Case Report: A Case of Epstein Barr Virus-related Glial Fibrillary Acidic Protein Astrocytopathy Refractory to Conventional Immunotherapy

Case Report: A Case of Epstein Barr Virus-related Glial Fibrillary Acidic Protein Astrocytopathy Refractory to Conventional Immunotherapy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Case Report: A Case of Epstein Barr Virus-related Glial Fibrillary Acidic Protein Astrocytopathy Refractory to Conventional Immunotherapy Shaowen Ju, Yixue Liu, Tingfang Zhang, Donglei Song, Dongyang Heng, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4916639/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Epstein-Barr virus (EBV) infection has been associated with the development of glial fibrillary acidic protein astrocytopathy (GFAP-A), with most cases responding favorably to steroids and/or intravenous immunoglobulin (IVIG). We report a case of EBV-related GFAP-A exhibiting a poor response to conventional immunotherapy. Case presentation A 62-year-old Chinese male presented with dysuria, fever, and headache, rapidly progressing to paraparesis. Initial investigations indicated pulmonary infection and viral encephalitis. Despite intensive care and antiviral treatment, his condition deteriorated, necessitating tracheostomy and intubation. Upon transfer to a tertiary neurology center, he had reduced tone, power, and areflexia in the lower limbs, and a loss of sensation below the T6 level. Cerebrospinal fluid (CSF) analysis revealed markedly elevated cell counts and protein levels. MRI showed leptomeningeal enhancement in the left frontal lobe, cervical and thoracic spines. EBV DNA and GFAP-IgG were detected in the CSF, suggesting a diagnosis of EBV-related GFAP-A. Treatment with IV acyclovir, high-dose steroids, and IVIG was administered with no clinical improvement. Conclusions This report presents a case of EBV-related GFAP-A refractory to treatments with steroids and IVIG. It suggests that higher levels of CSF protein and cell count may predict worse outcomes and a poorer prognosis. Epstein-Barr virus glial fibrillary acidic protein astrocytopathy steroids intravenous immunoglobulin refractory case report Figures Figure 1 Figure 2 Background Epstein-Barr virus (EBV), or human herpesvirus 4, is a double-stranded DNA virus affecting 90–95% of the global population ( 1 ). The pathophysiology of EBV-related neurological disorders remains unclear and has been suggested to involve direct infection, immune hyperactivity, or reactivation of latent infections ( 2 , 3 ). Glial fibrillary acidic protein astrocytopathy (GFAP-A) is an autoimmune inflammatory disorder of the central nervous system first described in 2016 ( 4 ), presenting with symptoms involving the meninges, brain parenchyma, spinal cord, optic or peripheral nerves. Radiologically, it is characterized by linear radial perivascular enhancement on brain MRI and longitudinally extensive T2- hyperintense lesion with linear enhancement in the spine ( 5 , 6 ). Histologically, the presence of GFAP-IgG antibodies in cerebrospinal fluid (CSF) is a key diagnostic marker with high specificity ( 6 ). Standard acute treatment involves steroid and/or intravenous immunoglobulin (IVIG) therapy, with 80% of cases showing good responses ( 5 ). Chronic treatment involves mycophenolate mofetil (MMF), rituximab, azathioprine and cyclosporine; however, evidence is not clear on the effectiveness of these treatments and their clinical outcomes ( 7 ). In rare cases, GFAP-A has been linked to EBV infection, with most patients responding to standard immunotherapy ( 8 – 11 ). We report a new case of GFAP-A associated with EBV infection which had a poor response to steroids and IVIG. Case Presentation A 62-year-old Chinese male with a background of Type II diabetes was admitted to a local hospital in China with dysuria, fever, and headache. CT chest indicated a pulmonary infection, which failed to respond to antibiotics. On Day 4, he developed paraparesis and was diagnosed with viral encephalitis based on CSF analysis (exact values undisclosed). He was then transferred to the intensive care unit of another hospital for further treatment. Following transfer, his pulmonary condition deteriorated, leading to tracheostomy and intubation. Antiviral treatment was initiated. On Day 9, a repeat CSF analysis showed an elevated cell count (339×10 6 /L) and high protein levels (> 3g/L), suggesting