Mucocutaneous ulcer positive for Epstein–Barr virus,misdiagnosed as a small bowel adenocarcinoma:A case report

BACKGROUND Epstein–Barr virus(EBV)-positive mucocutaneous ulcers(MCUs)are an uncommon disorder characterized by ulcerative lesions in the skin,oral cavity or gastrointestinal tract in patients with iatrogenic or aging-induced immunosuppression.The nonspecific lesions are difficult to differentiate from small bowel adenocarcinomas.We present the case of a 69-year-old woman who was initially misdiagnosed with a small bowel adenocarcinoma but was later surgically diagnosed with and treated for EBV-MCU.Through this case,we aim to emphasize the importance of accurately distinguishing between the two conditions.CASE SUMMARY The patient presented with an incidental finding of a small bowel tumor during computed tomography(CT)examination performed for hematuria.The CT scan showed irregular thickening of the distal ileum,which was suggestive of a malignant small bowel tumor.An exploratory laparotomy revealed an 8-cm mass in the distal ileum;thus,a segment of the small intestine,including the mass,was resected.Histopathological analysis revealed an ulceroinfiltrative mass-like lesion with luminal narrowing,marked inflammatory cell infiltration,and large atypical lymphoid cells(positive for EBV-encoded small RNA).A final diagnosis of an EBV-MCU was established.The postoperative course was uneventful,and the patient was discharged on postoperative day 7.The patient remained recurrencefree until 12 mo after surgery.CONCLUSION This case highlights the diagnostic challenges for EBV-MCUs and emphasizes the importance of comprehensive evaluation and accurate histopathological analysis.

Recombinant Vaccinia Virus is an Effective and Non-perturbing Vector for Human Dendritic Cells Transfected with Epstein-Barr Virus Latent Membrane Protein 2A

ObjectiveTo study the effects of dendritic cells (DC) transfected with recombinant vaccinia virus encoding Epstein Barr virus (EBV) latent membrane protein 2A(LMP2A) gene,and to provide evidence for further investigation on the therapeutic vaccines against EBV associated malignancies. MethodsMature DC were transfected with EBV LMP2A recombinant vaccinia virus (rVV LMP2A). Before and after the transfection,the expression of surface antigens on mature DC including CD1a,CD83,CD40,CD80,HLA DR was measured by fluorescence activated cell sorter (FACS) and the function of DC to stimulate allogeneic T cells proliferation was measured by mixed leukocyte reactions (MLR). ResultsLMP2A protein was highly expressed (66.1 %) in DC after the transfection of rVV LMP2A. No significant changes in the primary surface antigens expression and in the MLR were detected during the transfection. Transfected DC still had strong potential in stimulating the proliferation of allogeneic T cells. ConclusionRecombinant vaccinia virus was an effective and non perturbing vector to mediate the transfection of LMP2A into DC. The functions of mature DC were not affected significantly by the transfection of Vac LMP2A. This study could provide evidence for the further immunotherapy of EBV associated malignancies,e.g. nasopharyngeal carcinoma (NPC).

STUDIES ON THE RELATIONSHIP BETWEEN EPSTEIN BARR VIRUS (EBV) AND PATHOGENESIS OF MULTIPLE MYELOMA

In order to explore the relationship between Epstein Barr virus (EBV) and pathogenesis of multiple myeloma (MM), the presence of EBV DNA in mononuclear cells of bone marrow (BMMC) and peripheral blood (PBMC) taken from 23 multiple myeloma patients who were neither posttransplanted nor HIV positive were examined by polymerase chain reaction (PCR). Meanwhile the presence of EBV EBERs in bioptic bone marrow's specimens of 4 MM patients were examined by in situ hybridization (ISH). Acute leukemia, aplastic anemia and malnourished anemia patients were taken as control. It showed EBV DNA detective rate in BMMC (69 6%) and in PBMC (39 1%) of MM patients were higher significantly than control groups (P<0 05). The positive signals of EBERs were located in BMMC and the EBV positive samples detected by ISH were consistent with those by PCR. The results indicate that EBV is closely correlated to pathogenesis of MM.

Epstein Barr Virus—The Cause of Multiple Sclerosis

Although many studies have found a kind of a relationship between an Epstein-Barr Virus (EBV) and the development of Multiple Sclerosis (MS), a fundamental aspect of this relationship remains uncertain. What is the cause of Multiple Sclerosis (MS)? In this study, we re-analysed the data as published by Wandinger et al. and were able to establish a new insight: without an Epstein-Barr Virus (EBV) infection no development of Multiple Sclerosis (MS). Furthermore, we determined a highly significant causal relationship between Epstein-Barr Virus (EBV) and multiple sclerosis. Altogether, Epstein-Barr Virus (EBV) is the cause of multiple sclerosis (p-value 0.0004251570).

