Human T-lymphotropic virus: Difference between revisions

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== Background ==
==Background==


=== Microbiology ===
===Microbiology===


* Single-stranded negative-sense RNA virus in the [[Retroviridae]] family, genus ''Deltaretrovirus''
*Single-stranded negative-sense RNA virus in the [[Retroviridae]] family, genus ''Deltaretrovirus''
* Four types:
*Four types:
** HTLV-1, cause of adult T-cell leukemia-lymphoma and HTLV-associated myelopathy
**HTLV-1, cause of adult T-cell leukemia-lymphoma and HTLV-associated myelopathy
** HTLV-2, cause of HTLV-associated myelopathy
**HTLV-2, cause of HTLV-associated myelopathy
** HTLV-3 and HTLV-4 are rare
**HTLV-3 and HTLV-4 are rare


=== Epidemiology ===
===Epidemiology===


* HTLV-1 endemic to central Africa, the Caribbean basin, parts of South America, and southwestern Japan
*HTLV-1 endemic to central Africa, the Caribbean basin, parts of South America, and southwestern Japan
* HTLV-2 endemic to indigenous people in the Americas, and Central African pygmies, as well as injection drug users in North America and Europe
*HTLV-2 endemic to indigenous people in the Americas, and Central African pygmies, as well as injection drug users in North America and Europe
* Transmitted sexually, parenterally (blood-borne), and vertically (mother-to-child, primarily through breastfeeding)
*Transmitted sexually, parenterally (blood-borne), and vertically (mother-to-child, primarily through breastfeeding)
* Seroprevalence increases with age and is higher in women than men
*Seroprevalence increases with age and is higher in women than men


== Clinical Manifestations ==
==Clinical Manifestations==
{| class="wikitable"
{| class="wikitable"
!Syndrome
!Syndrome
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=== Adult T-cell Leukemia-Lymphoma (ATL) ===
===Adult T-cell Leukemia-Lymphoma (ATL)===


* Associated with HTLV-1, with a lifetime risk of 2 to 4% and latent period to 30 to 50 years
*Associated with HTLV-1, with a lifetime risk of 2 to 4% and latent period to 30 to 50 years
* Aggressive T-cell [[leukemia]] or [[lymphoma]] with four subtypes
*Aggressive T-cell [[leukemia]] or [[lymphoma]] with four subtypes
** Smoldering (5%), with β‰₯5% abnormal T-cells but otherwise normal differential, Β± skin lesions Β± pulmonary involvement
**Smoldering (5%), with β‰₯5% abnormal T-cells but otherwise normal differential, Β± skin lesions Β± pulmonary involvement
** Chronic (19%), with lymphocytosis β‰₯4 and T-cells >3.5, Β± lymphadenopathy/organomegaly/skin lesions/pulmonary involvement
**Chronic (19%), with lymphocytosis β‰₯4 and T-cells >3.5, Β± lymphadenopathy/organomegaly/skin lesions/pulmonary involvement
** Lymphoma/leukemia (19%), with lymphadenopathy without lymphocytosis; poor prognosis (median 10 months)
**Lymphoma/leukemia (19%), with lymphadenopathy without lymphocytosis; poor prognosis (median 10 months)
** Acute (57%), with increased leukemic T cells and worsening clinical picture including hypercalcemia; poor prognosis (median 6 months)
**Acute (57%), with increased leukemic T cells and worsening clinical picture including hypercalcemia; poor prognosis (median 6 months)
* Presents with lymphadenopathy, hepatosplenomegaly, hypercalcemia, skin lesions, lytic bone lesions, and abnormal peripheral blood film with lymphocytosis and "flower cells"
*Presents with lymphadenopathy, hepatosplenomegaly, hypercalcemia, skin lesions, lytic bone lesions, and abnormal peripheral blood film with lymphocytosis and "flower cells"
* Skin findings can be either localized or diffuse as papules, nodules, plaques, erythematous patches, and diffuse erythroderma
*Skin findings can be either localized or diffuse as papules, nodules, plaques, erythematous patches, and diffuse erythroderma