an intracranial infection. Despite treatment with IV methylprednisolone (0.5g×3d), there was no improvement, and he was transferred to a tertiary neurology center on Day 17. Upon arrival, he presented with a Glasgow Coma Scale score of E4VTM6, nuchal rigidity, and reduced tone in all four limbs. Power was grade 4 in the upper limbs and grade 0 in the lower limbs. Reflexes were absent in the lower limbs and Babinski signs were negative. Deep and superficial sensation was absent below the T6 level. On Day 18, a persistently elevated cell count (160×10 6 /L) and protein levels (1g/L) were noted. Targeted next-generation sequencing (tNGS) identified EBV (8766 reads), indicating a possible EBV-related central nervous system infection. Treatment with IV acyclovir (0.75g q8h), dexamethasone (10mg qd), and human immunoglobulin (IVIG, 0.4g/kg/d×5d) was initiated without improvement. CT scans showed no significant abnormalities in the brain and spinal regions. On Day 28, a repeat CSF analysis showed a decrease in cell count (90×10 6 /L) and protein levels (0.4g/L), and tNGS revealed a reduction in EBV sequences (2857 reads). On Day 38, he was successfully extubated. MRI showed leptomeningeal enhancement in the left frontal lobe, cervical and thoracic spines, with discontinuous long T1- and T2-weighted signals (Fig. 1 ). However, lumbar spine MRI and electromyography were both normal. Despite these results, he continued to have flaccid paraparesis. Subsequently, another course of IVIG (0.4g/kg/d×5d) was administered. On Day 45, a stable CSF cell count (92×10 6 /L) and protein level (5g/L) were observed, and tNGS demonstrated clearance of EBV (0 read). Autoimmune antibody testing detected GFAP IgG antibody (serum titer 1:10, CSF titer 1:1) and type 2 oligoclonal bands, leading to a diagnosis of GFAP astrocytopathy. Consequently, acyclovir was discontinued, and dexamethasone was converted to methylprednisolone pulse therapy (500mg/d×5d, 80mg/d×5d, and 40mg/d×5d). On Day 53, when his lung infection improved, methylprednisolone was stepped down to oral prednisone acetate 15mg, and oral MMF 1g was added as chronic treatment. Despite these interventions, the patient’s paraparesis persisted without signs of improvement. Discussion and Conclusions The literature on EBV-associated GFAP-A is limited, with eight cases identified through our search (Supplementary Table 1) ( 8 – 11 ). This report presents a patient with high EBV sequence count in the CSF and clinical and imaging findings characteristic of GFAP-A, suggesting a potential linkage between EBV infection and the development of GFAP-A. While the underlying mechanism remains unclear, EBI2 (EBV-induced gene 2) has been suggested to play a role by influencing astrocyte migration and modulating immune cell responses via the MAPK/ERK signaling pathway ( 9 , 12 ). Another significant finding was the patient’s lack of response to extensive steroid and IVIG therapy, diverging from the positive outcomes observed in the previously reported cases (Supplementary Table 1). This discrepancy may be attributed to the severity of the cytokine storm induced by the EBV infection, as evidenced by the patient's high initial CSF protein (> 3 g/L) and cell count (339×10 6 /L) (Fig. 2 ). Notably, only one case, Patient 5, reported similar CSF protein (2.8 g/L) and cell count (392×10 6 /L) levels, associated with a poorer outcome at the 6-month follow-up (Supplementary Table 1) ( 9 ). These observations suggest that early elevated CSF protein levels and cell counts might be indicative of a poor response to steroid and IVIG therapy. This differential response could be linked to the GFAP-A's reliance on cytotoxic T-cell responses ( 5 ). In the case of significantly heightened immune hyperactivity, steroid and IVIG may not fully suppress T-cell activity, potentially leading to a partial response and a poorer prognosis. Meanwhile, the relationship between treatment outcomes and EBV replication levels in the CSF remains to be elucidated. While our study utilized tNGS, most reported cases employed metagenomic Next-Generation Sequencing (mNGS) and polymerase chain reaction (PCR) to assess EBV levels. While mNGS offers a broader detection range and greater sequencing depth, tNGS selectively amplifies and sequences specific pathogens or genetic markers, enabling precise detection of low-abundance sequences ( 13 , 14 ). Because cases with