Human T-lymphotropic virus: Difference between revisions

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(Created page with "== Background == === Microbiology === * Single-stranded negative-sense RNA virus in the Retroviridae family, genus ''Deltaretrovirus'' * Four types: ** HTLV-1, cause of...")
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== Background ==
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==Background==
   
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=== Microbiology ===
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===Microbiology===
   
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* Single-stranded negative-sense RNA virus in the [[Retroviridae]] family, genus ''Deltaretrovirus''
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*Single-stranded negative-sense RNA virus in the [[Retroviridae]] family, genus ''Deltaretrovirus''
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* Four types:
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*Four types:
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** HTLV-1, cause of adult T-cell leukemia-lymphoma and HTLV-associated myelopathy
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**HTLV-1, cause of adult T-cell leukemia-lymphoma and HTLV-associated myelopathy
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** HTLV-2, cause of HTLV-associated myelopathy
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**HTLV-2, cause of HTLV-associated myelopathy
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** HTLV-3 and HTLV-4 are rare
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**HTLV-3 and HTLV-4 are rare
   
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=== Epidemiology ===
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===Epidemiology===
   
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* HTLV-1 endemic to central Africa, the Caribbean basin, parts of South America, and southwestern Japan
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*HTLV-1 endemic to central Africa, the Caribbean basin, parts of South America, and southwestern Japan
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* HTLV-2 endemic to indigenous people in the Americas, and Central African pygmies, as well as injection drug users in North America and Europe
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*HTLV-2 endemic to indigenous people in the Americas, and Central African pygmies, as well as injection drug users in North America and Europe
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* Transmitted sexually, parenterally (blood-borne), and vertically (mother-to-child, primarily through breastfeeding)
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*Transmitted sexually, parenterally (blood-borne), and vertically (mother-to-child, primarily through breastfeeding)
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* Seroprevalence increases with age and is higher in women than men
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*Seroprevalence increases with age and is higher in women than men
   
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== Clinical Manifestations ==
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==Clinical Manifestations==
 
{| class="wikitable"
  
{| class="wikitable"
 
!Syndrome
  
!Syndrome
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|}
   
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=== Adult T-cell Leukemia-Lymphoma (ATL) ===
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===Adult T-cell Leukemia-Lymphoma (ATL)===
   
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* Associated with HTLV-1, with a lifetime risk of 2 to 4% and latent period to 30 to 50 years
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*Associated with HTLV-1, with a lifetime risk of 2 to 4% and latent period to 30 to 50 years
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* Aggressive T-cell [[leukemia]] or [[lymphoma]] with four subtypes
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*Aggressive T-cell [[leukemia]] or [[lymphoma]] with four subtypes
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** Smoldering (5%), with β‰₯5% abnormal T-cells but otherwise normal differential, Β± skin lesions Β± pulmonary involvement
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**Smoldering (5%), with β‰₯5% abnormal T-cells but otherwise normal differential, Β± skin lesions Β± pulmonary involvement
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** Chronic (19%), with lymphocytosis β‰₯4 and T-cells >3.5, Β± lymphadenopathy/organomegaly/skin lesions/pulmonary involvement
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**Chronic (19%), with lymphocytosis β‰₯4 and T-cells >3.5, Β± lymphadenopathy/organomegaly/skin lesions/pulmonary involvement
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** Lymphoma/leukemia (19%), with lymphadenopathy without lymphocytosis; poor prognosis (median 10 months)
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**Lymphoma/leukemia (19%), with lymphadenopathy without lymphocytosis; poor prognosis (median 10 months)
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** Acute (57%), with increased leukemic T cells and worsening clinical picture including hypercalcemia; poor prognosis (median 6 months)
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**Acute (57%), with increased leukemic T cells and worsening clinical picture including hypercalcemia; poor prognosis (median 6 months)
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* Presents with lymphadenopathy, hepatosplenomegaly, hypercalcemia, skin lesions, lytic bone lesions, and abnormal peripheral blood film with lymphocytosis and "flower cells"
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*Presents with lymphadenopathy, hepatosplenomegaly, hypercalcemia, skin lesions, lytic bone lesions, and abnormal peripheral blood film with lymphocytosis and "flower cells"
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* Skin findings can be either localized or diffuse as papules, nodules, plaques, erythematous patches, and diffuse erythroderma
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*Skin findings can be either localized or diffuse as papules, nodules, plaques, erythematous patches, and diffuse erythroderma
   
