Clinical manifestations and outcomes of EBV related secondary hemophagocytic lymphohistiocytosis

Clinical manifestations and outcomes of EBV related secondary hemophagocytic lymphohistiocytosis | 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 Research Article Clinical manifestations and outcomes of EBV related secondary hemophagocytic lymphohistiocytosis Dan Liu, Xuying Pei, Xiaohui Zhang, Lanping Xu, Yu Wang, Chenhua Yan, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4768158/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 20 Oct, 2025 Read the published version in Annals of Hematology → Version 1 posted 7 You are reading this latest preprint version Abstract Aim: Epstein-Barr virus (EBV) is the important pathogen of infection after allogeneic hematopoietic stem cell transplantation (allo-HSCT), which is also the common cause of secondary hemophagocytic lymphohistiocytosis (sHLH). Thus, we aimed to identify the clinical manifestations and outcomes of EBV-related sHLH after allo-HSCT. Methods: We enrolled the patients who experienced sHLH after EBV DNAemia after allo-HSCT from Jan 1 st , 2023 to Dec 31 st , 2023. Plasma EBV copies were monitored by Q-PCR analysis at least weekly and EBV-DNA copies of lymphocyte subpopulations in peripheral blood were also quantified by Q-PCR. Results: 11 patients developed sHLH after EBV DNAemia and all of them had post-transplant lymphoproliferative disorders (PTLD) before sHLH. The median time from PTLD to sHLH occurrence was 5 days (range, 2-101) days. The most common manifestation of sHLH was ferritin elevation (100%) and soluble CD25 antigen elevation (100%). Nine (81.8%) patients died after the diagnosis of sHLH, and the median time from the occurrence of sHLH to death was 10 days (range, 3 to 21) days. Temperature ≥ 39.6℃, achieving high-level EBV DNAemia (> 10 5 copies/ml), and with a high-level EBV in T or NK cells increase the risk of sHLH after EBV-PLTD. The 100-day probability of EBV-related mortality and overall survival after PTLD occurrence was 84.1% versus 8.3 % ( P ＜0.0001) and 15.9% versus 91.7% ( P ＜0.0001), respectively, for patients with and without sHLH. Conclusions: In summary, our study firstly reported the clinical manifestations and outcomes of EBV-related sHLH following allo-HSCT in the largest cohort at present. Epstein-Barr virus secondary hemophagocytic lymphohistiocytosis post-transplant lymphoproliferative disorders Figures Figure 1 Figure 2 Introduction Allogeneic hematopoietic stem cell transplantation is the most important curative method for hematologic malignancies 1,2 . Infection is still the most common cause of transplant failure, and Epstein-Barr virus (EBV) is one of the important pathogens. EBV related post-transplant lymphoproliferative disorders (EBV-PTLD) is recognized as a critical complication after allo-HSCT. The incidence of PTLD was 1.46–3.22% 3–5 , and its mortality rate was more than 80% in patients without rituximab treatment and could even be as high as 30% in those receiving rituximab-based therapies 4,6,7 . Secondary hemophagocytic lymphohistiocytosis (sHLH) is a life-threatening hyperinflammatory syndrome 8–10 . Particularly, the incidence of post-transplant sHLH was 1–8.8% 11–13 and its mortality rate was as high as 80% 12,14 . EBV is also the common cause of sHLH 15 ; however, there were only case reports about sHLH following EBV infection in allo-HSCT recipients 16–21 . The largest study about EBV-related sHLH was reported by Ali et al. 5 , that is, only 3 patients with EBV-PTLD developed sHLH and all of them died. Thus, sHLH is rare but very critical in patients with EBV infection after allo-HSCT, but the clinical manifestations, risk factors, and treatments of these patients were still unclear. In this study, we aimed to identify the clinical manifestation of EBV related sHLH in allo-HSCT recipients, and we also aimed to compare the characteristics and clinical outcomes between EBV-PTLD patients with or without sHLH. Patients and Methods Patients This study was conducted based on the transplant database of Peking University, Institute of Hematology (PUIH), and the including criteria were as followed: 1) receiving allo-HSCT between Jan 1st, 2023 and Dec 31st, 2023; 2) diagnosed as EBV DNAemia after allo-HSCT; 3) experienced sHLH after EBV infection. The last follow-up for survivors was Jan 1st, 2024. The study was conducted in accordance with the Declaration of Helsinki , and the protocol was approved by the Institutional Review Board of Peking University People’s Hospital. EBV monitoring after allo-HSCT Plasma EBV copies were monitored by quantitative polymerase chain reaction (Q-PCR) analysis at least weekly until day + 100, and patients who received systemic immunosuppressive therapies should be monitored regularly even after day + 100. Additional detection was performed if symptoms of suspected virus infection were present. The EBV DNAemia was defined as more than 1×10 3 copies/ml EBV-DNA in plasma by Q-PCR in one test 22 . Assays of EBV-infected lymphocyte subpopulations Fresh peripheral blood cells were prepared and washed once in phosphate-buffered saline (PBS) (Beijing Solarbio Science & Technology Co., Ltd., #P1020). Cells from PB samples were stained with anti-CD3, anti-CD4, anti-CD8, anti-CD19, anti-CD56 antibodies, washed again in PBS, and subsequent sorting for the CD3 + CD4 + T cells, CD3 + CD8 + T cells, CD3 − CD19 + B cells, CD56 + NK/NKT cells on the FACSMelody (BD). EBV-DNA copies were quantified by using a commercial polymerase chain reaction (PCR) diagnostic kit for EBV (Shanghai ZJ Bio-Tech Co., Ltd., # P20220201) in PB and sorted lymphocyte subpopulations according to the manufacturer’s recommendations. Definition The diagnosis of EBV-PTLD 6 and sHLH 23 was according to the international criteria. The primary endpoint was EBV-related mortality, which was defined as mortality directly caused by EBV infection. The secondary endpoint was overall survival (OS), which was defined as the time from diagnosis of EBV to death from any cause or the date of last contact. Statistical analysis Data were censored at the time of death or the last available follow-up. Continuous variables were compared with the Mann–Whitney U -test; categorical variables were compared with the χ 2 test and Fisher’s exact test. The Kaplan–Meier method was used to estimate the probability of OS. All reported P -values were based on two-sided tests. In all analyses, P <0.05 indicated statistical significance. Data analyses were conducted with SPSS software (SPSS Inc., Chicago, IL, USA). Results Characteristics of patients with EBV related sHLH after allo-HSCT The characteristics of the 11 patients with sHLH were summarized in Table 1 . All of them were diagnosed as PTLD before sHLH. The median time from allo-HSCT to the diagnosis of PTLD was 69 days (range, 39–98) days, and the median time from PTLD to sHLH occurrence was 5 days (range, 2-101) days. The median follow-up was 22 days (range, 7-122) days after the diagnosis of PTLD. Table 1 The characteristics of patients with EBV-related sHLH Characteristics Cohort (n = 11) Gender (Male) 9/11 Median age, y (range) 47 (19–66) Underlying disease, n (%) AML 3 (28%) ALL 4 (36%) MDS 2 (18%) AA 1 (9%) Others 1 (9%) EBV serostatus before HSCT, n (%) Donor+/recipient+ 10 (91%) Donor-/recipient+ 1 (9%) HLA disparity, n (%) 5/10 8 (80%) 6/10 1 (10%) 10/10 1 (10%) Disease status before allo-HSCT, n (%) CR1 9 (100%) >CR1 0 (0%) Graft type, n (%) PBSC 8 (80%) PBSC + BM 2 (20%) Donor type, n (%) HID 9 (82%) MUD 1 (9%) Others 1 (9%) MNC counts in graft, median (range, ×10 8 /kg) 9.11 (6.19–16.40) CD34 + cell counts in graft, median (range, ×10 6 /kg) 3.18 (1.24–9.56) Abbreviations: AML, acute myeloid leukemia; ALL, acute lymphocytic leukemia; MDS, myelodysplastic syndrome; AA, aplastic anemia; allo-HSCT, allogeneic hematopoietic stem cell transplantation; EBV, Epstein-Barr virus; PBSC, peripheral blood stem cells; BM, bone marrow; CR, complete remission; HID, haploidentical donor; MUD, matched unrelated donors; sHLH, secondary hemophagocytic lymphohistiocytosis; MNC, mononuclear cell. The most common manifestation of sHLH was ferritin elevation (100%) and soluble CD25 antigen elevation (100%), followed by pancytopenia (91%), fever (82%), hypertriglyceridemia (82%), and lactate dehydrogenase elevation (82%) (Fig. 1 ). The median body temperature was 38.4℃ (range, 37.2 to 39.8) ℃ when sHLH was diagnosed. The median value of ferritin, triglyceride, lactate dehydrogenase (LDH), NK cells activity, and soluble CD25 antigen was 9376 ng/mL (range, 2664 to 19619) ng/mL, 1.92 mmol/L (range, 1.33 to 6.33) mmol/L, 431U/L (range, 217 to 1438) U/L, 13.94% (range, 11.24–36.63%), and 20152 pg/mL (range, 10484 to 33479) pg/mL, respectively, at the time of sHLH occurrence (Table 2 ). One patient attained all the criteria of HLH. Table 2 Characteristics of EBV-related sHLH Variable Number (n = 11) Fever, ℃, median (range) 38.4 (37.2–39.8) LDH, U/L, median (range) 431 (217–1438) TBIL, µmol/L, median (range) 24.9 (7.6-265.6) TG, mmol/L, median (range) 1.92 (1.33–6.33) FIB, mg/dL, median (range) 248 (128–483) Neutrophil count, 10 9 /L, median (range) 1.0 (0.16–5.5) Hb count, g/L 63 (40–122) Platelet count, ×10 9 /L, median (range) 23 (2-113) Ferritin, ng/mL, median (range) 9376 (2664–19619) sCD25, U/mL, median (range) 20152 (10484–33479) NK cell activity, %, median (range) 13.94 (11.24–36.63) Pancytopenia, n (%) 10 (90.9%) Splenomegaly, n (%) 7 (63.6%) Hemophagocytosis in bone marrow, n (%) 3 (27.2%) EBV copy in blood when diagnosed PTLD, ×10 2 copies/ml, median (range) 81.6 (13.3-24400) EBV copy in blood when diagnosed sHLH, ×10 2 copies/ml, median (range) 677 (2.01–6030) Days