favorable treatment outcomes have typically reported lower EBV sequence counts using mNGS as opposed to tNGS as in our case (Supplementary Table 1), the exact relationship between EBV replication levels and prognosis requires further research to establish. In conclusion, our case of EBV-related GFAP-A refractory to steroids and IVIG demonstrates the complexity of treatment responses in this rare condition. The presence of higher CSF cell counts and protein levels may suggest a poorer therapeutic response, indicating a need for future research to clarify the relationship between EBV-induced immune responses and treatment outcomes. Abbreviations CSF Cerebrospinal fluid CT Computed tomography EBI2 Epstein-Barr virus-induced gene 2 EBV Epstein-Barr virus GFAP-A Glial fibrillary acidic protein astrocytopathy GFAP-IgG Glial fibrillary acidic protein immunoglobulin G IV Intravenous IVIG Intravenous immunoglobulin MAPK/ERK Mitogen-activated protein kinases/extracellular signal-regulated kinase MMF Mycophenolate mofetil mNGS Metagenomic next-generation sequencing MRI Magnetic resonance imaging PCR Polymerase chain reaction tNGS Targeted next-generation sequencing Declarations Ethics approval and consent to participate Ethics approval was exempt by the Ethics Committee of Shanghai Donglei Brain Hospital as all information is anonymized. Consent for publication Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that there are no conflicts of interest. Funding The authors report no targeted funding. Authors’ contributions WZ designed the study. TZ, DS and DH collected the data. YL prepared the figures. WZ and SJ drafted the manuscript and the supplementary table. SJ revised the manuscript. The authors read and approved the final manuscript. Acknowledgements We thank the patient and his family for their permission to publish this information. References Zhang N, Zuo Y, Jiang L, Peng Y, Huang X, Zuo L. Epstein-Barr Virus and Neurological Diseases. Front Mol Biosci. 2021;8:816098. Thorley-Lawson DA. EBV Persistence--Introducing the Virus. Curr Top Microbiol Immunol. 2015;390(Pt 1):151–209. Rodrigo-Armenteros P, Kapetanovic-García S, Antón-Méndez L, Gómez-Muga JJ, Río EBD, Fernández-Cuesta MÁ, et al. Akinetic mutism and status epilepticus due to Epstein Barr virus encephalitis. Clin Neurol Neurosurg. 2019 Oct;185:105492. Fang B, McKeon A, Hinson SR, Kryzer TJ, Pittock SJ, Aksamit AJ, et al. Autoimmune Glial Fibrillary Acidic Protein Astrocytopathy: A Novel Meningoencephalomyelitis. JAMA Neurol. 2016 Nov 1;73(11):1297–307. Kunchok A, Zekeridou A, McKeon A. Autoimmune glial fibrillary acidic protein astrocytopathy. Curr Opin Neurol. 2019 Jun;32(3):452–8. Flanagan EP, Hinson SR, Lennon VA, Fang B, Aksamit AJ, Morris PP, et al. Glial fibrillary acidic protein immunoglobulin G as biomarker of autoimmune astrocytopathy: Analysis of 102 patients. Ann Neurol. 2017 Feb;81(2):298–309. Francisco C, Meddles K, Waubant E. Pediatric glial fibrillary acidic protein meningoencephalomyelitis: A case report and review of the literature. Mult Scler Relat Disord. 2019 Apr;29:148–52. Li X, Wang J, Li L, Yang C, Zhao X, Yang B, et al. Epstein–Barr virus: To be a trigger of autoimmune glial fibrillary acidic protein astrocytopathy? CNS Neurosci Ther. 2023 Jul 17;29(12):4139–46. Zhang J ru, Zhuang S, Xu X dong, Song W li, Li K ru, Jiang Y, et al. Overlapping Epstein-Barr virus encephalitis and autoimmune glial fibrillary acidic protein astrocytopathy. Journal of Neuroimmunology [Internet]. 2023 Sep 15 [cited 2024 Jun 28];382. Available from: https://www.jni-journal.com/article/S0165-5728(23)00160-1/abstract Wang L, Dong L, Zhao M, Jiang C, Geng M, Li S, et al. A case of EBV encephalomyelitis with positive anti-GFAP-IgG antibody with recurrent fever and dysuresia as the main symptoms: Case report and retrospective analysis. Medicine (Baltimore). 2022 Dec 2;101(48):e31995. So H, Ohashi T, Yamagishi S, Mori H, Takanashi J ichi. Case of autoimmune glial fibrillary acidic protein astrocytopathy associated with Epstein–Barr virus reactivation. Clinical and Experimental Neuroimmunology. 2022;13(2):106–10. Rutkowska A, Preuss I, Gessier F, Sailer AW, Dev KK. EBI2 regulates intracellular signaling and migration in human astrocyte. Glia. 2015 Feb;63(2):341–51. Li J, Zhang L, Yang X, Wang P, Feng L, Guo E, et al. Diagnostic Significance of Targeted Next-Generation Sequencing in Central Nervous System Infections in Neurosurgery of Pediatrics. Infect Drug Resist. 