SERO-EPIDEMIOLOGICAL STUDIES OF EPSTEIN-BARR VIRUS(EBV) INFECTION BY TESTING ANTIBODIES AGAINST EBV SPECIFIC DNASE(EDAb) AS A METHOD FOR EARLY DETECTION OF NASOPHARYNGEAL CARCINOMA(NPC)

In 1987, a mass survey of EDAb was carried out in Sihui county of Gunagdong Province (the highest incidence area of NPC in China) and the city of Guangzhou using the methods previously established by our lab. In order to study the correlation between EDAb level and NPC, the titre of DEAb and their distribution in sera from 430 patients with NPC and 5030 normal persons were detected. It was found that the AER (level of EDAb was represented by the anti enzyme rate) of NPC patients gave a negative skew distribution and the Md=65.3% while the natural population (30 59 years old) gave a serious positive skew distribution and the Md is 7.9%. According to the pattern of EDAb distribution curve of 430 NPC patients and 2060 natural population. AER≥30% was defined as a cut off point between EDAb positive and negative. Using this value we got a rate of 90.7% (390/430) positive diagnosis in NPC patients, while in natural population the positive rate was 3.3% (68/2060), and in the IgA/VCA positive (1:5) normal person the positive rate was 6.0% (41/681). As to the other tumors including head and neck tumors the positive rate was 3.4% (7/204), similar to the natural population. After a period of 62 months of follow up surveillance, 15 of 224 EDAb positive normal persons found in the mass survey were diagnosed as NPC by histopathological examination. While in 4806 EDAb negative normal person only one case NPC patient was found in this period. 60% of these patients were diag nosed in their early stage of NPC. From these patients it was found that EDAb could appear in the sera of the patients as early as 62 months before NPC was definitely diagnosed. 2 of these patients were shown IgA/VCA negative and EDAb positive in mass survey. This suggested that in some of the precancerous patients EDAb could appear earlier than IgA/VCA. The signifi cance of the sera EDAb positivity of normal person was discussed.

THE DETECTION OF CD56 AND EPSTEIN-BARR VIRUS IN T-CELL LYMPHOMAS

Objective: To study the relationship between EBV infection and the expression of CD56 in T cell lymphomas (TCLs). Methods: 46 cases of TCLs and 15 cases of reactive hyperplasia of lymphonodes (RHs) were detected CD56 by immunohistochemistry and EBERs by in situ hybridization. Results: 8 cases of 46 TCLs (17.4%) showed CD56 positive. On sites, CD56 positive rate of nasopharyngeal TCLs was highest (5/17, 29.4%), and on subtypes, that of DLs was highest (6/16, 37.5%). Additionally, 4 RHs were also CD56 positive. Of 46 TCLs, 24 showed expression of EBERs. There were only 4 TCLs expressing both CD56 and EBERs. Conclusion: The expression of CD56 was not especially for TCLs that EBV infected. EBV infection was not related with CD56 positive TCLs. The findings also suggested the expression of CD56 in TCLs be possibly related to original sites and subtypes of TCLs.

THE INTRACELLULAR FORM OF EPSTEIN-BARR VIRUS GENOME IN NASOPHARYNGEAL CARCINOMA

This work was supported by the National Natural Science Foundation of China (No. 39370766). Object: To study the existent form of EBV genome in nasopharyngeal carcinoma (NPC) biopsies, in a trans planted NPC tumor SUNT 1 and its corresponding epithelial cell line SUNE 1. Methods: By using polymerase chain reaction (PCR) amplification of Epstein Barr virus (EBV) BamHI W fragment, EBV DNA was detected in 20/20 biopsy specimens of poorly differentiated, as well as in a nude mouse xenografted NPC tumor (SUNT 1, from passage 1 to 34) and in the corresponding epithelial cell line (SUNE 1, from passage 1 to 62). The intracellular form of EBV genome was studied by analyzing the terminal structure using a LMP2A probe and an “ in situ lysing gel” technique. Results: A single EBV fused terminal DNA fragment was detected in 19 biopsy specimens, two hybridized bands were seen in one specimen. These results indicate that an episomal form of EBV genome is predominantly present in most NPC biopsy specimens, but insertion of the genome into the host chromosome could not be excluded. Conclusion: The finding suggests that EBV infection precedes clonal amplification of transformed cells, or in a rare case, that a single EBV infected clone is predominant in the development of NPC. Linear form of EBV DNA was detected in the 20th passage of SUNE 1; this may imply the in vitro activation of the productive cycle of EBV.