from EBV DNAemia > 10 5 copies/ml to HLH, median (range) 8.5 (2-106) Days from HSCT to sHLH diagnosis, median (range) 89 (49–169) Days from PTLD to HLH diagnosis, median (range) 5 (2-101) Abbreviations: LDH, lactate dehydrogenase; TBIL, total bilirubine; TG, triglyceride; FIB, fibrinogen; Hb, hemoglobin; NK cell, natural killer cell, EBV, Epstein-Barr virus; sHLH, secondary hemophagocytic lymphohistiocytosis; PTLD, post-transplant lymphoproliferative disorders; HSCT, hematopoietic stem cell transplantation. All the patients received the analysis of EBV-infected lymphocytes. All of them showed CD19 + B cell involvement, and the median titers of EBV in B cells were 1×10 6 copies/million cells (range, 1.8×10 3 to 5.6×10 6 ) copies/million cells. Nine (82%) patients showed CD8 + T cell involvement, and the median titers of EBV in CD8 + T cells were 1.4×10 4 copies/million cells (range 6.7×10 2 to 3.5×10 5 ) copies/million cells. Six (55%) patients showed CD4 + T cell involvement, and the median titers of EBV in CD4 + T cells were 1.95×10 3 copies/million cells (range, 3.6×10 2 to 1.2×10 4 ) copies/million cells. Nine (82%) patients showed NK cell involvement, and the median titers of EBV in NK cells were 1.2×10 4 copies/million cells (range, 6.2×10 2 to 4.6×10 5 ) copies/million cells (Table 4 ). The treatment and outcomes of EBV-related sHLH All the patients received rituximab for EBV infection. In addition, the most common therapy for sHLH was corticosteroid treatment (100%), followed by etoposide (63.6%), intravenous immunoglobulin (IVIG, 45.5%), and ruxolitinib (27.3%). Three patients received EBV-specific cytotoxic T cell (CTL) infusion. Seven patients used the protocol of HLH-94 24 . Nine (81.8%) patients died after the diagnosis of sHLH, and the median time from the occurrence of sHLH to death was 10 days (range, 3 to 21) days. The characteristics between EBV-PTLD patients with and without sHLH As all the patients with EBV-related sHLH had PTLD simultaneously, the EBV-PTLD patients without HLH during the same time period were enrolled as controlled ( n = 30). The characteristics between patients with and without sHLH were showed in Table 3 . Particularly, we observed that body temperature at diagnosis of EBV-PTLD were significantly higher in sHLH group (39.6℃ versus 38.5℃, P = 0.0042). The initial value and peak value of EBV DNAemia was 8.16×10 3 copies/ml (range, 1.33×10 3 to 2.44×10 6 ) copies/ml versus 8.53×10 3 copies/ml (range, 3.14×10 2 to 8.23×10 4 ) copies/ml ( P = 0.68) and 3.63×10 5 copies/ml (range, 1.63×10 4 to 2.44×10 6 ) copies/ml versus 1.945×10 4 copies/ml (range, 1.04×10 3 to 8.42×10 5 ) copies/ml ( P = 0.0001), respectively, in patients with and without sHLH. Two (6.7%) and seven (63.6%) patients, respectively, in non-sHLH and sHLH group had the high-level EBV DNAemia (i.e., > 10 5 copies/ml) after the diagnosis of EBV-PTLD ( P = 0.001) (Table 3 ). The median time from EBV-PTLD diagnosis to achieving the high-level EBV DNAemia (i.e., > 10 5 copies/ml) in patients with and without sHLH was 0 days (range, -7 to 36 days) and 3.5 days (range, 3 to 4 days) ( P = 0.64). The median time from achieving high-level EBV DNAemia to sHLH occurrence was 8.5 days (range, 2 to 106) days. Table 3 Characteristics of patients with and without sHLH when PTLD was diagnosed PTLD without sHLH (n = 30) PTLD with sHLH (n = 11) P value Fever, median (range) 38.5 (37.5–40.4) 39.6 (38.5–40.4) 0.0042 * LDH, median (range) 348 (176–642) 355 (125–779) 0.39 TBIL, median (range) 12.65 (6.8–32.6) 25.7 (6.6–87) 0.23 TG, median (range) 2.155 (0.57–5.56) 2.19 (1.05–7.44) 0.46 FIB, median (range) 429 (209–686) 389 (161–701) 0.37 Neutrophil count, 10 9 /L 2.54 (0.50–10.9) 2.96 (0.30–12.2) 0.46 Hb count, g/L 89.5 (58–157) 87 (53–121) 0.66 Platelet count, median (range) 71 (21–231) 44 (5–73) 0.054 Pancytopenia, n(%) 15 (50%) 8 (72.7%) 0.29 Splenomegaly, n(%) 9 (30%) 6 (54.5%) 0.272 Hemophagocytosis in bone marrow 4 (13.3%) 3 (27.2%) 0.36 Days from HSCT to EBV positivity in blood, median (range) 58 (35–270) 57 (35–93) 0.83 Days from EBV initial positivity to more than 10 5 in blood, median (range) 11.5 ( 9 – 14 ) 7 (4–56) 0.25 Days from EBV initial positivity to maximum in blood, median (range) 8.5 (1–44) 13 (6–56) 0.07 Maximum EBV copy>10 5 in blood, n(%) 2 (6.7%) 7 (63.6%) 0.001 * Abbreviations: LDH, lactate dehydrogenase; TBIL, total bilirubine; TG, triglyceride; FIB, fibrinogen; Hb, hemoglobin; EBV, Epstein-Barr virus; sHLH, secondary hemophagocytic lymphohistiocytosis; PTLD, post-transplant lymphoproliferative disorders; HSCT, hematopoietic stem cell transplantation. Sixteen non-sHLH patients received the analysis of EBV-infected lymphocytes. The comparation between patients with and without sHLH were showed in Table 4 . Thus, we defined high-level EBV in lymphocytes using the median value of sHLH cohort as cut off point, that is EBV value more than 1.95×10 3 copies/million cells, 1.4×10 4 copies/million cells, 1.2×10 4 copies/million cells, and 1×10 6 copies/million cells in CD4 + T cell, CD8 + T cell, NK cell, and CD19 + B cell, respectively. We observed that the ratio of patients with high-level EBV in CD4 + T cell, CD8 + T cell, or NK cell was 90.9% in sHLH group, which was significantly higher than that of non-sHLH group (50%, P = 0.008) (Suppl. Table 1). We categorized the 27 patients into three groups according to body temperature at EBV-PTLD diagnosis (≥ 39.6℃ vs. < 39.6℃), achieving high-level EBV DNAemia (yes vs. no), and patients with high-level EBV in CD4 + T cell, CD8 + T cell, or NK cell (yes vs. no): low-risk (0 risk factor, n = 8), intermediate-risk (1 risk factor, n = 7), and high-risk group (≥ 2 risk factors, n = 12). The ratio of sHLH was 0%, 28.6%, and 77.8% for patients in low-, intermediate-, and high-risk group ( P = 0.005, Fig. 2 ). The 100-day probability of EBV-related mortality and OS after PTLD occurrence was 84.1% (95% CI 48.9%-100%) versus 8.3% (95%CI 0%-24.6%) with P <0.0001 and 15.9% (95% CI 3.0%-83.8%) versus 91.7% (95%CI 77.3%-100%) with P <0.0001, respectively, for patients with and without EBV-sHLH. Table 4 EBV copies per million cells in peripheral lymphocyte subsets in patients with and without sHLH All Patients (n = 27) PTLD without sHLH (n = 16) PTLD with sHLH (n = 11) CD4 + T cells (median, range) 2200 (320-170000) 12000 (320-170000) 1950 (360-12000) CD8 + T cells (median, range) 9900 (48-350000) 5550 (48-80000) 14000 (670-350000) CD3 − CD19 + B cells (median, range) 1000000 (1800-5770000) 1000000 (82000-5770000) 1000000 (1800-5600000) CD56 + NK cells (median, range) 6600 (110-460000) 1700 (110-58900) 12000 (620-460000) Discussion In the present study, we observed that the 100-day probability of mortality and OS was 84.1% and 15.9%, respectively, in those with EBV-related sHLH after allo-HSCT. EBV-PTLD patients with sHLH had a significant worse prognosis than those without sHLH. Temperature ≥ 39.6℃, achieving high-level EBV DNAemia and with a high-level EBV in T or NK cells increase the risk of sHLH after EBV-PLTD. Particularly, the ratio of sHLH could be as high as 77.8% in those with all the three risk factors. To our knowledge, this is the largest cohort to present the clinical manifestations, risk factors, treatment and clinical outcomes sHLH after EBV-related sHLH. Previous studies have recognized high-level EBV DNAemia is a risk factor for poor outcomes, for example, it was associated with the development of EBV-PTLD 25,26 . In addition, the high-level of EBV DNAemia after rituximab therapy was also associated with a poor survival 27 . In the present study, we firstly observed that EBV-PTLD patients with a high-level EBV DNAemia also had a higher risk of sHLH. This further confirmed the poor prognosis of a high-level EBV DNAemia in EBV-PTLD, and patients with a high-level EBV DNAemia should receive more intensive and aggressive therapy. In lymphoma other than EBV-PTLD, most of the sHLH are observed in patients with T cells or NK/T cells lymphoma, and sHLH was rare in patients with B cell lymphoma 10,28–31 . This might contribute to the low incidence of sHLH after EBV-PTLD, because most of the EBV-PTLD originated from B cells and T or NK cells lymphomas only represented 2–15% of all cases. 32 In the present study, we observed that the B cell involvement by EBV was more prominent compared with T cells or NK cells involvement in all the EBV-PTLD patients, even in those with sHLH. However, we firstly observed that sHLH could occur in B-cell EBV-PTLD patients with a high-level EBV in T or NK cells. This further confirmed the important role of assays of EBV-infected lymphocyte subpopulations in EBV-PTLD patients. The elimination of EBV is the most important treatment for EBV-PTLD, which was also critical for sHLH after EBV-PTLD. However, rituximab could not clear the EBV in T or NK cells. Thus, cytotherapy, particularly the EBV-specific CTL may be one of the most important treatments to clear the EBV in T or NK cells in patients with EBV-PTLD. Several studies have confirmed that donor-derived EBV-CTLs can clear viremia and help to achieve durable complete remission (CR) rates of 50%-70% in patients with EBV-positive lymphomas 33–35 . Prockop et al. 36 reported that third-party EBV-CTL is also effective in the treatment of PTLD patients who had failed to rituximab therapy. The CR or sustained partial remission rate was 68% and the 1-year OS rate was 88.9%. However, efficacy and safety of EBV-specific CTL should be further confirmed in patients with sHLH after EBV-PTLD. In addition, PD-1 blockade could enhance the ability of T cells to control the outgrowth of EBV-induced lymphomas 37 , and anti-PD-1 antibody combined with chemotherapies were associated with