Persistent Anemia in a Patient with Diffuse Large B Cell Lymphoma: Pure Red Cell Aplasia Associated with Latent Epstein-Barr Virus Infection in Bone Marrow

We report a case of pure red cell aplasia (PRCA), which was initially suspected as a result of bone marrow involvement of diffuse large B cell lymphoma. Persistent anemia without an obvious cause was observed in a 47-yr-old man diagnosed with relapsed diffuse large B cell lymphoma. The bone marrow study showed only erythroid hypoplasia without the evidence of bone marrow involvement with lymphoma cells, thus PRCA was suggested. However, parvovirus infection was excluded as a potential cause of PRCA because of negative IgM anti-parvovirus B19 antibody and negative parvovirus PCR in the serum. Latent Epstein-Barr virus (EBV) infection of bone marrow was suggested by in situ hybridization with EBV-encoded small RNA (EBER) that showed a strong positive expression in bone marrow cells. Thus, PRCA was thought to be associated with latent EBV infection in bone marrow cells. Although the finding of unexplained anemia is a possible predictor of bone marrow involvement with lymphoma cells, PRCA as a result of a viral infection including EBV should be considered in lymphoma patients. This is the first report of the occurrence of PRCA associated with latent EBV infection in a patient with non-Hodgkin's lymphoma.

[1]  S. Chiang,et al.  Discovery of Epstein-Barr virus (EBV)-encoded RNA signal and EBV nuclear antigen leader protein DNA sequence in pet dogs. , 2005, The Journal of general virology.

[2]  E. Ma,et al.  Diagnostic cues for natural killer cell lymphoma: primary nodal presentation and the role of in situ hybridisation for Epstein-Barr virus encoded early small RNA in detecting occult bone marrow involvement , 2005, Journal of Clinical Pathology.

[3]  P. Neame,et al.  Autologous peripheral blood progenitor cells are a potential source of parvovirus B19 infection , 2005, Transfusion.

[4]  Y. Cheung,et al.  Can patients with early-stage diffuse large B-cell lymphoma be treated without bone marrow biopsy? , 2005, Annals of oncology : official journal of the European Society for Medical Oncology.

[5]  S. Lade,et al.  Diagnostic application of Epstein–Barr virus‐encoded RNA in situ hybridisation , 2004, Pathology.

[6]  H. Bessler,et al.  Pure red cell aplasia--a rare disease with multiple causes. , 2003, Biomedicine & pharmacotherapy = Biomedecine & pharmacotherapie.

[7]  H. Taguchi,et al.  Pure Red Cell Aplasia in a Patient with Trrisomy X Chromosome Abnormality and Reactivated Epstein-Barr Virus Infection , 2003 .

[8]  M. Crump,et al.  Pure red cell aplasia due to parvovirus following treatment with CHOP and rituximab for B‐cell lymphoma * , 2002, British journal of haematology.

[9]  B. Altun,et al.  Pure Red Cell Aplasia Preceding Malignant Lymphoma in a Renal Transplant Patient , 2002, Nephron.

[10]  T. Yoshino,et al.  Epstein-Barr Virus Associated Diffuse Large B-Cell Lymphoma Complicated by Autoimmune Hemolytic Anemia and Pure Red Cell Aplasia , 2001, Leukemia & lymphoma.

[11]  A. Ho,et al.  Remarkable Response to Rituximab in a 72-Year-Old Patient with Refractory Non-Hodgkin's Lymphoma and Marrow Aplasia , 2001, Leukemia & lymphoma.

[12]  M. Mittelman,et al.  Splenic Lymphoma Presenting as Warm Autoimmune Hemolytic Anemia Associated with Pure Red Cell Aplasia , 2000, Vox Sanguinis.

[13]  T. Fujii,et al.  [Acquired pure red cell aplasia associated with relapsed non-Hodgkin's lymphoma: a case report-improvement of PRCA after acute hepatitis]. , 1998, [Rinsho ketsueki] The Japanese journal of clinical hematology.

[14]  T. Südhoff,et al.  [Severe anemia requiring transfusion in the early stage of low-grade malignant non-Hodgkin's lymphoma]. , 1994, Der Internist.

[15]  M. Fukumoto,et al.  Pure red cell aplasia associated with non-Hodgkin's lymphoma and hemolytic anemia. , 1991, Japanese journal of clinical oncology.

[16]  M. Socinski,et al.  Pure red blood cell aplasia associated with chronic Epstein-Barr virus infection: evidence for T cell-mediated suppression of erythroid colony forming units. , 1984, The Journal of laboratory and clinical medicine.

[17]  U. Fink,et al.  [Simultaneous occurrence of pure red cell aplasia and malignant lymphoma (author's transl)]. , 1977, Medizinische Klinik.

[18]  C. M. Lander,et al.  Successful use of combination chemotherapy in pure red cell aplasia associated with malignant lymphoma, histiocytic type. , 1975, Australian and New Zealand journal of medicine.

[19]  H. Taguchi,et al.  Pure red cell aplasia in a patient with trisomy X chromosome abnormality and reactivated Epstein-Barr virus infection. , 2003, International journal of hematology.

[20]  D. Fleming,et al.  Pure red cell aplasia due to parvovirus B19 in a patient treated with rituximab. , 2000, Blood.

[21]  D. Weisenburger,et al.  Pure red cell aplasia associated with B cell lymphoma: demonstration of bone marrow colony inhibition by serum immunoglobulin. , 1990, Leukemia research.