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Updated: Apr 22 2019

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