a prolonged survival in EBV-related lymphoma-associated sHLH 38 . Thus, PD-1 antibody may also be the potential treatment for sHLH after EBV-PTLD. Besides of clearing the EBV, the standard treatment for sHLH is the HLH-94 protocol, which includes dexamethasone, etoposide, cyclosporin A and in selected patients, intrathecal methotrexate 24 . However, this protocol had some limitations in allo-HSCT recipients. For example, etoposide may cause severe bone marrow suppression and secondary graft failure was one of the most severe post-transplant complications. In addition, some EBV-PTLD patients with sHLH were too weak to tolerate HLH-94 protocol. On the other hand, Sandler et al. 11 reported that sHLH following HSCT could be treated with high-dose corticosteroids, but this study did not include patients with sHLH following EBV-PTLD. Thus far, there was no common accepted therapeutic protocol for patients with sHLH after EBV-PTLD, which was also the major reason for the poor survival of these patients. New therapies for sHLH after PTLD should be further identified in future. This study has several limitations. Although it is the largest cohort of patients with EBV-related sHLH after allo-HSCT, there are only 11 cases and our results should be further confirmed by multicenter studies. In addition, some PTLD patients did not perform EBV-DNA copy quantification in lymphocyte subpopulations, which may affect our results of the association of EBV distribution in cell subpopulations and the risk of sHLH. In addition, the therapies were variation among sHLH patients, and we could not further compare the efficacy among different therapies for EBV-related sHLH after allo-HSCT. In summary, our study firstly reported the clinical manifestationsand clinical outcomes of EBV-related sHLH after allo-HSCT in a large cohort. We also identify a subgroup of patients who had a higher risk of EBV-related sHLH. Our results should be further confirmed by multicenter, prospective studies. Abbreviations AML acute myeloid leukemia ALL acute lymphocytic leukemia MDS myelodysplastic syndrome AA aplastic anemia allo-HSCT allogeneic hematopoietic stem cell transplantation EBV Epstein-Barr virus PBSC peripheral blood stem cells BM bone marrow CR complete remission HID haploidentical donor MUD matched unrelated donors sHLH secondary hemophagocytic lymphohistiocytosis MNC mononuclear cell. Declarations Ethics approval and consent to participate This study was approved by the Institutional Review Board of Peking University. The committee evaluated the ethical aspects of the study in accordance with the World Medical Association’s Declaration of Helsinki. All of the included patients in this study provided written informed consent. Competing interests The authors declare no competing interests. Funding This study was supported by major Program of the National Natural Science Foundation of China (No. 82293630), Peking University Medicine Fund for world's leading discipline or discipline cluster development (No.71003Y3035), National Key Research and Development Program of China (2022YFC2502606), and Tongzhou District Distinguished Young Scholars (JCQN2023009). Author’s Contributions Xiao-Dong Mo and Xiao-Jun Huang conceived and designed the study. Dan-Liu and Xiao-Dong Mo collected and analyzed the data and drafted the manuscript. All the authors contributed to the data interpretation and manuscript preparation. All the authors approved the final version of the manuscript. References Lv M, Shen M, Mo X (2023) Development of allogeneic hematopoietic stem cell transplantation in 2022: Regenerating Groot to heal the world. 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Blood 119:2644–2656 Comoli P et al (2007) Preemptive therapy of EBV-related lymphoproliferative disease after pediatric haploidentical stem cell transplantation. Am J Transpl 7:1648–1655 Icheva V et al (2013) Adoptive transfer of epstein-barr virus (EBV) nuclear antigen 1-specific t cells as treatment for EBV reactivation and lymphoproliferative disorders after allogeneic stem-cell transplantation. J Clin Oncol 31:39–48 Prockop S et al (2020) Off-the-shelf EBV-specific T cell immunotherapy for rituximab-refractory EBV-associated lymphoma following transplantation. J Clin Invest 130:733–747 Ma SD et al (2016) PD-1/CTLA-4 Blockade Inhibits Epstein-Barr Virus-Induced Lymphoma Growth in a Cord Blood Humanized-Mouse Model. PLoS Pathog 12:e1005642 He Y et al (2023) The emerging role of anti-PD-1 antibody-based regimens in the treatment of extranodal NK/T-cell lymphoma-associated hemophagocytic lymphohistiocytosis. J Cancer Res Clin Oncol 149:2017–2027 Additional Declarations No competing interests reported. Supplementary Files Suppl.docx Cite Share Download PDF Status: Published Journal Publication published 20 Oct, 2025 Read the published version in Annals of Hematology → Version 1 posted Editorial decision: Revision requested 12 Jan, 2025 Reviews received at journal 17 Sep, 2024 Reviewers agreed at journal 27 Aug, 2024 Reviewers invited by journal 19 Aug, 2024 Editor assigned by journal 23 Jul, 2024 Submission checks completed at journal 23 Jul, 2024 First submitted to journal 19 Jul, 2024 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. 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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-4768158","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":342345537,"identity":"e8b6f831-d340-495b-b165-19fdc4b31773","order_by":0,"name":"Dan Liu","email":"","orcid":"","institution":"Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease","correspondingAuthor":false,"prefix":"","firstName":"Dan","middleName":"","lastName":"Liu","suffix":""},{"id":342345538,"identity":"532a226f-018a-491a-8dac-080d6ad59b4d","order_by":1,"name":"Xuying Pei","email":"","orcid":"","institution":"Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease","correspondingAuthor":false,"prefix":"","firstName":"Xuying","middleName":"","lastName":"Pei","suffix":""},{"id":342345539,"identity":"23dfbd4a-1294-4fd6-aebd-2efd23cc76fe","order_by":2,"name":"Xiaohui Zhang","email":"","orcid":"","institution":"Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease","correspondingAuthor":false,"prefix":"","firstName":"Xiaohui","middleName":"","lastName":"Zhang","suffix":""},{"id":342345540,"identity":"2e961bad-4a65-4739-a242-6b390087c4c3","order_by":3,"name":"Lanping Xu","email":"","orcid":"","institution":"Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease","correspondingAuthor":false,"prefix":"","firstName":"Lanping","middleName":"","lastName":"Xu","suffix":""},{"id":342345541,"identity":"51dd05b0-6db7-466f-a6e5-22cd9847fcad","order_by":4,"name":"Yu Wang","email":"","orcid":"","institution":"Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease","correspondingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Wang","suffix":""},{"id":342345542,"identity":"253d1150-07c7-4ad2-9e91-5684ac038de1","order_by":5,"name":"Chenhua Yan","email":"","orcid":"","institution":"Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease","correspondingAuthor":false,"prefix":"","firstName":"Chenhua","middleName":"","lastName":"Yan","suffix":""},{"id":342345543,"identity":"b5bb9628-12fd-4312-82cf-6c2f1f9d1c00","order_by":6,"name":"Huan Chen","email":"","orcid":"","institution":"Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease","correspondingAuthor":false,"prefix":"","firstName":"Huan","middleName":"","lastName":"Chen","suffix":""},{"id":342345544,"identity":"15b5b2b1-0b18-415f-82bb-72383d3d7cbc","order_by":7,"name":"Yuhong Chen","email":"","orcid":"","institution":"Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease","correspondingAuthor":false,"prefix":"","firstName":"Yuhong","middleName":"","lastName":"Chen","suffix":""},{"id":342345545,"identity":"b12c57e4-7354-43fb-971f-6d39b411e911","order_by":8,"name":"Wei Han","email":"","orcid":"","institution":"Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease","correspondingAuthor":false,"prefix":"","firstName":"Wei","middleName":"","lastName":"Han","suffix":""},{"id":342345546,"identity":"5691352b-21b0-433c-a080-3d535c75f207","order_by":9,"name":"Fengrong Wang","email":"","orcid":"","institution":"Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease","correspondingAuthor":false,"prefix":"","firstName":"Fengrong","middleName":"","lastName":"Wang","suffix":""},{"id":342345547,"identity":"3e7055bb-11fd-46bb-93ef-f65718daa828","order_by":10,"name":"Jingzhi Wang","email":"","orcid":"","institution":"Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease","correspondingAuthor":false,"prefix":"","firstName":"Jingzhi","middleName":"","lastName":"Wang","suffix":""},{"id":342345548,"identity":"93159597-d7e4-46e0-b3c2-9c9eb7f42b89","order_by":11,"name":"Yuqian Sun","email":"","orcid":"","institution":"Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease","correspondingAuthor":false,"prefix":"","firstName":"Yuqian","middleName":"","lastName":"Sun","suffix":""},{"id":342345549,"identity":"c5c058c1-1515-4510-b1b0-5bf4d734efad","order_by":12,"name":"Xiaojun Huang","email":"","orcid":"","institution":"Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease","correspondingAuthor":false,"prefix":"","firstName":"Xiaojun","middleName":"","lastName":"Huang","suffix":""},{"id":342345550,"identity":"fd495136-a32c-46e7-8035-466676b12ac7","order_by":13,"name":"Xiaodong Mo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8klEQVRIiWNgGAWjYJCCAwwMzECK+QBjAwNDApBlQKwWtgTitTBAtPAYEKdFt73H8MCPCms5c/413x7ObLuTx8DevE2CoeYOTi1mZ44lHOw5k25sOePtdsONbc+KGXiOlUkwHHuGW8uN5AMHeNsOJ264cXab5EMgo0Eix0yCseEwHi2JDQf/grWceQbRIv+GkJbkA4fBtpzvYZPcCLaFh4AWoF8OywD9YnCDzdxwxrlniW08acUWCcfwaDneY/zxDTDEDM4ffvawp+xOYj/74Y03PtTg1oIAEglsDKBoBZHg2CEM+A9AtIyCUTAKRsEoQAcAd2JkWB8HRzAAAAAASUVORK5CYII=","orcid":"","institution":"Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease","correspondingAuthor":true,"prefix":"","firstName":"Xiaodong","middleName":"","lastName":"Mo","suffix":""}],"badges":[],"createdAt":"2024-07-19 14:00:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4768158/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4768158/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00277-025-06677-4","type":"published","date":"2025-10-20T16:16:48+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":63279054,"identity":"5044e386-c04e-4f9f-9eca-d6c7b89cc719","added_by":"auto","created_at":"2024-08-26 12:41:01","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":210422,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe characteristics of the patients diagnosed with EBV-related sHLH after allo-HSCT.