Epstein Barr Virus Infection Induced Suspected Acute Myocarditis in COVID-19 Pandemic

Background: Epstein Barr Virus infection (EBV) could be associated with cardiovascular disease, including myocarditis. We informed a case of EBV infection presenting initially as myocarditis, followed 5 days later by the typical symptoms of infectious mononucleosis. Case Presentation: A 19-year-old man with persistent retrosternal chest pain was admitted to the emergency department. On physical examination, the patient had sub-febrile fever (37.2°C) and palpable cervical lymphadenopathy, with no hepatosplenomegaly. Initial ECG has repolarization abnormalities in leads II, aVF and III. Laboratory testing revealed elevated cardiac enzymes and liver enzymes (high sensitive troponin I levels 3000 ng/mL, aspartate transaminase 158 U/L, alanine transaminase 100 U/L). Blood white cells were 10,500 μL, platelet level were low 98,000 (thrombocytopenia), and lenfo-monocytosis in complete blood count. We hospitalized the patients the intensive coronary unit (ICU) because of high troponin levels. We recognized hypokinesia of the posterolateral wall of the left ventricle with mild impaired systolic function and increased perimyocardial brightness by echocardiography. Antibody serology tests showed that the anti-EBV capsid antigen IgM (EBV-VCA) was positive, EBV-VCA) IgG was negative. Other etiologies were excluded. Therefore, the patient was referred to cardiac positron emission tomography due to technic problems of magnetic resonance imaging device. We documented in positron emission tomography imaging that increased 18F-FDG uptake on posterior and posterolateral walls of left ventricle (indicating a large jeopardized area). We diagnosed suspected diagnosis of myocarditis without associated pericarditis. We monitored the patient and gave beta blocker, and aldosterone antagonists. Complications in the intensive care unit not occurred. We discharged patients after one week. After three weeks, we re-evaluated the patient. We not observed wall segment motion abnormality on echocardiography and liver tests were near normal. Conclusion: In suspected EBV myocarditis, 18F-FDG PET-CT cardiac positron emission tomography imaging represents an interesting noninvasive imaging technique to identify inflammatory processes in acute myocarditis and can be considered in patients with contraindications/unavailable to cardiac magnetic resonance.

Chronic Active Epstein–Barr Virus Infection

Chronic active Epstein-Barr virus(CAEBV)infection is a systemic Epstein–Barr virus(EBV)positive lymphoprolifetative disease characterized by fever,lymphadenopathy,splenomegaly,unusual pattern of antiEBV antibodies,and/or increased EBV genomes in affected tissues.Most cases are from Asia.So far,there is hardly any adult case reported from mainland of China.We herein presented a 33-year-old man with fever,facial erythema and rash,lymphadenopathy,lower limbs weakness,splenomegaly and liver lesion.EBV VCA,EA and EBNA were all positive.EBV DNA could be found in serum and PBMC.In situ hybridization of EBV encoded RNA in skin and liver biopsy was positive.Viral load in serum decreased under interferon alpha therapy.To our knowledge,it’s the first adult case reported from mainland of China.

Acute Kidney Injury with Epstein Barr Virus-Associated Hemophagocytic Syndrome

A 59-year-old man, who was treated for schizophrenia and psoriasis vulgaris with risperidone and cyclosporine, presented with high fever and myalgia. Those did not respond to treatment for neuroleptic malignant syndrome for two weeks, and multiple organ dysfunction developed, so he was admitted to our hospital, but died two days later. Autopsy detected the hemophagocytosis, Epstein Barr Virus (EBV)-reactivated cells, and the absence of glomerulonephritis and interstitial tubulitis. We considered that hemophagocytic syndrome (HPS) and myalgia were caused by reactivated EBV and the viremia under immunosuppression, and renal failure was caused by sepsis-like state by cytokine storm of HPS.

