The company malaria keeps: how co-infection with Epstein-Barr virus leads to endemic Burkitt lymphoma

Abstract

Purpose of review: Co-infection with Plasmodium falciparum malaria and Epstein-Barr virus (EBV) are implicated in the cause of endemic Burkitt lymphoma (eBL), the most prevalent pediatric cancer in equatorial Africa. Although the causal association between EBV and eBL has been established, P. falciparum malaria's role is not as clearly defined. This review focuses on how malaria may disrupt EBV persistence and immunity.

Recent findings: Two mutually compatible theories have been proposed. One suggests that P. falciparum malaria induces polyclonal B-cell expansion and lytic EBV reactivation, leading to the expansion of latently infected B cells and the likelihood of a c-myc translocation, a hallmark of Burkitt lymphoma tumors. The other advocates that EBV-specific T-cell immunity is impaired during P. falciparum malaria co-infection, either as a cause or consequence of enhanced EBV replication, leading to loss of viral control. Advancements in our ability to query the complexity of human responses to infectious diseases have stimulated interest in eBL pathogenesis.

Summary: EBV is necessary but not sufficient to cause eBL. A more dynamic model encompasses incremental contributions from both chronic and acute P. falciparum malaria leading to alterations in EBV persistence and EBV-specific immunity that culminate in eBL. A better understanding of how P. falciparum malaria modifies EBV infections in children may allow us to anticipate reductions in eBL incidence coinciding with malaria control programs.

Figures

Figure 1. Chronology of Pf-malaria and EBV infections in relation to eBL incidence

Timing of co-infections prior to peak age-related incidence of eBL suggest a cumulative interaction that results in the deterioration of immune control over EBV.