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4768158/v1/0515b60c41cb75ff29871528.jpg"},{"id":63279055,"identity":"262d92f2-1db8-4aa2-9c11-39aad72f4f11","added_by":"auto","created_at":"2024-08-26 12:41:01","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":354717,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eEBV-related sHLH occurrence among the low-risk, medium-risk and high-risk group. \u003c/strong\u003ePercentage of sHLH \u003cstrong\u003e(A)\u003c/strong\u003eand cumulative incidence of sHLH \u003cstrong\u003e(B)\u003c/strong\u003e in the low-risk, medium-risk and high-risk\u003cstrong\u003e \u003c/strong\u003egroup.\u003c/p\u003e","description":"","filename":"figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4768158/v1/20d6a2ed4f3652fb7eb07c24.jpg"},{"id":94490548,"identity":"faba79d2-6fd2-406b-a394-20e82732231e","added_by":"auto","created_at":"2025-10-27 17:11:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1668722,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4768158/v1/495bd5c0-167e-43ab-989d-881cf2e4fc6e.pdf"},{"id":63279056,"identity":"7e8f13b1-7db6-4d2b-814a-2d749e653970","added_by":"auto","created_at":"2024-08-26 12:41:01","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":22040,"visible":true,"origin":"","legend":"","description":"","filename":"Suppl.docx","url":"https://assets-eu.researchsquare.com/files/rs-4768158/v1/3cc05aa9a9a715e4eae148ba.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical manifestations and outcomes of EBV related secondary hemophagocytic lymphohistiocytosis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAllogeneic hematopoietic stem cell transplantation is the most important curative method for hematologic malignancies\u003csup\u003e1,2\u003c/sup\u003e. Infection is still the most common cause of transplant failure, and Epstein-Barr virus (EBV) is one of the important pathogens. EBV related post-transplant lymphoproliferative disorders (EBV-PTLD) is recognized as a critical complication after allo-HSCT. The incidence of PTLD was 1.46\u0026ndash;3.22% \u003csup\u003e3\u0026ndash;5\u003c/sup\u003e, and its mortality rate was more than 80% in patients without rituximab treatment and could even be as high as 30% in those receiving rituximab-based therapies \u003csup\u003e4,6,7\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSecondary hemophagocytic lymphohistiocytosis (sHLH) is a life-threatening hyperinflammatory syndrome \u003csup\u003e8\u0026ndash;10\u003c/sup\u003e. Particularly, the incidence of post-transplant sHLH was 1\u0026ndash;8.8% \u003csup\u003e11\u0026ndash;13\u003c/sup\u003e and its mortality rate was as high as 80%\u003csup\u003e12,14\u003c/sup\u003e. EBV is also the common cause of sHLH\u003csup\u003e15\u003c/sup\u003e; however, there were only case reports about sHLH following EBV infection in allo-HSCT recipients \u003csup\u003e16\u0026ndash;21\u003c/sup\u003e. The largest study about EBV-related sHLH was reported by Ali et al. \u003csup\u003e5\u003c/sup\u003e, that is, only 3 patients with EBV-PTLD developed sHLH and all of them died. Thus, sHLH is rare but very critical in patients with EBV infection after allo-HSCT, but the clinical manifestations, risk factors, and treatments of these patients were still unclear.\u003c/p\u003e \u003cp\u003eIn this study, we aimed to identify the clinical manifestation of EBV related sHLH in allo-HSCT recipients, and we also aimed to compare the characteristics and clinical outcomes between EBV-PTLD patients with or without sHLH.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eThis study was conducted based on the transplant database of Peking University, Institute of Hematology (PUIH), and the including criteria were as followed: 1) receiving allo-HSCT between Jan 1st, 2023 and Dec 31st, 2023; 2) diagnosed as EBV DNAemia after allo-HSCT; 3) experienced sHLH after EBV infection. The last follow-up for survivors was Jan 1st, 2024. The study was conducted in accordance with the \u003cem\u003eDeclaration of Helsinki\u003c/em\u003e, and the protocol was approved by the Institutional Review Board of Peking University People\u0026rsquo;s Hospital.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eEBV monitoring after allo-HSCT\u003c/h2\u003e \u003cp\u003ePlasma EBV copies were monitored by quantitative polymerase chain reaction (Q-PCR) analysis at least weekly until day\u0026thinsp;+\u0026thinsp;100, and patients who received systemic immunosuppressive therapies should be monitored regularly even after day\u0026thinsp;+\u0026thinsp;100. Additional detection was performed if symptoms of suspected virus infection were present. The EBV DNAemia was defined as more than 1\u0026times;10\u003csup\u003e3\u003c/sup\u003e copies/ml EBV-DNA in plasma by Q-PCR in one test\u003csup\u003e22\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eAssays of EBV-infected lymphocyte subpopulations\u003c/h2\u003e \u003cp\u003eFresh peripheral blood cells were prepared and washed once in phosphate-buffered saline (PBS) (Beijing Solarbio Science \u0026amp; Technology Co., Ltd., #P1020). Cells from PB samples were stained with anti-CD3, anti-CD4, anti-CD8, anti-CD19, anti-CD56 antibodies, washed again in PBS, and subsequent sorting for the CD3\u003csup\u003e+\u003c/sup\u003eCD4\u003csup\u003e+\u003c/sup\u003e T cells, CD3\u003csup\u003e+\u003c/sup\u003eCD8\u003csup\u003e+\u003c/sup\u003e T cells, CD3\u003csup\u003e\u0026minus;\u003c/sup\u003eCD19\u003csup\u003e+\u003c/sup\u003e B cells, CD56\u003csup\u003e+\u003c/sup\u003e NK/NKT cells on the FACSMelody (BD). EBV-DNA copies were quantified by using a commercial polymerase chain reaction (PCR) diagnostic kit for EBV (Shanghai ZJ Bio-Tech Co., Ltd., # P20220201) in PB and sorted lymphocyte subpopulations according to the manufacturer\u0026rsquo;s recommendations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eDefinition\u003c/h2\u003e \u003cp\u003eThe diagnosis of EBV-PTLD \u003csup\u003e6\u003c/sup\u003e and sHLH \u003csup\u003e23\u003c/sup\u003e was according to the international criteria. The primary endpoint was EBV-related mortality, which was defined as mortality directly caused by EBV infection. The secondary endpoint was overall survival (OS), which was defined as the time from diagnosis of EBV to death from any cause or the date of last contact.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData were censored at the time of death or the last available follow-up. Continuous variables were compared with the Mann\u0026ndash;Whitney \u003cem\u003eU\u003c/em\u003e-test; categorical variables were compared with the \u003cem\u003eχ\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e test and Fisher\u0026rsquo;s exact test. The Kaplan\u0026ndash;Meier method was used to estimate the probability of OS. All reported \u003cem\u003eP\u003c/em\u003e-values were based on two-sided tests. In all analyses, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.05 indicated statistical significance. Data analyses were conducted with SPSS software (SPSS Inc., Chicago, IL, USA).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n\u003ch2\u003eCharacteristics of patients with EBV related sHLH after allo-HSCT\u003c/h2\u003e\n\u003cp\u003eThe characteristics of the 11 patients with sHLH were summarized in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. All of them were diagnosed as PTLD before sHLH. The median time from allo-HSCT to the diagnosis of PTLD was 69 days (range, 39\u0026ndash;98) days, and the median time from PTLD to sHLH occurrence was 5 days (range, 2-101) days. The median follow-up was 22 days (range, 7-122) days after the diagnosis of PTLD.