=== HTLV-Associated Myelopathy ===
===HTLV-Associated Myelopathy===


* Also called '''tropical spastic paraparesis'''
*Also called '''tropical spastic paraparesis'''
* Associated with HTLV-1 and -2, with lifetime prevalence of 4%
*Associated with HTLV-1 and -2, with lifetime prevalence of 4%
* Thought to be caused by an autoimmune response from HTLV-1 antibodies due to molecular mimicry
*Thought to be caused by an autoimmune response from HTLV-1 antibodies due to molecular mimicry
* Chronic progressive demyelinating disease affecting white matter and spinal cord
*Chronic progressive demyelinating disease affecting white matter and spinal cord
** Unexplained central neurological disease with loss of pyramidal tract
**Unexplained central neurological disease with loss of pyramidal tract
** Stiff gait progressing to spasticity and weakness, back pain, urinary incontinence, and impotence
**Stiff gait progressing to spasticity and weakness, back pain, urinary incontinence, and impotence
** Can have parasthesias and burning sensation
**Can have parasthesias and burning sensation
** Impaired vibration sense
**Impaired vibration sense
** Hyperreflexia with clonus and upgoing plantar reflexes
**Hyperreflexia with clonus and upgoing plantar reflexes
* Usually insidious onset, but can be acute
*Usually insidious onset, but can be acute
* MRI may be normal or show atrophy of the spinal cord and non-specific brain lesions
*MRI may be normal or show atrophy of the spinal cord and non-specific brain lesions
* CSF can have mild lymphocytosis and mild protein elevation, including oligoclonal bands
*CSF can have mild lymphocytosis and mild protein elevation, including oligoclonal bands


=== Other Syndromes ===
===Other Syndromes===


==== HTLV-1 ====
====HTLV-1====


* Other neurological abnormalities, including sensory neuropathy, gait abnormality, bladder dysfunction, erectile dysfunction, amyotrophic lateral sclerosis, mild cognitive deficit, and motor neuropathy
*Other neurological abnormalities, including sensory neuropathy, gait abnormality, bladder dysfunction, erectile dysfunction, amyotrophic lateral sclerosis, mild cognitive deficit, and motor neuropathy
* Infective dermatitis, which occurs in children who experience failure to thrive, eczema, and Gram-positive infections
*Infective dermatitis, which occurs in children who experience failure to thrive, eczema, and Gram-positive infections
* Polymyositis (HTLV-1-associated inflammatory myopathy of skeletal muscle)
*Polymyositis (HTLV-1-associated inflammatory myopathy of skeletal muscle)
* Large joint polyarthropathy
*Large joint polyarthropathy
* Uveitis
*Uveitis
* Infiltrative pneumonitis
*Infiltrative pneumonitis
* Chronic lympadenopathy
*Chronic lympadenopathy
*Increased infections:
* [[Strongyloides]] hyperinfection
**[[Strongyloides]] hyperinfection
* Crusted [[scabies]]
**Crusted [[scabies]]
**[[Pneumocystis jirovecii]]
**[[Mycobacterium avium complex]]


==== HTLV-2 ====
====HTLV-2====


* Rarely, HAM and other neurological abnormalities
*Rarely, HAM and other neurological abnormalities


== Differential Diagnosis ==
==Differential Diagnosis==


=== HTLV-Associated Myelopathy ===
===HTLV-Associated Myelopathy===


* [[Multiple sclerosis]], which should have a more waxing-waning course
*[[Multiple sclerosis]], which should have a more waxing-waning course
* Spinal cord tumour
*Spinal cord tumour
* Toxic neuropathy
*Toxic neuropathy
* [[Malnutrition]]
*[[Malnutrition]]
* [[HIV]]
*[[HIV]]
* [[Syphilis]]
*[[Syphilis]]


== Management ==
==Management==


* Monitoring for signs or symptoms of leukemia, lymphoma, and neurological disease
*Monitoring for signs or symptoms of leukemia, lymphoma, and neurological disease
* Management of ATL per Hematologi-Oncology service
*Management of ATL per Hematologi-Oncology service


[[Category:Infectious diseases]]
[[Category:Infectious diseases]]

