Epstein-Barr virus positive gastric adenocarcinoma with systemic EBV reactivation in a patient with persistently active systemic lupus erythematosus

Objectives: Epstein-Barr virus (EBV) has been associated with several types of cancers, most often with nasopharyngeal carcinomas and hematological malignancies. It is also suggested that EBV has significant role in the pathogenesis of different types of autoimmune diseases including systemic lupus erythematosus (SEL). The exact mechanisms behind these processes are not elucidated.Case presentation: We present a case of a 52-years old female patients with moderately active SLE presenting with severe fatigue, purpuric lesions, alopecia, polyarthritis, mucosal ulcerations, and progressive thrombocytopenia over a period of 10 months. During the work-up, the patient was evaluated for several viral infections. Serology testing showed elevation of anti-EBV, anti-CMV and anti-HSV1/2 IgM antibodies with the presence of IgG antibodies against all mentioned viruses except HSV2. Corticosteroid therapy was escalated, and azathioprine was introduced. Due to the persistence of significant thrombocytopenia and monoclonal IgG sternal puncture was performed. Morphological and immunohistochemical analysis of bone marrow specimen presented infiltration with metastatic deposits of adenocarcinoma and monoclonal plasmacytosis. Esophagogastroduodenoscopy showed multiple prepyloric erosions of gastric mucosa, which were biopsied. Pathohistological analysis demonstrated infiltration of gastric mucosa with diffuse type adenocarcinoma. Further PCR testing of biopsied gastric adenocarcinoma revealed the presence of EBV DNA in carcinoma tissue. The patient was sent to the oncologist for further evaluation.Conclusions: Assessment of SLE patients with persistently active disease should include the analysis of the herpesvirus infection status. Reactivations of EBV may be considered as possible trigger for lupus flares and the factor for increased risk of developing malignancies.