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January 13, 2011

Epstein-Barr Virus

Identified in 1964 in Burkitt lymphoma Lab technician

became ill with mononucleosis EBV seroconversion

Ubiquitous Harbored by nearly all adults

No seasonal variation or clustering of cases

Epstein-Barr Virus

Most infected by oral route “kissing disease”

Other modes of transmission Blood transfusions Bone Marrow transplants Sexually transmitted

Epstein-Barr Virus

Incubation period 30-50 days Age at infection varies with living

conditions Age 2 to 3

20% to 80% infected Industrialized countries:

More common primary EBV in adolescents IM in 30% to 50% of these cases

Infectious Mononucleosis

Illness Script

Infectious Mononucleosis

FeverSore Throat (exudative pharyngitis)MalaiseLymphadenitis (Cervical)+/- HepatosplenomegalyAtypical Lymphocytosis

Infectious Mononucleosis

Highly suggestive findings Palatal petechiae Splenomegaly Posterior cervical adenopathy

Absence of cervical lymphadenopathy and fatigue make the diagnosis much less likely.

Clinical Manifestations

Rash 4% of older patients

With antibiotic (ampicillin) administration Nonallergic

morbilliform rash Seen in nearly 100%. Benzyl-penicilloyl-

specific IgM

Rare Clinical Manifestations

CNS (5%) Aseptic meningitis Encephalitis Optic neuritis CN palsies Transverse myelitis Guillian-Barre

Rare Clinical Manifestations

Hematologic Splenic rupture Thrombocytopenia Neutropenia Hemolytic anemia

Others Respiratory Compromise Pneumonia Orchitis Myocarditis

Diagnostic Tests

Viral culture is difficult Diagnosis implicated by:

Characteristic clinical signs Lymphocytosis (>50%)

Absolute (> 4500/mL) Atypical Lymphocytosis (>10%)

Confirmed by: Criteria above + positive heterophile

Heterophile Test (Monospot)

Heterophile antibodies react to antigens from unrelated species

Monospot- Latex agglutination assay using horse erythrocytes and patient serum. Peak levels at 2-6 weeks May remain elevated for up to 1 year Sensitivity 85%

Less sensitive in children < age 3. Specificity 100%

Diagnostic Testing

Other antibody Testing (useful if heterophile negative) anti-VCA IgM

Some evidence for active/recent infection anti-EBNA

Excludes active primary infection

Treatment

“Take it easy” No contact sports until spleen no longer

palpable Avoid ampicillin and amoxicillin Steroids reserved for most severe of

cases

Associated Conditions

X-linked Lymphoproliferative Disease (XLP) Defect in signaling lymphocytic activation

molecule-associated protein Characterized by

Nodular B-cell lymphomas +/- CNS involvement Profound hypogammaglogulinemia Aplastic anemia Severe infectious mono early in life

4% survival

Associated Conditions

EBV associated B-Cell Lymphoproliferative Disease 10% of transplant recipients Donor organ is common vehicle of EBV

infection Occurs early after transplant

Time of most severe immunosuppression

Other Associated Conditions

Hemophagocytic Lymphohistiocytosis Chronic Active EBV Infection Malignancies

Burkitt Lymphoma Nasopharyngeal Carcinoma Hodgkin Disease T-Cell Lymphoma Gastric carcinoma