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab4\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eThe characteristics of patients with EBV-related sHLH\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCharacteristics\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCohort (n\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eGender (Male)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e9/11\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eMedian age, y (range)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e47 (19\u0026ndash;66)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eUnderlying disease, n (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAML\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e3 (28%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eALL\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e4 (36%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMDS\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2 (18%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAA\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e1 (9%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOthers\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e1 (9%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eEBV serostatus before HSCT, n (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDonor+/recipient+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e10 (91%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDonor-/recipient+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e1 (9%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eHLA disparity, n (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5/10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e8 (80%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6/10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e1 (10%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10/10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e1 (10%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eDisease status before allo-HSCT, n (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCR1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e9 (100%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026gt;CR1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e0 (0%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eGraft type, n (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePBSC\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e8 (80%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePBSC\u0026thinsp;+\u0026thinsp;BM\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2 (20%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eDonor type, n (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHID\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e9 (82%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMUD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e1 (9%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOthers\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e1 (9%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eMNC counts in graft, median (range, \u0026times;10\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003c/sup\u003e\u003cstrong\u003e/kg)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e9.11 (6.19\u0026ndash;16.40)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eCD34\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e+\u003c/strong\u003e\u003c/sup\u003e \u003cstrong\u003ecell counts in graft, median (range, \u0026times;10\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e6\u003c/strong\u003e\u003c/sup\u003e\u003cstrong\u003e/kg)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e3.18 (1.24\u0026ndash;9.56)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: AML, acute myeloid leukemia; ALL, acute lymphocytic leukemia; MDS, myelodysplastic syndrome; AA, aplastic anemia; allo-HSCT, allogeneic hematopoietic stem cell transplantation; EBV, Epstein-Barr virus; PBSC, peripheral blood stem cells; BM, bone marrow; CR, complete remission; HID, haploidentical donor; MUD, matched unrelated donors; sHLH, secondary hemophagocytic lymphohistiocytosis; MNC, mononuclear cell.\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eThe most common manifestation of sHLH was ferritin elevation (100%) and soluble CD25 antigen elevation (100%), followed by pancytopenia (91%), fever (82%), hypertriglyceridemia (82%), and lactate dehydrogenase elevation (82%) (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). The median body temperature was 38.4℃ (range, 37.2 to 39.8) ℃ when sHLH was diagnosed. The median value of ferritin, triglyceride, lactate dehydrogenase (LDH), NK cells activity, and soluble CD25 antigen was 9376 ng/mL (range, 2664 to 19619) ng/mL, 1.92 mmol/L (range, 1.33 to 6.33) mmol/L, 431U/L (range, 217 to 1438) U/L, 13.94% (range, 11.24\u0026ndash;36.63%), and 20152 pg/mL (range, 10484 to 33479) pg/mL, respectively, at the time of sHLH occurrence (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). One patient attained all the criteria of HLH.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eCharacteristics of EBV-related sHLH\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eVariable\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eNumber (n\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFever, ℃, median (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e38.4 (37.2\u0026ndash;39.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLDH, U/L, median (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e431 (217\u0026ndash;1438)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTBIL, \u0026micro;mol/L, median (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24.9 (7.6-265.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTG, mmol/L, median (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.92 (1.33\u0026ndash;6.33)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFIB, mg/dL, median (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e248 (128\u0026ndash;483)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNeutrophil count, 10\u003csup\u003e9\u003c/sup\u003e/L, median (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.0 (0.16\u0026ndash;5.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHb count, g/L\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e63 (40\u0026ndash;122)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePlatelet count, \u0026times;10\u003csup\u003e9\u003c/sup\u003e/L, median (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23 (2-113)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFerritin, ng/mL, median (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9376 (2664\u0026ndash;19619)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003esCD25, U/mL, median (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20152 (10484\u0026ndash;33479)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNK cell activity, %, median (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13.94 (11.24\u0026ndash;36.63)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePancytopenia, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10 (90.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSplenomegaly, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7 (63.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHemophagocytosis in bone marrow, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (27.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEBV copy in blood when diagnosed PTLD, \u0026times;10\u003csup\u003e2\u003c/sup\u003e copies/ml, median (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e81.6 (13.3-24400)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEBV copy in blood when diagnosed sHLH, \u0026times;10\u003csup\u003e2\u003c/sup\u003e copies/ml, median (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e677 (2.01\u0026ndash;6030)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDays from EBV DNAemia\u0026thinsp;\u0026gt;\u0026thinsp;10\u003csup\u003e5\u003c/sup\u003e copies/ml to HLH, median (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8.5 (2-106)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDays from HSCT to sHLH diagnosis, median (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e89 (49\u0026ndash;169)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDays from PTLD to HLH diagnosis, median (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (2-101)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\"\u003eAbbreviations: LDH, lactate dehydrogenase; TBIL, total bilirubine; TG, triglyceride; FIB, fibrinogen; Hb, hemoglobin; NK cell, natural killer cell, EBV, Epstein-Barr virus; sHLH, secondary hemophagocytic lymphohistiocytosis; PTLD, post-transplant lymphoproliferative disorders; HSCT, hematopoietic stem cell transplantation.\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eAll the patients received the analysis of EBV-infected lymphocytes. All of them showed CD19\u003csup\u003e+\u003c/sup\u003e B cell involvement, and the median titers of EBV in B cells were 1\u0026times;10\u003csup\u003e6\u003c/sup\u003e copies/million cells (range, 1.8\u0026times;10\u003csup\u003e3\u003c/sup\u003e to 5.6\u0026times;10\u003csup\u003e6\u003c/sup\u003e) copies/million cells. Nine (82%) patients showed CD8\u003csup\u003e+\u003c/sup\u003e T cell involvement, and the median titers of EBV in CD8\u003csup\u003e+\u003c/sup\u003e T cells were 1.4\u0026times;10\u003csup\u003e4\u003c/sup\u003e copies/million cells (range 6.7\u0026times;10\u003csup\u003e2\u003c/sup\u003e to 3.5\u0026times;10\u003csup\u003e5\u003c/sup\u003e) copies/million cells. Six (55%) patients showed CD4\u003csup\u003e+\u003c/sup\u003e T cell involvement, and the median titers of EBV in CD4\u003csup\u003e+\u003c/sup\u003eT cells were 1.95\u0026times;10\u003csup\u003e3\u003c/sup\u003e copies/million cells (range, 3.6\u0026times;10\u003csup\u003e2\u003c/sup\u003e to 1.2\u0026times;10\u003csup\u003e4\u003c/sup\u003e) copies/million cells. Nine (82%) patients showed NK cell involvement, and the median titers of EBV in NK cells were 1.2\u0026times;10\u003csup\u003e4\u003c/sup\u003e copies/million cells (range, 6.2\u0026times;10\u003csup\u003e2\u003c/sup\u003e to 4.6\u0026times;10\u003csup\u003e5\u003c/sup\u003e) copies/million cells (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n\u003ch2\u003eThe treatment and outcomes of EBV-related sHLH\u003c/h2\u003e\n\u003cp\u003eAll the patients received rituximab for EBV infection. In addition, the most common therapy for sHLH was corticosteroid treatment (100%), followed by etoposide (63.6%), intravenous immunoglobulin (IVIG, 45.5%), and ruxolitinib (27.3%). Three patients received EBV-specific cytotoxic T cell (CTL) infusion. Seven patients used the protocol of HLH-94 \u003csup\u003e24\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eNine (81.8%) patients died after the diagnosis of sHLH, and the median time from the occurrence of sHLH to death was 10 days (range, 3 to 21) days.