Epstein-Barr virus infection of sinonasal lymphoepithelial carcinoma in Guangzhou

Objectives To investigate the prevalence of sinonasal lymphoepithelial carcinoma (SNLEC) in Guangzhou, a high incidence area of nasopharyngeal carcinoma (NPC), and to detect whether it is associated with Epstein-Barr virus (EBV) infection.Methods Twenty confirmed SNLEC specimens were collected from all of the sinonasal carcinoma biopsies performed in the 8 years 1989-1996 at the Sun Yat-sen University of Medical Sciences. EBV encoded early RNAs were detected by use of in-situ hybridization. A variety of antigens, including the EBV nuclear antigen 1, latent membrane protein 1, BZLF1 protein, diffuse early antigen, viral capsid antigen and membrane antigen, were detected using immunohistochemistry. Additionally, 36 NPC specimens were used for comparison.Results Twenty SNLECs were identified. Seventeen SNLECs were developed in the nasal cavity, and 3 in the maxillary sinus. The mean age (46.25 y), male to female ratio (3∶1), histopathology and lymphoinfiltration of the 20 SNLECs were identical with those of the 36 NPCs. Thirteen (65.0%) of the 20 SNLECs showed an expansive growth pattern, while 27 (75.0%) of the 36 NPCs showed an infiltrating or mixed growth pattern. The majority of cancer cells in all of the 20 SNLECs showed EBV encoded early RNAs. The EBV nuclear antigen 1 expression of SNLEC was less intensive than that of NPC. The expression rate of latent membrane protein 1 for SNLEC (3/20,15%) was lower than that for NPC (19/36, 52.8%). The expression rates of BZLF1 protein (2/20, 10.0%), diffuse early antigen (19/20, 95.0%), viral capsid antigen (15/20, 75.0%), and membrane antigen (13/20, 65.0%) for SNLEC were higher than those (0/36, 0.0%; 31/36, 86.0%; 18/36, 50%; and 14/36, 38.9%) for NPC. Conclusions SNLEC is not uncommon in Guangzhou. This tumour is also consistently associated with EBV infection like NPC. As compared to NPC, the EBV harbored in SNLECs seems to express the EBV nuclear antigen 1 weakly and has a lower expression rate of latent membrane protein 1 as well as higher expression rates of EBV lytic products.

CK5/6-positive,P63-positive lymphoepithelioma-like hepatocellular carcinoma:A case report and literature review

BACKGROUND Lymphoepithelioma-like carcinoma(LELC),a rare and unique variant of liver cancer,can be divided into lymphoepithelioma-like hepatocellular carcinoma and lymphoepithelioma-like intrahepatic cholangiocarcinoma.Dense lymphocytic infiltration is its characteristic pathological feature.In recent years,the number of reported cases of this type has increased each year.Studies have shown that lymphoepithelioma-like cholangiocarcinoma occurs more frequently in Asian women;LELC is associated with Epstein–Barr virus infection of liver cells of epithelial origin.Existing research shows that the prognosis of this tumour is good.CASE SUMMARY A 38-year-old female patient was hospitalized after 3 mo of abdominal pain and nausea.She had been infected with hepatitis B virus more than 10 years prior.The patient was hospitalized on January 21,2022.Magnetic resonance imaging showed a 36 mm×28 mm mass under the envelope of the left inner lobe of the liver.No metastasis of lymph nodes or other organs was observed.After left hemihepatectomy,biopsy and immunohistochemistry yielded a final diagnosis of lymphoepithelial hepatocellular carcinoma.After 12 mo of outpatient follow-up and chemotherapy,no tumour metastases were found on the latest computed tomography examination.CONCLUSION Herein,the patient was treated surgically and then followed up as an outpatient for 12 mo.This case will further expand our overall knowledge of the diagnosis and treatment of this rare tumor.

Epstein-Barr virus encoded latent membrane protein 1 induces TRAF1 expression to promote anti-apoptosis activity via NF-κB signaling pathway in nasopharyngeal carcinoma

Objectives To identify whether Epstein Barr virus (EBV) encoded latent membrane protein 1 (LMP1) can induce tumor necrosis factor receptor associated factor 1 (TRAF1) expression and promote its anti apoptosis activity via the NF κB signaling pathway, and assess that LMP1 suppresses apoptosis in nasopharyngeal carcinoma (NPC) Methods A stable transfected cell line HNE2 LMP1 was established by introducing LMP1 cDNA into HNE2 cells Transactivation of TRAF1 was determined by luciferase reporter assay, while expression of TRAF1 mRNA was detected by RT PCR and expression of TRAF1 protein and caspase 3 by Western blot analysis Apoptosis activity was observed through fluorescence staining Results LMP1 induced TRAF1 expression in NPC cells and caused a decrease in apoptosis This induction could be blocked by antisense LMP1 Moreover, LMP1 mediated induction of a TRAF1 promoter driven reporter gene was significantly impaired when the κB site κB1 or κB5 was disrupted, whereas mutation of κB3 had only a minor effect on LMP1 dependent up regulation of the reporter gene Conclusion LMP1 induces TRAF1 expression and promotes its anti apoptosis activity via the NF κB signaling pathway, which may be one of the mechanisms that LMP1 uses to suppress apoptosis in NPC cells

