History of the KSHV Inflammatory Cytokine Syndrome (KICS)

• Assessment of the natural history of KICS, including the spectrum of clinical, laboratory and radiographic abnormalities seen in affected patients. [ Time Frame: 5 years ] [ Designated as safety issue: No ]
  

• Exploration of the relationship of KICS clinical manifestations to KSHV viral loads, cytokines including viral IL-6, human IL-6, human IL-10 and other human cytokines, and KSHV lytic activation assessed by gene array. [ Time Frame: 5 years ] [ Designated as safety issue: No ]
  
• Exploration of the pathophysiology of KICS, by assessment of affected tissue, including lymph nodes, bone marrow, effusions and sites of KS (where present), including immunohistochemical evaluation of cells with KSHV latent and lytic infection i... [ Time Frame: 5 years ] [ Designated as safety issue: No ]
  
• Exploratory assessment of potential stimuli of KSHV lytic activation in KICS patients, including potential stimuli such as coincident infection, uncontrolled HIV viremia, hypoxia, immune reconstitution with institution of HAART, or association o... [ Time Frame: 5 years ] [ Designated as safety issue: No ]
  
• Exploratory assessment of the prevalence of KICS in a cohort of KSHV infected patients with symptoms potentially attributable to KICS. [ Time Frame: 5 years ] [ Designated as safety issue: No ]
  
• Assessment of 18[F]-Fluorodeoxyglucose positron emission tomographyfindings at KICS symptomatic time points compared with those following symptom resolution. [ Time Frame: 5 years ] [ Designated as safety issue: No ]
  
• Estimation of clinical response rate with institution of each specific therapy (high dose zidovudine/valganciclovir or rituximab/liposomal doxorubicin). [ Time Frame: 5 years ] [ Designated as safety issue: No ]
  
• Estimation of rates of progression of patients to multicentric Castleman disease and other KSHV-associated diseases including KSHV-associated lymphomas. [ Time Frame: 5 years ] [ Designated as safety issue: No ]
  
• Estimation of overall survival for the entire cohort, and of progressionfree survival and overall survival for each specific therapy (high dose zidovudine/valganciclovir or rituximab/liposomal doxorubicin). [ Time Frame: 5 years ] [ Designated as safety issue: No ]
  

BACKGROUND:

KSHV inflammatory cytokine syndrome (KICS) is a newly recognized syndrome caused by Kaposi sarcoma-associated herpesvirus (KSHV). It is characterized by severe inflammatory symptoms including fevers, wasting, cytopenias, hypoalbuminemia, and hyponatremia, associated in some cases with lymphadenopathy or effusions, without pathological evidence of MCD. Patients with KICS exhibit elevated KSHV viral loads and cytokine dysregulation, with elevations of IL-6, IL-10, and a KSHV-encoded IL-6 homolog, viral IL-6.

OBJECTIVES:

The primary study objective is to enable intensive study and description of the natural history of KICS. Secondary objectives include assessment in affected persons of KSHV viral loads and cytokine levels, evaluation of tissue pathophysiology, exploration of FDG-PET abnormalities, and pilot assessment of response to two therapies: high dose zidovudine/valganciclovir or rituximab/liposomal doxorubicin.

ELIGIBILITY:

Adults of any HIV status with:

• At least two symptoms, laboratory or radiographic abnormalities which are at least possibly attributable to KICS (including fever, fatigue, cachexia, edema, respiratory or gastrointestinal symptoms, hematologic cytopenias, hypoalbuminemia, hyponatremia, lymphadenopathy,organomegaly, effusions)
• C-reactive protein > 3mg/dL.
• Evidence of KSHV infection, demonstrated by either presence of antibodies to KSHV, or presence of Kaposi sarcoma (KS) or primary effusion lymphoma
• No evidence of KSHV-associated multicentric Castleman disease

Patients with these characteristics will be further evaluated to identify those whose clinical and laboratory features are consistent with the working KICS working case definition to be followed in the natural history phase of the study.

DESIGN:

This is a single center natural history cohort with an observation arm and two nested open label pilot treatment arms, and an accrual ceiling of 40 patients to the overall natural history arm. Natural history patients will undergo clinical, laboratory and correlative assessment every 3 months until sustained resolution. Patients with clinical and laboratory manifestations of KICS, elevated inflammatory markers and KSHV viral load will be eligible for therapy with high dose zidovudine/valganciclovir or, if they have intercurrent KS requiring cytotoxic therapy, rituximab/liposomal doxorubicin. Each treatment arm uses a two stage design, with interim analysis at 8 patients in each arm and potential accrual of 14 per arm.