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=== HTLV-Associated Myelopathy ===
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===HTLV-Associated Myelopathy===
   
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* Also called '''tropical spastic paraparesis'''
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*Also called '''tropical spastic paraparesis'''
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* Associated with HTLV-1 and -2, with lifetime prevalence of 4%
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*Associated with HTLV-1 and -2, with lifetime prevalence of 4%
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* Thought to be caused by an autoimmune response from HTLV-1 antibodies due to molecular mimicry
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*Thought to be caused by an autoimmune response from HTLV-1 antibodies due to molecular mimicry
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* Chronic progressive demyelinating disease affecting white matter and spinal cord
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*Chronic progressive demyelinating disease affecting white matter and spinal cord
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** Unexplained central neurological disease with loss of pyramidal tract
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**Unexplained central neurological disease with loss of pyramidal tract
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** Stiff gait progressing to spasticity and weakness, back pain, urinary incontinence, and impotence
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**Stiff gait progressing to spasticity and weakness, back pain, urinary incontinence, and impotence
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** Can have parasthesias and burning sensation
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**Can have parasthesias and burning sensation
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** Impaired vibration sense
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**Impaired vibration sense
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** Hyperreflexia with clonus and upgoing plantar reflexes
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**Hyperreflexia with clonus and upgoing plantar reflexes
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* Usually insidious onset, but can be acute
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*Usually insidious onset, but can be acute
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* MRI may be normal or show atrophy of the spinal cord and non-specific brain lesions
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*MRI may be normal or show atrophy of the spinal cord and non-specific brain lesions
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* CSF can have mild lymphocytosis and mild protein elevation, including oligoclonal bands
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*CSF can have mild lymphocytosis and mild protein elevation, including oligoclonal bands
   
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=== Other Syndromes ===
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===Other Syndromes===
   
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==== HTLV-1 ====
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====HTLV-1====
   
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* Other neurological abnormalities, including sensory neuropathy, gait abnormality, bladder dysfunction, erectile dysfunction, amyotrophic lateral sclerosis, mild cognitive deficit, and motor neuropathy
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*Other neurological abnormalities, including sensory neuropathy, gait abnormality, bladder dysfunction, erectile dysfunction, amyotrophic lateral sclerosis, mild cognitive deficit, and motor neuropathy
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* Infective dermatitis, which occurs in children who experience failure to thrive, eczema, and Gram-positive infections
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*Infective dermatitis, which occurs in children who experience failure to thrive, eczema, and Gram-positive infections
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* Polymyositis (HTLV-1-associated inflammatory myopathy of skeletal muscle)
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*Polymyositis (HTLV-1-associated inflammatory myopathy of skeletal muscle)
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* Large joint polyarthropathy
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*Large joint polyarthropathy
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* Uveitis
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*Uveitis
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* Infiltrative pneumonitis
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*Infiltrative pneumonitis
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* Chronic lympadenopathy
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*Chronic lympadenopathy
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*Increased infections:
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* [[Strongyloides]] hyperinfection
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**[[Strongyloides]] hyperinfection
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* Crusted [[scabies]]
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**Crusted [[scabies]]
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**[[Pneumocystis jirovecii]]
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**[[Mycobacterium avium complex]]
   
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==== HTLV-2 ====
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====HTLV-2====
   
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* Rarely, HAM and other neurological abnormalities
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*Rarely, HAM and other neurological abnormalities
   
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== Differential Diagnosis ==
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==Differential Diagnosis==
   
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=== HTLV-Associated Myelopathy ===
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===HTLV-Associated Myelopathy===
   
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* [[Multiple sclerosis]], which should have a more waxing-waning course
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*[[Multiple sclerosis]], which should have a more waxing-waning course
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* Spinal cord tumour
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*Spinal cord tumour
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* Toxic neuropathy
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*Toxic neuropathy
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* [[Malnutrition]]
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*[[Malnutrition]]
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* [[HIV]]
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*[[HIV]]
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* [[Syphilis]]
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*[[Syphilis]]
   
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== Management ==
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==Management==
   
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* Monitoring for signs or symptoms of leukemia, lymphoma, and neurological disease
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*Monitoring for signs or symptoms of leukemia, lymphoma, and neurological disease
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* Management of ATL per Hematologi-Oncology service
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*Management of ATL per Hematologi-Oncology service
   
 
[[Category:Infectious diseases]]
  
[[Category:Infectious diseases]]

Latest revision as of 11:49, 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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