2023 Apr 15;16:2227–36. Li S, Tong J, Liu Y, Shen W, Hu P. Targeted next generation sequencing is comparable with metagenomic next generation sequencing in adults with pneumonia for pathogenic microorganism detection. J Infect. 2022 Nov;85(5):e127–9. Lan W, Li J, Ai P, Luo W. Autoimmune glial fibrillary acidic protein astrocytopathy: clinical analysis and review of 15 cases. Acta Neurol Belg. 2023 Aug 1;123(4):1465–79. Additional Declarations No competing interests reported. Supplementary Files SupplementaryFile.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4916639","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":354674673,"identity":"db791b32-b2a1-4954-a18e-75d2ebb504a2","order_by":0,"name":"Shaowen Ju","email":"","orcid":"","institution":"University of Cambridge, Addenbrooke's Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Shaowen","middleName":"","lastName":"Ju","suffix":""},{"id":354674674,"identity":"0b31e64a-fbbc-46a2-9422-fa2d385cf900","order_by":1,"name":"Yixue Liu","email":"","orcid":"","institution":"Brandeis University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yixue","middleName":"","lastName":"Liu","suffix":""},{"id":354674675,"identity":"4fb4ec6d-af11-4534-bb30-018872a4c0f1","order_by":2,"name":"Tingfang Zhang","email":"","orcid":"","institution":"Shanghai Donglei Brain Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Tingfang","middleName":"","lastName":"Zhang","suffix":""},{"id":354674676,"identity":"500f3e35-d9f5-44a6-b84b-90add78ba69b","order_by":3,"name":"Donglei Song","email":"","orcid":"","institution":"Shanghai Donglei Brain Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Donglei","middleName":"","lastName":"Song","suffix":""},{"id":354674678,"identity":"e9332057-66e0-4247-8ea2-5c7647d8ff00","order_by":4,"name":"Dongyang Heng","email":"","orcid":"","institution":"Shanghai Donglei Brain Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Dongyang","middleName":"","lastName":"Heng","suffix":""},{"id":354674679,"identity":"cc861ea7-1186-4e6a-85f5-13194cf900c2","order_by":5,"name":"Wenli Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAUlEQVRIie3PMWrDMBSAYQlDuyhotWkhV5CXhIJbX0Uh0CkH8PiMwZm6u2Nv4KnQ7RkNWUS8GlJosjRLB2crxEPs0NKpssdC9SOQBO8DiRCb7W9GURLs9nhbRwHjHPrNF3ESP9P3116GA8h5kcv0apSqQIA0j4vVA+K2eR1P+RO4TJdMEKT1YWEgei1Rsnf/JduBcKMNmzrgeI/Pv5NJtRAoXUXzqgAp9IbdAF44IxN5+2iJUGFHcJauWXvtIVU3I9UsL+MYihT7Sai7h6Ga5xVNKOg587IiMf7FW2p/99mo27xc7Y9NdBdynhT1wUB+cuX3icKQ+TaOAwdtNpvt33UC61tmnG3/u/QAAAAASUVORK5CYII=","orcid":"","institution":"Shanghai Donglei Brain Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Wenli","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2024-08-15 02:42:35","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4916639/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4916639/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":66632704,"identity":"277accfc-f45e-48fa-a0b2-5258e2bd2376","added_by":"auto","created_at":"2024-10-15 05:00:43","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":5077004,"visible":true,"origin":"","legend":"\u003cp\u003eNeuroimaging results. \u003cstrong\u003eA:\u003c/strong\u003eEnhanced brain MRI: linear enhancement is observed in the leptomeninges of the left frontal lobe; \u003cstrong\u003eB:\u003c/strong\u003e Cervical spine MRI (left): multiple patchy areas with long T2-weighted signals are observed in the cervical spinal cord; cervical spine MRI with contrast (right): discontinuous linear enhancement of the leptomeninges; \u003cstrong\u003eC:\u003c/strong\u003e Immunofluorescence of CSF cell-based assay: overlapping red and green signals indicate the presence of GFAP-IgG; \u003cstrong\u003eD: \u003c/strong\u003eThoracic spine MRI (left): discontinuous long T2-weighted signal can be seen from T1 to T12 levels; thoracic spine MRI with contrast (right): meningeal linear enhancement and punctate enhancement around the central canal.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4916639/v1/ae3961b76b6bd8a3b45a7e42.jpg"},{"id":66632711,"identity":"56034eaa-23e2-4927-bbe6-3461305d635b","added_by":"auto","created_at":"2024-10-15 05:00:48","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":93750,"visible":true,"origin":"","legend":"\u003cp\u003eA time series of CSF cell count (1×10\u003csup\u003e9\u003c/sup\u003e/L), total protein (g/L) and EBV reads (1×10\u003csup\u003e4\u003c/sup\u003e) as measured from symptom onset.