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n\u003ch2\u003eThe characteristics between EBV-PTLD patients with and without sHLH\u003c/h2\u003e\n\u003cp\u003eAs all the patients with EBV-related sHLH had PTLD simultaneously, the EBV-PTLD patients without HLH during the same time period were enrolled as controlled (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;30). The characteristics between patients with and without sHLH were showed in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e. Particularly, we observed that body temperature at diagnosis of EBV-PTLD were significantly higher in sHLH group (39.6℃ versus 38.5℃, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0042). The initial value and peak value of EBV DNAemia was 8.16\u0026times;10\u003csup\u003e3\u003c/sup\u003e copies/ml (range, 1.33\u0026times;10\u003csup\u003e3\u003c/sup\u003e to 2.44\u0026times;10\u003csup\u003e6\u003c/sup\u003e) copies/ml versus 8.53\u0026times;10\u003csup\u003e3\u003c/sup\u003e copies/ml (range, 3.14\u0026times;10\u003csup\u003e2\u003c/sup\u003e to 8.23\u0026times;10\u003csup\u003e4\u003c/sup\u003e) copies/ml (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.68) and 3.63\u0026times;10\u003csup\u003e5\u003c/sup\u003e copies/ml (range, 1.63\u0026times;10\u003csup\u003e4\u003c/sup\u003e to 2.44\u0026times;10\u003csup\u003e6\u003c/sup\u003e) copies/ml versus 1.945\u0026times;10\u003csup\u003e4\u003c/sup\u003e copies/ml (range, 1.04\u0026times;10\u003csup\u003e3\u003c/sup\u003e to 8.42\u0026times;10\u003csup\u003e5\u003c/sup\u003e) copies/ml (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0001), respectively, in patients with and without sHLH. Two (6.7%) and seven (63.6%) patients, respectively, in non-sHLH and sHLH group had the high-level EBV DNAemia (i.e., \u0026gt; 10\u003csup\u003e5\u003c/sup\u003e copies/ml) after the diagnosis of EBV-PTLD (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). The median time from EBV-PTLD diagnosis to achieving the high-level EBV DNAemia (i.e., \u0026gt; 10\u003csup\u003e5\u003c/sup\u003e copies/ml) in patients with and without sHLH was 0 days (range, -7 to 36 days) and 3.5 days (range, 3 to 4 days) (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.64). The median time from achieving high-level EBV DNAemia to sHLH occurrence was 8.5 days (range, 2 to 106) days.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003e\u003cstrong\u003eCharacteristics of patients with and without sHLH when PTLD was diagnosed\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePTLD without sHLH (n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePTLD with sHLH (n\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eP value\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFever, median (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e38.5 (37.5\u0026ndash;40.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e39.6 (38.5\u0026ndash;40.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u003cstrong\u003e0.0042\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLDH, median (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e348 (176\u0026ndash;642)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e355 (125\u0026ndash;779)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.39\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTBIL, median (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12.65 (6.8\u0026ndash;32.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25.7 (6.6\u0026ndash;87)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.23\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTG, median (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.155 (0.57\u0026ndash;5.56)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.19 (1.05\u0026ndash;7.44)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.46\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFIB, median (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e429 (209\u0026ndash;686)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e389 (161\u0026ndash;701)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.37\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNeutrophil count, 10\u003csup\u003e9\u003c/sup\u003e/L\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.54 (0.50\u0026ndash;10.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.96 (0.30\u0026ndash;12.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.46\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHb count, g/L\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e89.5 (58\u0026ndash;157)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e87 (53\u0026ndash;121)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.66\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePlatelet count, median (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e71 (21\u0026ndash;231)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e44 (5\u0026ndash;73)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.054\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePancytopenia, n(%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15 (50%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8 (72.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.29\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSplenomegaly, n(%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9 (30%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6 (54.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.272\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHemophagocytosis in bone marrow\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (13.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (27.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.36\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDays from HSCT to EBV positivity in blood, median (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e58 (35\u0026ndash;270)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e57 (35\u0026ndash;93)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.83\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDays from EBV initial positivity to more than 10\u003csup\u003e5\u003c/sup\u003e in blood, median (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11.5 (\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7 (4\u0026ndash;56)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.25\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDays from EBV initial positivity to maximum in blood, median (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8.5 (1\u0026ndash;44)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13 (6\u0026ndash;56)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.07\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMaximum EBV copy\u0026gt;10\u003csup\u003e5\u003c/sup\u003e in blood, n(%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (6.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7 (63.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: LDH, lactate dehydrogenase; TBIL, total bilirubine; TG, triglyceride; FIB, fibrinogen; Hb, hemoglobin; EBV, Epstein-Barr virus; sHLH, secondary hemophagocytic lymphohistiocytosis; PTLD, post-transplant lymphoproliferative disorders; HSCT, hematopoietic stem cell transplantation.\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eSixteen non-sHLH patients received the analysis of EBV-infected lymphocytes. The comparation between patients with and without sHLH were showed in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e. Thus, we defined high-level EBV in lymphocytes using the median value of sHLH cohort as cut off point, that is EBV value more than 1.95\u0026times;10\u003csup\u003e3\u003c/sup\u003e copies/million cells, 1.4\u0026times;10\u003csup\u003e4\u003c/sup\u003e copies/million cells, 1.2\u0026times;10\u003csup\u003e4\u003c/sup\u003e copies/million cells, and 1\u0026times;10\u003csup\u003e6\u003c/sup\u003e copies/million cells in CD4\u003csup\u003e+\u003c/sup\u003eT cell, CD8\u003csup\u003e+\u003c/sup\u003eT cell, NK cell, and CD19\u003csup\u003e+\u003c/sup\u003e B cell, respectively. We observed that the ratio of patients with high-level EBV in CD4\u003csup\u003e+\u003c/sup\u003e T cell, CD8\u003csup\u003e+\u003c/sup\u003e T cell, or NK cell was 90.9% in sHLH group, which was significantly higher than that of non-sHLH group (50%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.008) (Suppl. Table\u0026nbsp;1).\u003c/p\u003e\n\u003cp\u003eWe categorized the 27 patients into three groups according to body temperature at EBV-PTLD diagnosis (\u0026ge;\u0026thinsp;39.6℃ vs. \u0026lt; 39.6℃), achieving high-level EBV DNAemia (yes vs. no), and patients with high-level EBV in CD4\u003csup\u003e+\u003c/sup\u003e T cell, CD8\u003csup\u003e+\u003c/sup\u003e T cell, or NK cell (yes vs. no): low-risk (0 risk factor, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;8), intermediate-risk (1 risk factor, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;7), and high-risk group (\u0026ge;\u0026thinsp;2 risk factors, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;12). The ratio of sHLH was 0%, 28.6%, and 77.8% for patients in low-, intermediate-, and high-risk group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.005, Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eThe 100-day probability of EBV-related mortality and OS after PTLD occurrence was 84.1% (95% CI 48.9%-100%) versus 8.3% (95%CI 0%-24.6%) with \u003cem\u003eP\u003c/em\u003e\u0026lt;0.0001 and 15.9% (95% CI 3.0%-83.8%) versus 91.7% (95%CI 77.3%-100%) with \u003cem\u003eP\u003c/em\u003e \u0026lt;0.0001, respectively, for patients with and without EBV-sHLH.