EBV-positive mucocutaneous ulcer arising in a post-hematopoietic cell transplant patient: A difficult diagnosis

Background: EBV-positive Mucocutaneous Ulcer (EBV-MCU) is a newly recognized clinicopathological entity characterized by ulcerated lesions affecting cutaneous and/or mucosal sites typically in immunosuppressed patients. To our knowledge, only 2 cases of EBV-MCU have been described following allogeneic Hematopoietic stem cell transplantation (alloHSCT). Here we describe a case of EBV-MCU that developed acutely 22 days after HSCT with massive intestinal bleeding and rapidly worsening clinical condition. Case report: A 46-year-old male was diagnosed with Severe Aplastic Anemia (SAA) and underwent immunosuppressive therapy. Because lacking response, he subsequently underwent Matched Unrelated Donor (MUD) allogeneic HSCT after Myeloablative Conditioning (MAC). The donor and the patient were IgG positive and IgM negative for EBV Viral Capsid Antigen (VCA) before transplantation, while the donor was seronegative for CMV and the patient was seropositive. Hematologic recovery was reached rapidly after engraftment. During aplasia, the patient experienced Hepatic Veno-occlusive Disease, treated with Defi brotide. From day 22 after allografting, the patient developed worsening melena and rectal bleeding. CT angiography of the abdomen showed multiple jejunal bleeding sites, compatible with severe erosion of the intestinal mucosa. EGDS, Colonoscopy, and Capsule Endoscopy confi rmed multiple duodenal and jejunal ulcers. Duodenal biopsies were performed for histological evaluation. PCR for EBV-DNA and CMV-DNA was negative throughout the course. Stool cultures were negative for viral, bacterial, and fungal infections. The patient was empirically treated with steroids and Ganciclovir, associated with massive transfusional support. After many attempts to stop the bleeding with multiple intestinal peripheric arterial embolization and medical therapy, because of worsening clinical conditions, the patient was indicated to laparotomy with a double ileostomy to remove the bleeding intestinal tract. Just before the surgical intervention, histological fi ndings confi rmed the diagnosis of EBV-MCUs and the last serologic evaluation fi nally showed increasing EBV-DNA-emia. Unfortunately, before admission to the Surgery Room, the patient became septic, most likely from bacterial superinfection. After a cardiac arrest, he fi nally died. Conclusion: Massive intestinal bleeding is a rare major complication after HSCT. It is important to properly recognize the etiology among massive chemotherapyinduced mucositis, acute Graft versus Host Disease (aGvHD), and bacterial, fungal, or viral infections. Not only CMV-related infections but also EBV-related lesions should be considered, especially in patients previously treated with intense immunosuppressive therapies. Even if EBV-MCU is known to have an indolent course here we described an aggressive course, maybe related to intense immunosuppression and infl ammatory background. These cases may need additional treatments other than conservative management. Besides, strict observation should be done to recognize evolution towards systemic disease (PTLDs) and the need for more intensive treatment with chemotherapy. Case Report EBV-positive mucocutaneous ulcer arising in a posthematopoietic cell transplant patient: A diffi cult diagnosis Mariateresa Giaimo1*, Lucia Prezioso1, Benedetta Cambò1, Benedetta Dalla Palma1, Federica Falcioni1, Amelia Rinalidi1, Alessandro Tafuni2, Gianluca Di Rienzo2, Valerio Copelli2, Pellegrino Crafa2 and Daniele Vallisa1 1MD, Integrated Activity Department General and Specialized Medicine, Hematology Unit and CTMO, University Hospital of Parma, Italy 2MD, PhD, Diagnostic Department, Anatomy and Pathological Histology Operating Unit, University Hospital of Parma, Italy Received: 18 February, 2021 Accepted: 01 March, 2021 Published: 02 March, 2021 *Corresponding author: Mariateresa Giaimo, MD, Integrated Activity Department General and Specialized Medicine, Hematology Unit and CTMO, University Hospital of Parma, Italy, E-mail:


Introduction
Epstein Barr Virus (EBV) is a ubiquitous micro-organism member of the subfamily Gammaherpesvirinae. At least 90% of the population become infected with EBV, mostly early in life, and develop a latent infection of memory B cells.
EBV-PTLDs can arise following primary EBV infection or reactivation of a prior infection. They constitute a spectrum ranging from EBV-driven polyclonal proliferations to monoclonal proliferations resembling B-cell (less often T/ NK-cell) lymphomas usually affecting immunocompetent individuals. Diagnosis is based on signs and symptoms (lymphadenopathy, intermittent tonsillar enlargement, progressive reduction in cellular lineages, fever, or end-organ disease) together with detection of both EBV-DNA-emia and EBV infection in a tissue specimen [3].

