Epstein-Barr Virus

Snapshot

A 15-year-old boy presents with 1 week of fever and sore throat. A few days ago, the patient had gone to an urgent care and had started taking amoxicillin for a presumed bacterial infection. On the 2nd day of antibiotics, he developed a rash. He works at a daycare center after school every weekday. On physical exam, he is found with a diffuse maculopapular rash as well as cervical lymphadenopathy and tonsillar exudates. A Monospot test was positive. He was counseled to stop the antibiotics and to avoid contact sports during this illness.

Introduction

Classification
- Epstein-Barr virus (EBV) or human herpesvirus-4 (HHV-4)
  - an enveloped, linear double-stranded DNA virus
  - transmitted via respiratory secretions
    - “kissing disease”
  - causes mononucleosis
Epidemiology
- incidence
  - common
- demographics
  - common in teens and young adults
- risk factors
  - Asian descent
    - EBV causes nasopharyngeal carcinoma
  - living in endemic areas
    - EBV causes Burkitt lymphoma
  - transplant recipient
    - EBV causes lymphoproliferative disease
  - poor sanitation
  - kissing
  - daycare centers
Pathogenesis
- binds to B-cells via CD21, acting as a B-cell mitogen
- can establish lifelong persistent infection in B-cells
- T-cell-mediated immunity controls the latent infection
  - immunocompromised patients are at risk of reactivation
Associated conditions
- lymphomas
  - e.g., Burkitt lymphoma and central nervous system lymphoma
- nasopharyngeal carcinoma
- lymphoproliferative disease
- gastric carcinoma
- oral hairy leukoplakia in HIV patients
Prognosis
- most cases resolve

Presentation

Symptoms
- fatigue
- pharyngitis
- maculopapular rash
  - if patients with mononucleosis were treated with amoxicillin
Physical exam
- fever
- posterior cervical lymphadenopathy
- hepatosplenomegaly
- palatal petechiae
- tonsillar exudate

Studies

Labs
- ↑ atypical lymphocytes on peripheral blood smear
  - enlarged nuclei
- + Monospot test
  - heterophile IgM antibodies detected by agglutination of sheep red blood cells
Making the diagnosis
- based on clinical presentation and laboratory studies

Differential

Cytomegalovirus
- distinguishing factors
  - can present with mononucleosis-like syndrome but can also present with more myalgias, arthralgias, and cough
  - does not typically present with a sore throat and lymphadenopathy

Treatment

Management approach
- management is centered around supportive care and avoidance of contact sports, as patients are at risk of splenic rupture
Conservative
- supportive care
  - indication
    - all patients
  - modalities
    - hydration
    - pain management

Complications