Sickle cell trait is not associated with endemic Burkitt lymphoma: An ethnicity and malaria endemicity-matched case-control study suggests factors controlling EBV may serve as a predictive biomarker for this pediatric cancer

Endemic Burkitt lymphoma (eBL) is associated with Epstein-Barr virus (EBV) and Plasmodium falciparum coinfections. Malaria appears to dysregulate immunity that would otherwise control EBV, thereby contributing to eBL etiology. Juxtaposed to human genetic variants associated with protection from malaria, it has been hypothesized that such variants could decrease eBL susceptibility, historically referred to as the protective hypothesis. Past studies attempting to link sickle cell trait (HbAS), which is known to be protective against malaria, with protection from eBL were contradictory and underpowered. Therefore, using a case-control study design, we examined HbAS frequency in 306 Kenyan children diagnosed with eBL compared to 537 geographically defined and ethnically matched controls. We found 23.8% HbAS for eBL patients, which was not significantly different compared to 27.0% HbAS for controls [odds ratio (OR)=0.85; 95% confidence interval (CI) 0.61-1.17; p-value=0.33]. Even though cellular EBV titers, indicative of the number of latently infected B cells, were significantly higher (p-value<0.0003) in children residing in malaria holoendemic compared to hypoendemic areas, levels were not associated with HbAS genotype. Combined, this suggests that although HbAS protects against severe malaria and hyperparasitemia, it is not associated with viral control or eBL protection. However, based on receiver operating characteristic curves factors that enable the establishment of EBV persistence, in contrast to those involved in EBV lytic reactivation, may have utility as an eBL precursor biomarker. This has implications for future human genetic association studies to consider variants influencing control over EBV in addition to malaria as risk factors for eBL. What's new? Although the hypothesis dates back to 1970, studies of the protective effect of sickle cell trait (HbAS) on the development of endemic Burkitt lymphoma (eBL) have led to contradictory conclusions. This new study analyzed an unprecedented number of eBL cases and highlighted the importance of matching controls on ethnicity as well as malaria endemicity. The findings contribute to resolving the controversy by showing that HbAS frequency does not differ between children diagnosed with eBL and healthy children. The study also examined cellular Epstein-Barr Virus (EBV) titers, which in contrast to plasma EBV levels may serve as an informative eBL biomarker.