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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(M1.MC.15.74) 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? Tested Concept

QID: 106673
FIGURES:
1

Figure A

34%

(20/59)

2

Figure B

31%

(18/59)

3

Figure C

15%

(9/59)

4

Figure D

10%

(6/59)

5

Figure E

5%

(3/59)

L 1 D

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