Patient characteristics and clinical course
A 46-year-old male otherwise healthy developed asymptomatic pancytopenia and was diagnosed with Severe Aplastic Anemia (SAA) at the bone marrow analysis. No Cytogenetic alterations were found, while NGS evaluation found mutations in ABL1 and ASXL1 of uncertain signifi cance.
First-line treatment consisted of high-dose corticosteroids, without any improvement. Then immunosuppressive combination therapy of horse Antithymocyte Globulin (hATG), and Cyclosporine-A (CyA) was chosen as salvage therapy. Immunodepressed patient suffered from Clostridium diffi cile infection with acute diarrhea, treated with antibiotic therapy.
Lacking response to pharmacological treatment, the patient was referred to our center for the indication to alloHSCT. He subsequently underwent Matched Unrelated Donor (MUD) allogeneic HSCT after Myeloablative Conditioning (MAC) with Thiotepa, Busulfan, Fludarabine. GvHD prophylaxis consisted of rabbit-ATG, Methotrexate and CyA. Both the donor and the patient were IgG positive and IgM negative for EBV Viral Capsid Antigen (VCA) before transplantation, while the donor was seronegative for CMV and the patient was seropositive.
Hematologic recovery was reached rapidly after engraftment. During aplasia, the patient experienced Hepatic Veno-Occlusive Disease (VOD), which required treatment with Defi brotide from day 12 to day 22 post-HSCT. Treatment was stopped due to almost complete resolution of VOD and development of melena and rectal bleeding.
CT angiography of the abdomen showed multiple jejunal bleeding sites, compatible with severe erosion of the intestinal mucosa ( Figure 1A,B). EGDS, Colonoscopy and Capsule Endoscopy confi rmed multiple duodenal and jejunal ulcers ( Figure 2), with spotting bleeding throughout the mucosa. Multiple duodenal biopsies were performed for histological evaluation.
The patient was massively supported with transfusion and he underwent multiple intestinal peripheric arterial embolization without any improvement.
PCR for EBV-DNA and CMV-DNA was negative throughout the course. Stool cultures were negative for viral, bacterial, and fungal infections; no Clostridium diffi cile enterotoxin or cytotoxin were found in stool specimens. Even if in absence of abdominal pain and diarrhea, the patient was empirically treated with steroids for supposed acute intestinal GVHD. Additionally, Ganciclovir was added because of the high CMV reactivation risk, with no response.
After many attempts to stop the bleeding with embolization and medical therapy, because of worsening clinical conditions, the patient was indicated to laparotomy with a double ileostomy to remove the bleeding intestinal tract.
Just before the surgical intervention, histological fi ndings confi rmed diagnosis of EBV-MCUs and the last serologic evaluation fi nally showed increasing EBV-DNA-emia.
Unfortunately, before admission to the Surgery Room, the patient became septic with high fever, worsening tachycardia, and hypotension, most likely from bacterial superinfection.
After a cardiac arrest, he fi nally died.

Discussion
Massive intestinal bleeding is a rare major complication after HSCT. Differential diagnoses must include massive chemotherapy-induced mucositis, acute Graft versus Host Disease (aGvHD), and bacterial, fungal, or viral infections.
Not only CMV-related infections but also EBV-related lesions should be considered, especially in patients previously treated with intense immunosuppressive therapies [7].
Endoscopic evaluation with bioptic samples should be performed in order to recognize pathological entity, along with CMV-DNA-emia and EBV-DNA-emia monitoring because of high reactivation risk and gastrointestinal related complications [3]. The case we presented is particularly relevant because both CMV and EBV viremia were persistently negative and signs/ symptoms were aspecifi c: only through invasive methods we fi nally managed to reach a proper diagnosis.
The most striking histological feature is the presence of apoptotic bodies, which is not normal in gastrointestinal biopsies. However, it would not be possible to fi nd a reasonable explanation for this fi nding without appropriate medical information. Indeed, many causes (infections, medication, GVHD, IBDs, coeliac disease) are associated with an apoptotic pattern [8]. Knowledge of recent hemopoietic-cell transplantation allows the pathologist to exclude some of them such as IBDs and coeliac disease. Therefore, it is also necessary to make use of immunohistochemistry to search for viruses and fungal stains to exclude concomitant infectious complications related to immunosuppressive therapy [9].