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4916639/v1/6aa7b426ee8965ed373db168.jpg"},{"id":79667450,"identity":"653e86ad-16fd-426b-9420-d895972d5198","added_by":"auto","created_at":"2025-04-01 10:31:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5583811,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4916639/v1/3cbf45d9-466c-4e20-a9bf-9c1acb180e80.pdf"},{"id":66632713,"identity":"a8988663-50c0-4b9b-bbf7-ae5ba5c6bfdc","added_by":"auto","created_at":"2024-10-15 05:00:49","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":30769,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile.docx","url":"https://assets-eu.researchsquare.com/files/rs-4916639/v1/d05e4b0a3700fcec683a9408.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Case Report: A Case of Epstein Barr Virus-related Glial Fibrillary Acidic Protein Astrocytopathy Refractory to Conventional Immunotherapy","fulltext":[{"header":"Background","content":"\u003cp\u003eEpstein-Barr virus (EBV), or human herpesvirus 4, is a double-stranded DNA virus affecting 90\u0026ndash;95% of the global population (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The pathophysiology of EBV-related neurological disorders remains unclear and has been suggested to involve direct infection, immune hyperactivity, or reactivation of latent infections (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGlial fibrillary acidic protein astrocytopathy (GFAP-A) is an autoimmune inflammatory disorder of the central nervous system first described in 2016 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), presenting with symptoms involving the meninges, brain parenchyma, spinal cord, optic or peripheral nerves. Radiologically, it is characterized by linear radial perivascular enhancement on brain MRI and longitudinally extensive T2- hyperintense lesion with linear enhancement in the spine (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Histologically, the presence of GFAP-IgG antibodies in cerebrospinal fluid (CSF) is a key diagnostic marker with high specificity (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Standard acute treatment involves steroid and/or intravenous immunoglobulin (IVIG) therapy, with 80% of cases showing good responses (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Chronic treatment involves mycophenolate mofetil (MMF), rituximab, azathioprine and cyclosporine; however, evidence is not clear on the effectiveness of these treatments and their clinical outcomes (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn rare cases, GFAP-A has been linked to EBV infection, with most patients responding to standard immunotherapy (\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). We report a new case of GFAP-A associated with EBV infection which had a poor response to steroids and IVIG.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 62-year-old Chinese male with a background of Type II diabetes was admitted to a local hospital in China with dysuria, fever, and headache. CT chest indicated a pulmonary infection, which failed to respond to antibiotics. On Day 4, he developed paraparesis and was diagnosed with viral encephalitis based on CSF analysis (exact values undisclosed). He was then transferred to the intensive care unit of another hospital for further treatment.\u003c/p\u003e \u003cp\u003eFollowing transfer, his pulmonary condition deteriorated, leading to tracheostomy and intubation. Antiviral treatment was initiated. On Day 9, a repeat CSF analysis showed an elevated cell count (339\u0026times;10\u003csup\u003e6\u003c/sup\u003e/L) and high protein levels (\u0026gt;\u0026thinsp;3g/L), suggesting an intracranial infection. Despite treatment with IV methylprednisolone (0.5g\u0026times;3d), there was no improvement, and he was transferred to a tertiary neurology center on Day 17.\u003c/p\u003e \u003cp\u003eUpon arrival, he presented with a Glasgow Coma Scale score of E4VTM6, nuchal rigidity, and reduced tone in all four limbs. Power was grade 4 in the upper limbs and grade 0 in the lower limbs. Reflexes were absent in the lower limbs and Babinski signs were negative. Deep and superficial sensation was absent below the T6 level. On Day 18, a persistently elevated cell count (160\u0026times;10\u003csup\u003e6\u003c/sup\u003e/L) and protein levels (1g/L) were noted. Targeted next-generation sequencing (tNGS) identified EBV (8766 reads), indicating a possible EBV-related central nervous system infection.