鼻咽癌病人治疗前后血清中IgG／Z抗体的观察

本研究以ＥＬＩＳＡ法检测了鼻咽癌病人治疗前后血清中Ｅｐｓｔｅｉｎ－Ｂａｒｒ病毒的ＩｇＧ／Ｚ抗体阳性率及其滴度。结果显示，鼻咽癌患者血清ＩｇＧ／Ｚ抗体滴度显著升高，与治疗后的病人血清ＩｇＧ／Ｚ抗体滴度比较有显著的差别（Ｐ＜０．０１），表明ＩｇＧ／ｚ抗体对鼻咽癌的诊断有指导意义。鼻咽癌血清ＩｇＧ／Ｚ抗体阳性率治疗前高达１００％，治疗后随存活时间延长，抗体出现的阳性率逐渐降低。可见ＩｇＧ／Ｚ抗体对鼻咽癌颈后判定也有一定的参考值价。

VCA+EA多肽片段联合包被ELISA对血液EBV IgA检测效果的研究

目的探讨中山大学附属肿瘤医院研制的病毒壳抗原(VCA)+早期抗原(EA)多肽片段联合包被聚苯乙烯微孔板酶联免疫吸附测定(ELISA)方法对血液中Epstein-Barr病毒(EBV)免疫球蛋白A(IgA)的检测效果,并将其与进口筛选试剂盒进行比较,最终对VCA+EA多肽片段联合包被ELISA试剂盒性能进行评价。方法收集鼻咽癌患者血清86例,健康人群血清100例,用ELISA检测血清中IgA的OD值,观察该方法的最低检测限、线性范围、精密度、回收率,同时采用进口的Epstein-Barr病毒持续表达核抗原(EBNA1)+VCA-p18抗原包被ELISA方法进行检测,观察其临床性能。结果 VCA+EA多肽片段联合包被ELISA方法最低检测限为(0.003 4±0.002 6),血清稀释100倍数(及以上),其水平与吸光度呈线性关系,阴性标本、弱阳性标本、阳性标本IgA水平的日内变异系数为3.97%、9.76%、9.23%,日间变异变异系数分别为7.56%、10.20%、7.67%。VCA+EA多肽片段联合包被试剂盒与EBNA1+VCA-p18抗原包被试剂盒比较,相关系数为0.926 6;检测鼻咽癌敏感性为88.90%,特异性为77.80%,阳性预测值为80.00%,阴性预测值为87.50%。结论 VCA+EA多肽片段联合检测鼻咽癌有较高敏感性,重复性较好,阴性结果预测较可靠,可作为临床筛查鼻咽癌的新方法。

Helicobacter pylori and EBV in gastric carcinomas:Methylation status and microsatellite instability

AIM:To verify the methylation status of CDH1, DAPK, COX2, hMLH1 and CDKN2A genes and to evaluate their association with Helicobacter pylori (H. pylori)-cagA+ and Epstein Barr virus (EBV) infections in gastric adenocarcinomas.METHODS: Methylation-specific PCR (MSP) assay was performed in 89 primary gastric carcinomas (intestinal and diffuse types). Microsatellite instability (MSI) analysis was performed using the BAT26 primer set and PCR products were analyzed with the ABI PRISM 3100 Genetic Analyzer using Genescan 3.7 software (Applied Biosystems). Detection of H. pylori and genotyping were performed by PCR, using specifi c primers for ureaseC and cagA genes. The presence of EBV was assessed by in situ hybridization. Statistical analyses were performed using the χ2 or Fisher's exact test.RESULTS: The most frequent hypermethylated gene was COX-2 (63.5%) followed by DAPK (55.7%), CDH1 (51%), CDKN2A (36%) and hMLH1 (30.3%). Intestinal and diffuse adenocarcinomas showed different methylation profiles and there was an association between methylation of E-CDH1 and H. pylori-cagA+ in the intestinal adenocarcinoma type. MSI was correlated with hMLH1 methylation. There was an inverse correlation between DAPK hypermethylation and MSI.CONCLUSION: We found a strong association between CDH1 methylation and H. pylori-cagA+ in intestinal-type gastric cancer, association of MSI and better prognosis and an heterogeneous COX-2 overexpression.