Latest revision as of 15:49, 24 August 2020

Background

Microbiology

  • Single-stranded negative-sense RNA virus in the Retroviridae family, genus Deltaretrovirus
  • Four types:
    • HTLV-1, cause of adult T-cell leukemia-lymphoma and HTLV-associated myelopathy
    • HTLV-2, cause of HTLV-associated myelopathy
    • HTLV-3 and HTLV-4 are rare

Epidemiology

  • HTLV-1 endemic to central Africa, the Caribbean basin, parts of South America, and southwestern Japan
  • HTLV-2 endemic to indigenous people in the Americas, and Central African pygmies, as well as injection drug users in North America and Europe
  • Transmitted sexually, parenterally (blood-borne), and vertically (mother-to-child, primarily through breastfeeding)
  • Seroprevalence increases with age and is higher in women than men

Clinical Manifestations

Syndrome HTLV-1 HTLV-2
Children
Infective dermatitis yes no
Lymphadenopathy yes yes
Adults
Adult T-cell leukemia-lymphoma yes no
HTLV-associated myelopathy yes yes
Infective dermatitis yes no
Polymyositis possibly unknown
Uveitis yes unknown
HTLV-associated arthritis possibly possibly
SjΓΆgren syndrome possibly unknown
Strongyloidiasis possibly unknown
Pulmonary infiltrative pneumonitis possibly possibly
Invasive cervical cancer possibly unknown

Adult T-cell Leukemia-Lymphoma (ATL)

  • Associated with HTLV-1, with a lifetime risk of 2 to 4% and latent period to 30 to 50 years
  • Aggressive T-cell leukemia or lymphoma with four subtypes
    • Smoldering (5%), with β‰₯5% abnormal T-cells but otherwise normal differential, Β± skin lesions Β± pulmonary involvement
    • Chronic (19%), with lymphocytosis β‰₯4 and T-cells >3.5, Β± lymphadenopathy/organomegaly/skin lesions/pulmonary involvement
    • Lymphoma/leukemia (19%), with lymphadenopathy without lymphocytosis; poor prognosis (median 10 months)
    • Acute (57%), with increased leukemic T cells and worsening clinical picture including hypercalcemia; poor prognosis (median 6 months)
  • Presents with lymphadenopathy, hepatosplenomegaly, hypercalcemia, skin lesions, lytic bone lesions, and abnormal peripheral blood film with lymphocytosis and "flower cells"
  • Skin findings can be either localized or diffuse as papules, nodules, plaques, erythematous patches, and diffuse erythroderma

HTLV-Associated Myelopathy

  • Also called tropical spastic paraparesis
  • Associated with HTLV-1 and -2, with lifetime prevalence of 4%
  • Thought to be caused by an autoimmune response from HTLV-1 antibodies due to molecular mimicry
  • Chronic progressive demyelinating disease affecting white matter and spinal cord
    • Unexplained central neurological disease with loss of pyramidal tract
    • Stiff gait progressing to spasticity and weakness, back pain, urinary incontinence, and impotence
    • Can have parasthesias and burning sensation
    • Impaired vibration sense
    • Hyperreflexia with clonus and upgoing plantar reflexes
  • Usually insidious onset, but can be acute
  • MRI may be normal or show atrophy of the spinal cord and non-specific brain lesions
  • CSF can have mild lymphocytosis and mild protein elevation, including oligoclonal bands

Other Syndromes

HTLV-1

  • Other neurological abnormalities, including sensory neuropathy, gait abnormality, bladder dysfunction, erectile dysfunction, amyotrophic lateral sclerosis, mild cognitive deficit, and motor neuropathy
  • Infective dermatitis, which occurs in children who experience failure to thrive, eczema, and Gram-positive infections
  • Polymyositis (HTLV-1-associated inflammatory myopathy of skeletal muscle)
  • Large joint polyarthropathy
  • Uveitis
  • Infiltrative pneumonitis
  • Chronic lympadenopathy
  • Increased infections:

HTLV-2

  • Rarely, HAM and other neurological abnormalities

Differential Diagnosis

HTLV-Associated Myelopathy

Management

  • Monitoring for signs or symptoms of leukemia, lymphoma, and neurological disease
  • Management of ATL per Hematologi-Oncology service
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