\u003c/p\u003e \u003cp\u003eTreatment with IV acyclovir (0.75g q8h), dexamethasone (10mg qd), and human immunoglobulin (IVIG, 0.4g/kg/d\u0026times;5d) was initiated without improvement. CT scans showed no significant abnormalities in the brain and spinal regions. On Day 28, a repeat CSF analysis showed a decrease in cell count (90\u0026times;10\u003csup\u003e6\u003c/sup\u003e/L) and protein levels (0.4g/L), and tNGS revealed a reduction in EBV sequences (2857 reads).\u003c/p\u003e \u003cp\u003eOn Day 38, he was successfully extubated. MRI showed leptomeningeal enhancement in the left frontal lobe, cervical and thoracic spines, with discontinuous long T1- and T2-weighted signals (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). However, lumbar spine MRI and electromyography were both normal. Despite these results, he continued to have flaccid paraparesis. Subsequently, another course of IVIG (0.4g/kg/d\u0026times;5d) was administered.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOn Day 45, a stable CSF cell count (92\u0026times;10\u003csup\u003e6\u003c/sup\u003e/L) and protein level (5g/L) were observed, and tNGS demonstrated clearance of EBV (0 read). Autoimmune antibody testing detected GFAP IgG antibody (serum titer 1:10, CSF titer 1:1) and type 2 oligoclonal bands, leading to a diagnosis of GFAP astrocytopathy. Consequently, acyclovir was discontinued, and dexamethasone was converted to methylprednisolone pulse therapy (500mg/d\u0026times;5d, 80mg/d\u0026times;5d, and 40mg/d\u0026times;5d). On Day 53, when his lung infection improved, methylprednisolone was stepped down to oral prednisone acetate 15mg, and oral MMF 1g was added as chronic treatment. Despite these interventions, the patient\u0026rsquo;s paraparesis persisted without signs of improvement.\u003c/p\u003e"},{"header":"Discussion and Conclusions","content":"\u003cp\u003eThe literature on EBV-associated GFAP-A is limited, with eight cases identified through our search (Supplementary Table\u0026nbsp;1) (\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). This report presents a patient with high EBV sequence count in the CSF and clinical and imaging findings characteristic of GFAP-A, suggesting a potential linkage between EBV infection and the development of GFAP-A. While the underlying mechanism remains unclear, EBI2 (EBV-induced gene 2) has been suggested to play a role by influencing astrocyte migration and modulating immune cell responses via the MAPK/ERK signaling pathway (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAnother significant finding was the patient\u0026rsquo;s lack of response to extensive steroid and IVIG therapy, diverging from the positive outcomes observed in the previously reported cases (Supplementary Table\u0026nbsp;1). This discrepancy may be attributed to the severity of the cytokine storm induced by the EBV infection, as evidenced by the patient's high initial CSF protein (\u0026gt;\u0026thinsp;3 g/L) and cell count (339\u0026times;10\u003csup\u003e6\u003c/sup\u003e/L) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Notably, only one case, Patient 5, reported similar CSF protein (2.8 g/L) and cell count (392\u0026times;10\u003csup\u003e6\u003c/sup\u003e/L) levels, associated with a poorer outcome at the 6-month follow-up (Supplementary Table\u0026nbsp;1) (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). These observations suggest that early elevated CSF protein levels and cell counts might be indicative of a poor response to steroid and IVIG therapy. This differential response could be linked to the GFAP-A's reliance on cytotoxic T-cell responses (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). In the case of significantly heightened immune hyperactivity, steroid and IVIG may not fully suppress T-cell activity, potentially leading to a partial response and a poorer prognosis.