\u003c/p\u003e\n\u003cdiv class=\"colspec\" align=\"char\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"char\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eEBV copies per million cells in peripheral lymphocyte subsets in patients with and without sHLH\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAll Patients (n\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePTLD without sHLH (n\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePTLD with sHLH (n\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCD4\u003csup\u003e+\u003c/sup\u003e T cells (median, range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026minus;\"\u003e\n\u003cp\u003e2200 (320-170000)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026minus;\"\u003e\n\u003cp\u003e12000 (320-170000)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026minus;\"\u003e\n\u003cp\u003e1950 (360-12000)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCD8\u003csup\u003e+\u003c/sup\u003e T cells (median, range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026minus;\"\u003e\n\u003cp\u003e9900 (48-350000)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026minus;\"\u003e\n\u003cp\u003e5550 (48-80000)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026minus;\"\u003e\n\u003cp\u003e14000 (670-350000)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCD3\u003csup\u003e\u0026minus;\u003c/sup\u003eCD19\u003csup\u003e+\u003c/sup\u003e B cells (median, range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026minus;\"\u003e\n\u003cp\u003e1000000 (1800-5770000)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026minus;\"\u003e\n\u003cp\u003e1000000 (82000-5770000)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026minus;\"\u003e\n\u003cp\u003e1000000 (1800-5600000)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCD56\u003csup\u003e+\u003c/sup\u003e NK cells (median, range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026minus;\"\u003e\n\u003cp\u003e6600 (110-460000)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026minus;\"\u003e\n\u003cp\u003e1700 (110-58900)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026minus;\"\u003e\n\u003cp\u003e12000 (620-460000)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn the present study, we observed that the 100-day probability of mortality and OS was 84.1% and 15.9%, respectively, in those with EBV-related sHLH after allo-HSCT. EBV-PTLD patients with sHLH had a significant worse prognosis than those without sHLH. Temperature\u0026thinsp;\u0026ge;\u0026thinsp;39.6℃, achieving high-level EBV DNAemia and with a high-level EBV in T or NK cells increase the risk of sHLH after EBV-PLTD. Particularly, the ratio of sHLH could be as high as 77.8% in those with all the three risk factors. To our knowledge, this is the largest cohort to present the clinical manifestations, risk factors, treatment and clinical outcomes sHLH after EBV-related sHLH.\u003c/p\u003e \u003cp\u003ePrevious studies have recognized high-level EBV DNAemia is a risk factor for poor outcomes, for example, it was associated with the development of EBV-PTLD \u003csup\u003e25,26\u003c/sup\u003e. In addition, the high-level of EBV DNAemia after rituximab therapy was also associated with a poor survival \u003csup\u003e27\u003c/sup\u003e. In the present study, we firstly observed that EBV-PTLD patients with a high-level EBV DNAemia also had a higher risk of sHLH. This further confirmed the poor prognosis of a high-level EBV DNAemia in EBV-PTLD, and patients with a high-level EBV DNAemia should receive more intensive and aggressive therapy.\u003c/p\u003e \u003cp\u003eIn lymphoma other than EBV-PTLD, most of the sHLH are observed in patients with T cells or NK/T cells lymphoma, and sHLH was rare in patients with B cell lymphoma \u003csup\u003e10,28\u0026ndash;31\u003c/sup\u003e. This might contribute to the low incidence of sHLH after EBV-PTLD, because most of the EBV-PTLD originated from B cells and T or NK cells lymphomas only represented 2\u0026ndash;15% of all cases.\u003csup\u003e32\u003c/sup\u003e In the present study, we observed that the B cell involvement by EBV was more prominent compared with T cells or NK cells involvement in all the EBV-PTLD patients, even in those with sHLH. However, we firstly observed that sHLH could occur in B-cell EBV-PTLD patients with a high-level EBV in T or NK cells. This further confirmed the important role of assays of EBV-infected lymphocyte subpopulations in EBV-PTLD patients.\u003c/p\u003e \u003cp\u003eThe elimination of EBV is the most important treatment for EBV-PTLD, which was also critical for sHLH after EBV-PTLD. However, rituximab could not clear the EBV in T or NK cells. Thus, cytotherapy, particularly the EBV-specific CTL may be one of the most important treatments to clear the EBV in T or NK cells in patients with EBV-PTLD. Several studies have confirmed that donor-derived EBV-CTLs can clear viremia and help to achieve durable complete remission (CR) rates of 50%-70% in patients with EBV-positive lymphomas \u003csup\u003e33\u0026ndash;35\u003c/sup\u003e. Prockop et al.\u003csup\u003e36\u003c/sup\u003e reported that third-party EBV-CTL is also effective in the treatment of PTLD patients who had failed to rituximab therapy. The CR or sustained partial remission rate was 68% and the 1-year OS rate was 88.9%. However, efficacy and safety of EBV-specific CTL should be further confirmed in patients with sHLH after EBV-PTLD. In addition, PD-1 blockade could enhance the ability of T cells to control the outgrowth of EBV-induced lymphomas\u003csup\u003e37\u003c/sup\u003e, and anti-PD-1 antibody combined with chemotherapies were associated with a prolonged survival in EBV-related lymphoma-associated sHLH \u003csup\u003e38\u003c/sup\u003e. Thus, PD-1 antibody may also be the potential treatment for sHLH after EBV-PTLD.\u003c/p\u003e \u003cp\u003eBesides of clearing the EBV, the standard treatment for sHLH is the HLH-94 protocol, which includes dexamethasone, etoposide, cyclosporin A and in selected patients, intrathecal methotrexate\u003csup\u003e24\u003c/sup\u003e. However, this protocol had some limitations in allo-HSCT recipients. For example, etoposide may cause severe bone marrow suppression and secondary graft failure was one of the most severe post-transplant complications. In addition, some EBV-PTLD patients with sHLH were too weak to tolerate HLH-94 protocol. On the other hand, Sandler et al.\u003csup\u003e11\u003c/sup\u003e reported that sHLH following HSCT could be treated with high-dose corticosteroids, but this study did not include patients with sHLH following EBV-PTLD. Thus far, there was no common accepted therapeutic protocol for patients with sHLH after EBV-PTLD, which was also the major reason for the poor survival of these patients. New therapies for sHLH after PTLD should be further identified in future.\u003c/p\u003e \u003cp\u003eThis study has several limitations. Although it is the largest cohort of patients with EBV-related sHLH after allo-HSCT, there are only 11 cases and our results should be further confirmed by multicenter studies. In addition, some PTLD patients did not perform EBV-DNA copy quantification in lymphocyte subpopulations, which may affect our results of the association of EBV distribution in cell subpopulations and the risk of sHLH. In addition, the therapies were variation among sHLH patients, and we could not further compare the efficacy among different therapies for EBV-related sHLH after allo-HSCT.\u003c/p\u003e \u003cp\u003eIn summary, our study firstly reported the clinical manifestationsand clinical outcomes of EBV-related sHLH after allo-HSCT in a large cohort. We also identify a subgroup of patients who had a higher risk of EBV-related sHLH. Our results should be further confirmed by multicenter, prospective studies.\u003c/p\u003e \u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAML\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eacute myeloid leukemia\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eALL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eacute lymphocytic leukemia\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMDS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emyelodysplastic syndrome\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eaplastic anemia\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eallo-HSCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eallogeneic hematopoietic stem cell transplantation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEBV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEpstein-Barr virus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePBSC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eperipheral blood stem cells\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ebone marrow\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecomplete remission\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHID\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ehaploidentical donor\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMUD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ematched unrelated donors\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003esHLH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003esecondary hemophagocytic lymphohistiocytosis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMNC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emononuclear cell.