• Atypical lymphoid infiltrates of the skin and mucosal surfaces should undergo evaluation for EBV.
• If the lymphoid infiltrate is EBV-positive, EBVMCU should be considered.
• Diagnosis relies on clinical history and exclusion of systemic involvement.

Enhancing Healthcare Team Outcomes

The successful diagnosis and treatment of EBV positive mucocutaneous ulcers rely highly on an interprofessional and patient-centered approach. Given the rarity of EBVMCU and its typical self-remitting course, it is likely that this condition is commonly overlooked or misdiagnosed. As early diagnosis and treatment of EBVMCU can vastly decrease sequelae and improve patient outcomes, it is important for health care workers to work together to obtain a prompt diagnosis.