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eMeanwhile, the relationship between treatment outcomes and EBV replication levels in the CSF remains to be elucidated. While our study utilized tNGS, most reported cases employed metagenomic Next-Generation Sequencing (mNGS) and polymerase chain reaction (PCR) to assess EBV levels. While mNGS offers a broader detection range and greater sequencing depth, tNGS selectively amplifies and sequences specific pathogens or genetic markers, enabling precise detection of low-abundance sequences (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Because cases with favorable treatment outcomes have typically reported lower EBV sequence counts using mNGS as opposed to tNGS as in our case (Supplementary Table\u0026nbsp;1), the exact relationship between EBV replication levels and prognosis requires further research to establish.\u003c/p\u003e \u003cp\u003eIn conclusion, our case of EBV-related GFAP-A refractory to steroids and IVIG demonstrates the complexity of treatment responses in this rare condition. The presence of higher CSF cell counts and protein levels may suggest a poorer therapeutic response, indicating a need for future research to clarify the relationship between EBV-induced immune responses and treatment outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCSF Cerebrospinal fluid\u003c/p\u003e\n\u003cp\u003eCT Computed tomography\u003c/p\u003e\n\u003cp\u003eEBI2 Epstein-Barr virus-induced gene 2\u003c/p\u003e\n\u003cp\u003eEBV Epstein-Barr virus\u003c/p\u003e\n\u003cp\u003eGFAP-A Glial fibrillary acidic protein astrocytopathy\u003c/p\u003e\n\u003cp\u003eGFAP-IgG Glial fibrillary acidic protein immunoglobulin G\u003c/p\u003e\n\u003cp\u003eIV Intravenous\u003c/p\u003e\n\u003cp\u003eIVIG Intravenous immunoglobulin\u003c/p\u003e\n\u003cp\u003eMAPK/ERK Mitogen-activated protein kinases/extracellular signal-regulated kinase\u003c/p\u003e\n\u003cp\u003eMMF Mycophenolate mofetil\u003c/p\u003e\n\u003cp\u003emNGS Metagenomic next-generation sequencing\u003c/p\u003e\n\u003cp\u003eMRI Magnetic resonance imaging\u003c/p\u003e\n\u003cp\u003ePCR Polymerase chain reaction\u003c/p\u003e\n\u003cp\u003etNGS Targeted next-generation sequencing\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval was exempt by the Ethics Committee of Shanghai Donglei Brain Hospital as all information is anonymized.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there are no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors report no targeted funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWZ designed the study. TZ, DS and DH collected the data. YL prepared the figures. WZ and SJ drafted the manuscript and the supplementary table. SJ revised the manuscript. The authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the patient and his family for their permission to publish this information.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eZhang N, Zuo Y, Jiang L, Peng Y, Huang X, Zuo L. Epstein-Barr Virus and Neurological Diseases. Front Mol Biosci. 2021;8:816098. \u003c/li\u003e\n\u003cli\u003eThorley-Lawson DA. EBV Persistence--Introducing the Virus. Curr Top Microbiol Immunol. 2015;390(Pt 1):151\u0026ndash;209. \u003c/li\u003e\n\u003cli\u003eRodrigo-Armenteros P, Kapetanovic-Garc\u0026iacute;a S, Ant\u0026oacute;n-M\u0026eacute;ndez L, G\u0026oacute;mez-Muga JJ, R\u0026iacute;o EBD, Fern\u0026aacute;ndez-Cuesta M\u0026Aacute;, et al. Akinetic mutism and status epilepticus due to Epstein Barr virus encephalitis. Clin Neurol Neurosurg. 2019 Oct;185:105492. \u003c/li\u003e\n\u003cli\u003eFang B, McKeon A, Hinson SR, Kryzer TJ, Pittock SJ, Aksamit AJ, et al. Autoimmune Glial Fibrillary Acidic Protein Astrocytopathy: A Novel Meningoencephalomyelitis. JAMA Neurol. 2016 Nov 1;73(11):1297\u0026ndash;307. \u003c/li\u003e\n\u003cli\u003eKunchok A, Zekeridou A, McKeon A. Autoimmune glial fibrillary acidic protein astrocytopathy. Curr Opin Neurol. 2019 Jun;32(3):452\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eFlanagan EP, Hinson SR, Lennon VA, Fang B, Aksamit AJ, Morris PP, et al. Glial fibrillary acidic protein immunoglobulin G as biomarker of autoimmune astrocytopathy: Analysis of 102 patients. Ann Neurol. 2017 Feb;81(2):298\u0026ndash;309. \u003c/li\u003e\n\u003cli\u003eFrancisco C, Meddles K, Waubant E. Pediatric glial fibrillary acidic protein meningoencephalomyelitis: A case report and review of the literature. Mult Scler Relat Disord. 2019 Apr;29:148\u0026ndash;52. \u003c/li\u003e\n\u003cli\u003eLi X, Wang J, Li L, Yang C, Zhao X, Yang B, et al. Epstein\u0026ndash;Barr virus: To be a trigger of autoimmune glial fibrillary acidic protein astrocytopathy? CNS Neurosci Ther. 2023 Jul 17;29(12):4139\u0026ndash;46. \u003c/li\u003e\n\u003cli\u003eZhang J ru, Zhuang S, Xu X dong, Song W li, Li K ru, Jiang Y, et al. Overlapping Epstein-Barr virus encephalitis and autoimmune glial fibrillary acidic protein astrocytopathy. Journal of Neuroimmunology [Internet]. 