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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