A case of acute infectious mononucleosis presenting with very high ferritin

Hepatitis is an important but uncommon manifestation of acute Epstein Barr infection. Infectious mononucleosis is usually a disease of young adults. We report a case of infectious mononucleosis in a 72-year old jaundiced gentleman with ferritin level of 2438 that normalised on clinical improvement.

Epstein-Barr病毒膜抗原在昆虫细胞中的表达

目的 探索影响EpsteinBarr病毒膜抗原(EBVMA)在昆虫细胞中表达的因素。方法 携有截去穿膜区序列的EBVMA基因的重组昆虫杆状病毒感染不同生长阶段及生长条件的昆虫细胞,应用免疫打点法及MasterImagineVDS影像摄录分析系统测定目的蛋白的表达量。结果 重组病毒感染不同生长阶段的细胞,MA表达量不同。处于对数生长早期的细胞表达量明显高于处于对数生长晚期及静止期的细胞。将不同生长阶段的细胞补充新鲜培养液,MA的表达量在原基础上有所提高。进一步研究表明,在感染重组病毒之前,更换新鲜培养液,同时在感染过程中补充葡萄糖,L谷氨酰胺等营养物质,会大大提高MA表达量。结论 细胞培养液中营养物质的消耗和代谢产物的蓄积是影响EBVMA在昆虫细胞中表达的主要因素。

Recurrence of infectious mononucleosis in adults after remission for 3 years:A case report

BACKGROUND Infectious mononucleosis(IM)is a disease caused by Epstein–Barr virus(EBV).EBV infection is common in children;however,it can cause IM in adults.Studies on recurrence of IM in adults after remission are limited.CASE SUMMARY We report a 28-year-old man who presented with IM-like symptoms with mild liver damage after initial remission of IM for 3 years.He was first diagnosed with IM and treated in 2015.Follow-up tests in 2016 and 2017 did not show any abnormalities.In November 2018,he presented with swelling of the tonsils.He was misdiagnosed with acute suppurative tonsillitis and treated for 5 d.No signs of improvement were observed.He was readmitted with recurrent fever,pharyngalgia,fatigue,and systemic muscle pain.Examinations revealed enlargement of the tonsils and cervical lymph nodes.Blood tests revealed elevated transaminase levels.Anti-EBV test was positive,indicating virus reactivation.IM recurrence was confirmed on the basis of laboratory tests and clinical manifestations.He was treated with antiviral,anti-infective,and hepatoprotective drugs and vitamin supplements.His condition improved and no abnormalities were observed during follow-up.CONCLUSION Recurrence of IM after remission is possible in adults;therefore,long-term followup and monitoring are essential.

Aggressive natural killer cell leukemia with skin manifestation associated with hemophagocytic lymphohistiocytosis:A case report

BACKGROUND Aggressive natural killer cell leukemia(ANKL)is a rare natural killer cell neoplasm characterized by systemic infiltration of Epstein–Barr virus and rapidly progressive clinical course.ANKL can be accompanied with hemophagocytic lymphohistiocytosis(HLH).Here,we report a case of ANKL with rare skin lesions as an earlier manifestation,accompanied with HLH,and review the literature in terms of etiology,clinical manifestation,diagnosis and treatment.CASE SUMMARY A 30-year-old woman from Northwest China presented with the clinical characteristics of jaundice,fever,erythema,splenomegaly,progressive hemocytopenia,liver failure,quantities of abnormal cells in bone marrow,and associated HLH.The immunophenotypes of abnormal cells were positive for CD2,cCD3,CD7,CD56,CD38 and negative for sCD3,CD8 and CD117.The diagnosis of ANKL complicated with HLH was confirmed.Following the initial diagnosis and supplementary treatment,the patient received chemotherapy with VDLP regimen(vincristine,daunorubicin,L-asparaginase and prednisone).However,the patient had severe adverse reactions and complication such as severe hematochezia,neutropenia,and multiple organ dysfunction syndrome,and died a few days later.CONCLUSION This is the first reported case of ANKL with rare skin lesions as an earlier manifestation and associated with HLH.