2023 Sep 15 [cited 2024 Jun 28];382. Available from: https://www.jni-journal.com/article/S0165-5728(23)00160-1/abstract\u003c/li\u003e\n\u003cli\u003eWang L, Dong L, Zhao M, Jiang C, Geng M, Li S, et al. A case of EBV encephalomyelitis with positive anti-GFAP-IgG antibody with recurrent fever and dysuresia as the main symptoms: Case report and retrospective analysis. Medicine (Baltimore). 2022 Dec 2;101(48):e31995. \u003c/li\u003e\n\u003cli\u003eSo H, Ohashi T, Yamagishi S, Mori H, Takanashi J ichi. Case of autoimmune glial fibrillary acidic protein astrocytopathy associated with Epstein\u0026ndash;Barr virus reactivation. Clinical and Experimental Neuroimmunology. 2022;13(2):106\u0026ndash;10. \u003c/li\u003e\n\u003cli\u003eRutkowska A, Preuss I, Gessier F, Sailer AW, Dev KK. EBI2 regulates intracellular signaling and migration in human astrocyte. Glia. 2015 Feb;63(2):341\u0026ndash;51. \u003c/li\u003e\n\u003cli\u003eLi J, Zhang L, Yang X, Wang P, Feng L, Guo E, et al. Diagnostic Significance of Targeted Next-Generation Sequencing in Central Nervous System Infections in Neurosurgery of Pediatrics. Infect Drug Resist. 2023 Apr 15;16:2227\u0026ndash;36. \u003c/li\u003e\n\u003cli\u003eLi S, Tong J, Liu Y, Shen W, Hu P. Targeted next generation sequencing is comparable with metagenomic next generation sequencing in adults with pneumonia for pathogenic microorganism detection. J Infect. 2022 Nov;85(5):e127\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eLan W, Li J, Ai P, Luo W. Autoimmune glial fibrillary acidic protein astrocytopathy: clinical analysis and review of 15 cases. Acta Neurol Belg. 2023 Aug 1;123(4):1465\u0026ndash;79. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Epstein-Barr virus, glial fibrillary acidic protein astrocytopathy, steroids, intravenous immunoglobulin, refractory, case report","lastPublishedDoi":"10.21203/rs.3.rs-4916639/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4916639/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eEpstein-Barr virus (EBV) infection has been associated with the development of glial fibrillary acidic protein astrocytopathy (GFAP-A), with most cases responding favorably to steroids and/or intravenous immunoglobulin (IVIG). We report a case of EBV-related GFAP-A exhibiting a poor response to conventional immunotherapy.\u003c/p\u003e\u003ch2\u003eCase presentation\u003c/h2\u003e \u003cp\u003eA 62-year-old Chinese male presented with dysuria, fever, and headache, rapidly progressing to paraparesis. Initial investigations indicated pulmonary infection and viral encephalitis. Despite intensive care and antiviral treatment, his condition deteriorated, necessitating tracheostomy and intubation. Upon transfer to a tertiary neurology center, he had reduced tone, power, and areflexia in the lower limbs, and a loss of sensation below the T6 level. Cerebrospinal fluid (CSF) analysis revealed markedly elevated cell counts and protein levels. MRI showed leptomeningeal enhancement in the left frontal lobe, cervical and thoracic spines. EBV DNA and GFAP-IgG were detected in the CSF, suggesting a diagnosis of EBV-related GFAP-A. Treatment with IV acyclovir, high-dose steroids, and IVIG was administered with no clinical improvement.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis report presents a case of EBV-related GFAP-A refractory to treatments with steroids and IVIG. It suggests that higher levels of CSF protein and cell count may predict worse outcomes and a poorer prognosis.\u003c/p\u003e","manuscriptTitle":"Case Report: A Case of Epstein Barr Virus-related Glial Fibrillary Acidic Protein Astrocytopathy Refractory to Conventional Immunotherapy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-15 05:00:25","doi":"10.21203/rs.3.rs-4916639/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7e3a492c-a3ba-4f93-87b7-152e25e31be2","owner":[],"postedDate":"October 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-04-01T10:23:46+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-15 05:00:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4916639","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4916639","identity":"rs-4916639","version":["v1"]},"buildId":"rHA-KDH7Qsr4HCuvH75dn","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}