Sections

Human T-Cell Lymphotropic Viruses (HTLV)

Sections Human T-Cell Lymphotropic Viruses (HTLV)
Overview
Presentation
- History
- Physical
- Causes
- Complications
- Show All
DDx
Workup
Treatment
Medication
References

Workup

Laboratory Studies

Multiple serologic methodologies are commercially available for the diagnosis of HTLV-1 and HTLV-2 infections. Included in the diagnostic armamentarium are enzyme-linked immunosorbent assays (ELISA), chemiluminescence assays, and particle agglutination assays.

Any positive result in the aforementioned diagnostic studies should be followed by confirmatory western blot, immunofluorescence assay (IFA), or polymerase chain reaction (PCR).

Only individuals with risk factors for HTLV infection should undergo testing.

HTLV ELISA yields very high false-positive rates in areas of low prevalence.^[65]In patients in whom testing is deemed to be appropriate, recent test comparisons have found that those widely available perform with similar diagnostic accuracy.^[66]

Positive ELISA results in combination with indeterminate western blot findings can be interpreted as follows:

Cross-reactivity with Plasmodium falciparum infection
HTLV-3 or HTLV-4 infection
Delayed seroconversion with low antibody titers
False-positive ELISA result

In this setting, western blot testing may be repeated, and, if possible, a different confirmatory laboratory test (ie, HTLV PCR testing) should be performed. In a US-based study including more than 400 patients with indeterminate western blot results, only 1.4% had positive PCR results for HTLV infection.^[48]

PCR testing has additional uses. PCR or EIA with virus-specific synthetic peptides is necessary to distinguish between HTLV-1 and HTLV-2. PCR is also required in infants whose results may be false-positive because of circulating maternal anti-HTLV antibodies. PCR also quantifies the proviral load, which is frequently used as a marker for progression, especially in HAM/TSP. It is expressed as “the number of HTLV-1 DNA copies per fixed number of peripheral blood mononuclear cells.”^[49]

Patients diagnosed with HTLV-1 or HTLV-2 infection should also undergo the following tests:

Complete blood count with differential and peripheral blood smear
Complete chemistry with calcium level
Liver function tests
Lactate dehydrogenase testing
HIV screening
Viral hepatitis serology (A, B, C)
Rapid plasma reagin (RPR)
Purified protein derivative (PPD)
Strongyloides stercoralis serology and stool examination for ova and parasites (if the appropriate risk factors exist)

Imaging Studies

No specific imaging studies are recommended for asymptomatic HTLV infections. However, imaging studies may be considered in aiding in diagnoses/evaluation of HAM/TSP or ATL.

HAM/TSP

Brain MRI reveals nonspecific periventricular and subcortical white matter lesions in 50%-80% of patients with HAM/TSP; however, these lesions also occur in patients with asymptomatic HTLV-1 infections, and comparisons with controls have not been adequate.^[49]

ATL

Chest radiography is important, particularly in patients with ATL, to assess for pulmonary complications, opportunistic infections, and lytic bone lesions.

CT scanning of the neck, thorax, abdomen, and pelvis is crucial in assessing for nodal involvement.^[50]It can also aid in further assessment for opportunistic infections (ie, abscess formation, pneumonia, intestinal infections).

Procedures

No specific procedures are recommended for asymptomatic HTLV infections.

Lumbar puncture to evaluate CSF for anti–HTLV-1 antibodies (and/or HTLV-1 proviral load) might be beneficial in establishing a diagnosis of HAM/TSP. The laboratory results often show a mild lymphocyte pleocytosis and increased protein levels. A proviral load ratio of CSF to peripheral blood that exceeds 1 supports a diagnosis of HAM/TSP.^[49]

Lymph node biopsy may aid in the diagnosis of ATL.

Histologic Findings

No characteristic histologic findings are associated with asymptomatic HTLV infections.

HAM/TSP histopathology of the spinal cord shows perivascular and parenchymal infiltration of T cells, which worsens with the development of atrophy during disease progression.^[49]

Peripheral blood smear is required for definitive diagnosis and categorization of ATL. ATL peripheral blood lymphocytes are found to have convoluted nuclei (cloverleaf or flower lymphocytes); provirus can be detected within these malignant cells.

