  |
|
Transplant Q&AQuestion: I was a living donor for my son and I tested positive for EBV. So far, our son has tested negative and sometimes borderline positive for EBV. He had IV ganciclovir for 100 days post-transplant and is now on oral acyclovir four times a day for a year. How long do we need to be concerned that he may get full blown EBV, and what will that mean to him medically if he does?Answer: EBV is the short name for Epstein-Barr Virus infection, also called Mononucleosis, "Mono," and the "kissing disease." This virus is a member of the family of Herpes viruses that includes Herpes Simplex, which causes "cold sores" on the lips and mouth as well as genital Herpes; Herpes Zoster which causes Chicken Pox and Shingles; and CMV or cytomegalovirus, a virus that commonly infects post-transplant patients. About 85% of adult Americans will test "positive" for EBV antibodies, which means they have been exposed to the disease in the past. All of the diseases in the Herpes family share the common element that the infection can occur multiple times. This process is called "reactivation." It happens because the body doesn’t really eliminate the virus; rather the virus becomes dormant in cells, only to reemerge at a later date. Since the virus is not eliminated, organs from anyone who has ever been exposed to EBV can transmit the virus to the recipient. So to answer your question truthfully, the concern about EBV persists indefinitely. About one half to two thirds of EBV infections are in the first year and the rest occur after the first year. At present, the major concern regarding EBV infection is that it may later develop into lymphoproliferative disease (LPD), which is a malignant condition (cancer). However, the virus also may be responsible for chronic fatigue in transplant and healthy patients, and occasionally it can cause hepatitis and damage the liver. In four recent studies that looked at EBV infection in liver recipients, the incidence of EBV infection was between 4 and 20%. The major risk factor that seemed to increase the chance of getting EBV was having treatment for rejection with immunosuppressive antibodies, such as OKT3 and ATGAM. Also, the younger groups seem to have the highest risk. Finally, there seems to be more EBV infection in children treated with tacrolimus (Prograf) compared to cyclosporine; however, most patients who were treated with tacrolimus had a higher dosage than is currently in use. This may explain the higher incidence of EBV infection. It is unclear whether prophylactic treatment with anti-viral drugs, such as ganciclovir and acyclovir, decreases the risks of getting an EBV infection or not. Warning signs of EBV infection include an unexplained fever, lethargy and fatigue, and swelling of lymph node tissue. Lymph nodes are normal collection of immune cells that fight infections. The lymph node "lumps" are most noticeable in the groin area, under the arm pit, and in the neck. Enlargement of these nodes happens normally to fight infection. For example, the nodes in the neck under the jaw will swell when one has a sore throat. If the swelling does not resolve when the sore throat does, this is cause for concern. Diagnosis of an EBV infection can be difficult. The most commonly used method of diagnosing EBV is by monitoring for the presence of an antibody reaction to the virus. However, this test may not be positive early in an infection, and it may remain positive long after eradication of the virus. In many cases it appears that EBV infection can be controlled with anti-viral therapy and a concomitant reduction in immunosuppression. But because it is hard to tell who has EBV and who doesn’t, it is hard to measure for sure the effectiveness of the anti-viral therapy. Between one and two thirds of patients who develop EBV infection will develop lymphoproliferative disease (LPD). Treatment for LPD is not very effective and it is fatal in between 40% and 80% of cases. The thing about LPD is that most people don’t think of it as an infection but as a situation where the patient is or has been "over-immunosuppressed." The best way to prevent LPD may be to avoid "over-immunosuppression." Refs: Ho et al. The frequency of Epstein-Barr virus infection and associated lymphoproliferative syndrome after transplantation and its manifestations in children. Transplantation (1988 Apr) 45(4):719-27 Cox et al. An increased incidence of Epstein-Barr virus infection and lymphoproliferative disorder in young children on FK506 after liver transplantation. Transplantation (1995 Feb 27) 59(4):524-9 Newell et al. Posttransplant lymphoproliferative disease in pediatric liver transplantation. Interplay between primary Epstein-Barr virus infection and immunosuppression. Transplantation (1996 Aug 15) 62(3):370-5 Langnas et al. Epstein-Barr virus hepatitis after liver transplantation. Am J Gastroenterol (1994 Jul) 89(7):1066-70 -Jeffrey Punch,MD
|
|
|
Children’s Liver Association for Support Services
|
