Updated: 4/22/2019

Epstein-Barr Virus

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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
  • Splenic rupture
  • Malignancy
  • Hemolytic anemia
    • treat with rituximab
  • Guillain-Barre syndrome
 

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Questions (3)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.MC.74) A 16-year-old male comes to your office complaining of fever and sore throat. On physical exam, you note exudates in the oropharynx as well as palpable lymph nodes in the posterior neck. His abdominal examination is notable for an enlarged mass in the left upper quadrant. Which of the following figures most likely depicts what you would see on microscopic examination? Review Topic

QID: 106673
FIGURES:
1

Figure A

32%

(10/31)

2

Figure B

29%

(9/31)

3

Figure C

16%

(5/31)

4

Figure D

13%

(4/31)

5

Figure E

3%

(1/31)

M1

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