Treatment & Management

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Author

Joseph M Yabes, Jr, MD, FACP Deputy Director, USAF HIV Medical Evaluation Unit, Associate Program Director, Infectious Disease Fellowhip, Brooke Army Medical Center; Core Faculty, Infectious Disease Fellowship, Chair, Virtual Health Subcommittee, San Antonio Uniformed Services Health Education Consortium (SAUSHEC); Assistant Professor, Department of Medicine, Uniformed Services University of the Health Sciences; Adjunct Assistant Professor, Department of Medicine, University of Texas Health Science Center at San Antonio

Joseph M Yabes, Jr, MD, FACP is a member of the following medical societies: American College of Physicians, Armed Forces Infectious Diseases Society, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Joseph F John, Jr, MD, FACP, FIDSA, FSHEA Clinical Professor of Medicine, Molecular Genetics and Microbiology, Medical University of South Carolina College of Medicine; Associate Chief of Staff for Education, Ralph H Johnson Veterans Affairs Medical Center

Joseph F John, Jr, MD, FACP, FIDSA, FSHEA is a member of the following medical societies: Charleston County Medical Association, Infectious Diseases Society of America, South Carolina Infectious Diseases Society

Disclosure: Nothing to disclose.

Chief Editor

Pranatharthi Haran Chandrasekar, MBBS, MD Professor, Chief of Infectious Disease, Department of Internal Medicine, Wayne State University School of Medicine

Pranatharthi Haran Chandrasekar, MBBS, MD is a member of the following medical societies: American College of Physicians, American Society for Microbiology, International Immunocompromised Host Society, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

Joseph R Masci, MD, FACP, FCCP Professor of Medicine, Professor of Preventive Medicine, Icahn School of Medicine at Mount Sinai; Director of Medicine, Elmhurst Hospital Center

Joseph R Masci, MD, FACP, FCCP is a member of the following medical societies: American Academy of HIV Medicine, American Association for the Advancement of Science, American College of Chest Physicians, American College of Physicians, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Association of Professors of Medicine, Association of Program Directors in Internal Medicine, Association of Specialty Professors, Federation of American Scientists, HIV Medicine Association, Infectious Diseases Society of America, International AIDS Society, International Association of Providers of AIDS Care, International Society for Infectious Diseases, New York Academy of Medicine, New York Academy of Sciences, Physicians for Human Rights, Physicians for Social Responsibility, Royal Society of Medicine

Disclosure: Nothing to disclose.

Mark R Wallace, MD, FACP, FIDSA Infectious Disease Physician, Skagit Valley Hospital, Skagit Regional Health

Disclosure: Nothing to disclose.

Josiah D Rich, MD, MPH Professor of Medicine and Epidemiology, Brown University Medical School

Josiah D Rich, MD, MPH is a member of the following medical societies: American College of Physicians, American Federation for Medical Research, American Medical Association, American Public Health Association, Infectious Diseases Society of America, Massachusetts Medical Society, Rhode Island Medical Society

Disclosure: Received ownership interest from alkermes stockholder for none; Received ownership interest from isis stockholder for none; Received ownership interest from repligen for none.

Christopher Mark Salas, MD Fellow, Department of Infectious Diseases, Lifespan, The Warren Alpert Medical School of Brown University

Disclosure: Nothing to disclose.

Booth Wainscoat, DO Assistant Director, Division of Infectious Disease, Hartford Hospital; Assistant Professor of Clinical Medicine, University of Connecticut School of Medicine

Booth Wainscoat, DO is a member of the following medical societies: Infectious Diseases Society of America

Disclosure: Received consulting fee from Gilead for consulting.

Ewa Maria Szczypinska, MD Fellow, Department of Infectious Diseases, Orlando Health

Ewa Maria Szczypinska, MD is a member of the following medical societies: Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Sections Human T-Cell Lymphotropic Viruses (HTLV)
Overview
Presentation
- History
- Physical
- Causes
- Complications
- Show All
DDx
Workup
Treatment
Medication
References

Human T-Cell Lymphotropic Viruses (HTLV) Workup

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

References

Tables

Contributor Information and Disclosures

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