Epstein Barr virus and Helicobacter pylori co-infection are positively associated with severe gastritis in pediatric patients

Abstract

Background: H. pylori infection is acquired during childhood and causes a chronic inflammatory response in the gastric mucosa, which is considered the main risk factor to acquire gastric cancer (GC) later in life. More recently, infection by Epstein-Barr virus (EBV) have also been associated with GC. The role of EBV in early inflammatory responses and its relationship with H. pylori infection remains poorly studied. Here, we assessed whether EBV infection in children correlated with the stage of gastritis and whether co-infection with H. pylori affected the severity of inflammation.

Methodology/principal findings: 333 pediatric patients with chronic abdominal pain were studied. From them, gastric biopsies were taken and inflammation graded according to the Sydney system; peripheral blood was drawn and antibodies against EBV (IgG and IgM anti-VCA) and H. pylori (IgG anti-whole bacteria and anti-CagA) were measured in sera. We found that children infected only by EBV presented mild mononuclear (MN) and none polymorphonuclear (PMN) cell infiltration, while those infected by H. pylori presented moderate MN and mild PMN. In contrast, patients co-infected with both pathogens were significantly associated with severe gastritis. Importantly, co-infection of H. pylori CagA+/EBV+ had a stronger association with severe MN (PR 3.0) and PMN (PR 7.2) cells than cases with single H. pylori CagA+ infection.

Conclusions/significance: Co-infection with EBV and H. pylori in pediatric patients is associated with severe gastritis. Even single infections with H. pylori CagA+ strains are associated with mild to moderate infiltration arguing for a cooperative effect of H. pylori and EBV in the gastric mucosa and revealing a critical role for EBV previously un-appreciated. This study points out the need to study both pathogens to understand the mechanism behind severe damage of the gastric mucosa, which could identified children with increased risk to present more serious lesions later in life.

Figure 1. H. pylory and EBV infection frequencies in pediatric patients with gastritis according to the different grades of mononuclear (inflammation) and polymorphonuclear (activity) cell infiltration.

Asterisks denote associations with statistical significance: HP−/EBV− and HP−/EBV+ groups with mild MN and no PMN (open circle and triangle), HP+/EBV− (grey circle) with moderate MN and mild PMN, and HP+/EBV+ (grey triangle) with severe MN and moderate-severe PMN.

Figure 2. Infection frequencies and gastritis severity related to the presence of CagA.

Asterisks denote associations with statistical significance: HP CagA−/EBV− and HP CagA−/EBV+ groups with mild MN and no PMN (open circle and triangle), HP CagA+/EBV− (grey circle) with mild PMN, and HP CagA+/EBV+ (grey triangle) with severe MN and moderate-severe PMN.