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board of Peking University. The committee evaluated the ethical aspects of the study in accordance with the World Medical Association\u0026rsquo;s Declaration of Helsinki. All of the included patients in this study provided written informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by major Program of the National Natural Science Foundation of China (No. 82293630), Peking University Medicine Fund for world\u0026apos;s leading discipline or discipline cluster development (No.71003Y3035), National Key Research and Development Program of China (2022YFC2502606), and Tongzhou District Distinguished Young Scholars (JCQN2023009).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eXiao-Dong Mo and Xiao-Jun Huang conceived and designed the study. Dan-Liu and Xiao-Dong Mo collected and analyzed the data and drafted the manuscript. All the authors contributed to the data interpretation and manuscript preparation. All the authors approved the final version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLv M, Shen M, Mo X (2023) Development of allogeneic hematopoietic stem cell transplantation in 2022: Regenerating Groot to heal the world. Innov (Cambridge (Mass)) 4:100373\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang L, Zhang C, Fan S, Mo X, Hu X (2023) Treatment options for adult intermediate-risk AML patients in CR1: Allo-HSCT or chemotherapy? Innov (Cambridge (Mass)) 4:100461\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLuo L et al (2014) Post-transplant lymphoproliferative disease after allogeneic hematopoietic stem cell transplantation: a single-center experience. Ann Transpl 19:6\u0026ndash;12\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStyczynski J et al (2013) Response to rituximab-based therapy and risk factor analysis in Epstein Barr Virus-related lymphoproliferative disorder after hematopoietic stem cell transplant in children and adults: a study from the Infectious Diseases Working Party of the European Group for Blood and Marrow Transplantation. Clin Infect Dis 57:794\u0026ndash;802\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAli S et al (2019) Hemophagocytic lymphohistiocytosis is a sign of poor outcome in pediatric Epstein-Barr virus-associated post-transplant lymphoproliferative disease after allogeneic hematopoietic stem cell transplantation. Pediatr Transpl 23:e13319\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStyczynski J et al (2016), \u003cem\u003eManagement of Epstein-Barr Virus infections and post-transplant lymphoproliferative disorders in patients after allogeneic hematopoietic stem cell transplantation: Sixth European Conference on Infections in Leukemia (ECIL-6) guidelines. Haematologica 101, 803\u0026ndash;811\u003c/em\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCurtis RE et al (1999) Risk of lymphoproliferative disorders after bone marrow transplantation: a multi-institutional study. Blood 94:2208\u0026ndash;2216\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl-Samkari H, Berliner N (2018) Hemophagocytic Lymphohistiocytosis. 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Pediatr Blood Cancer 45:340\u0026ndash;343\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIemura T et al (2019) NK-cell post-transplant lymphoproliferative disease with chronic active Epstein-Barr virus infection-like clinical findings. Int J Infect Dis 88:31\u0026ndash;33\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFan S et al (2023) Machine learning algorithm as a prognostic tool for Epstein-Barr virus reactivation after haploidentical hematopoietic stem cell transplantation. Blood Sci (Baltimore Md) 5:51\u0026ndash;59\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHenter JI et al (2007) HLH-2004: Diagnostic and therapeutic guidelines for hemophagocytic lymphohistiocytosis. Pediatr Blood Cancer 48:124\u0026ndash;131\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHenter JI et al (1997) HLH-94: a treatment protocol for hemophagocytic lymphohistiocytosis. HLH study Group of the Histiocyte Society. Med Pediatr Oncol 28:342\u0026ndash;347\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaldanti F et al (2000) High levels of Epstein-Barr virus DNA in blood of solid-organ transplant recipients and their value in predicting posttransplant lymphoproliferative disorders. J Clin Microbiol 38:613\u0026ndash;619\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShapiro RS et al (1988) Epstein-Barr virus associated B cell lymphoproliferative disorders following bone marrow transplantation. Blood 71:1234\u0026ndash;1243\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLuo XY et al (2020) A retrospective analysis on anti-CD20 antibody-treated Epstein-Barr virus-related posttransplantation lymphoproliferative disorder following ATG-based haploidentical T-replete hematopoietic stem cell transplantation. 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PLoS Pathog 12:e1005642\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHe Y et al (2023) The emerging role of anti-PD-1 antibody-based regimens in the treatment of extranodal NK/T-cell lymphoma-associated hemophagocytic lymphohistiocytosis. J Cancer Res Clin Oncol 149:2017\u0026ndash;2027\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"annals-of-hematology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aohe","sideBox":"Learn more about [Annals of Hematology](http://link.springer.com/journal/277)","snPcode":"277","submissionUrl":"https://submission.nature.com/new-submission/277/3","title":"Annals of Hematology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Epstein-Barr virus, secondary hemophagocytic lymphohistiocytosis, post-transplant lymphoproliferative disorders","lastPublishedDoi":"10.21203/rs.3.rs-4768158/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4768158/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eAim: \u003c/strong\u003eEpstein-Barr virus (EBV) is the important pathogen of infection after allogeneic hematopoietic stem cell transplantation (allo-HSCT), which is also the common cause of secondary hemophagocytic lymphohistiocytosis (sHLH). Thus, we aimed to identify the clinical manifestations and outcomes of EBV-related sHLH after allo-HSCT.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e We enrolled the patients who experienced sHLH after EBV DNAemia after allo-HSCT from Jan 1\u003csup\u003est\u003c/sup\u003e, 2023 to Dec 31\u003csup\u003est\u003c/sup\u003e, 2023. Plasma EBV copies were monitored by Q-PCR analysis at least weekly and EBV-DNA copies of\u003cstrong\u003e \u003c/strong\u003elymphocyte subpopulations in peripheral blood were also quantified by Q-PCR.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003e11 patients developed sHLH after EBV DNAemia and all of them had post-transplant lymphoproliferative disorders\u003cstrong\u003e \u003c/strong\u003e(PTLD) before sHLH. The median time from PTLD to sHLH occurrence was 5 days (range, 2-101) days. The most common manifestation of sHLH was ferritin elevation (100%) and soluble CD25 antigen elevation (100%). Nine (81.8%) patients died after the diagnosis of sHLH, and the median time from the occurrence of sHLH to death was 10 days (range, 3 to 21) days. Temperature ≥ 39.6℃, achieving high-level EBV DNAemia (\u0026gt; 10\u003csup\u003e5 \u003c/sup\u003ecopies/ml), and with a high-level EBV in T or NK cells increase the risk of sHLH after EBV-PLTD. The 100-day probability of EBV-related mortality and overall survival after PTLD occurrence was 84.1% versus 8.3 % (\u003cem\u003eP \u003c/em\u003e＜0.0001) and 15.9% versus 91.7% (\u003cem\u003eP\u003c/em\u003e ＜0.0001), respectively, for patients with and without sHLH.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eIn summary, our study firstly reported the clinical manifestations and outcomes of EBV-related sHLH following allo-HSCT in the largest cohort at present.\u003c/p\u003e","manuscriptTitle":"Clinical manifestations and outcomes of EBV related secondary hemophagocytic lymphohistiocytosis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-26 12:40:55","doi":"10.21203/rs.3.rs-4768158/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-01-12T16:19:58+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-17T07:30:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"281387812656998238968469388240105439902","date":"2024-08-27T15:46:42+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-19T22:10:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-23T14:54:57+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-23T14:54:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"Annals of Hematology","date":"2024-07-19T13:58:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"annals-of-hematology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aohe","sideBox":"Learn more about [Annals of Hematology](http://link.springer.com/journal/277)","snPcode":"277","submissionUrl":"https://submission.nature.com/new-submission/277/3","title":"Annals of Hematology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"5d8998ac-d38e-44b4-b1a8-a969e1e0f749","owner":[],"postedDate":"August 26th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-27T16:38:37+00:00","versionOfRecord":{"articleIdentity":"rs-4768158","link":"https://doi.org/10.1007/s00277-025-06677-4","journal":{"identity":"annals-of-hematology","isVorOnly":false,"title":"Annals of Hematology"},"publishedOn":"2025-10-20 16:16:48","publishedOnDateReadable":"October 20th, 2025"},"versionCreatedAt":"2024-08-26 12:40:55","video":"","vorDoi":"10.1007/s00277-025-06677-4","vorDoiUrl":"https://doi.org/10.1007/s00277-025-06677-4","workflowStages":[]},"version":"v1","identity":"rs-4768158","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4768158","identity":"rs-4768158","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}