Today, I review, link to, and excerpt from The Cribsiders‘ #119: Epstein Barr Virus – A MONO-lithic Overview.*
*Engel S, Anosike I, Masur S, Chiu C, Berk J. “### Epstein Barr Virus – A MONO-lithic Overview”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ August 28, 2024.
All that follows is from the above resource.
Summary:
Join us and expert guest Dr. IJ Anosike (The Children’s Hospital at Montefiore) to dissect the complexities of diagnosing and managing Epstein-Barr virus! From sneaky symptoms to tricky tests, Dr. Anosike provides insight on identifying and tackling this troublesome virus. Don’t miss this infectiously enlightening episode!
EBV Pearls
- EBV can be shed in saliva, even when patients are no longer symptomatic
- Use the “scratch test” to assess for splenomegaly – put stethoscope on the abdomen and then scratch finger along the abdomen’s surface – the quality of sound will become duller along the edge of the spleen/liver
- In most cases, antibody serologies to the viral capsid antigen is the test of choice for diagnosis. The presence of VCA IgM antibodies suggests acute infection while antibodies to EBV nuclear antigen suggest a past infection due to the timeframe in which these antibodies appear.
- Additional lab work to order includes a CBC and liver enzymes; lymphocytosis is common, prolonged illness may also be associated with anemia.
- Treatment with amoxicillin in patients with EBV can lead to a non-allergic morbilliform rash.
EBV Notes
Pathophysiology
- EBV is a type of herpesvirus (type 4)
- Acquired by close contact with a person who is actively shedding. The virus continues to shed in saliva even in asymptomatic individuals for several months.
- The virus invades B lymphocytes which then spread the infection to the lymph nodes, spleen, liver, and throat.
Presentation
- Classic triad: fever, exudative pharyngitis, cervical lymphadenopathy (usually posterior cervical chain)
- Atypical presentations (more common in older patients):
- Abdominal pain – this may be related to hepatitis or splenomegaly/splenic rupture.
- Aseptic meningitis
- Neurologic changes including (rarely) “Alice in Wonderland Syndrome” – distortion of perception
- Tumor-associated manifestations including Burkett’s lymphoma
Physical Exam
Tip for assessing for splenomegaly:
- Start in the inguinal area and work “up” (spleen grows inferiorly and medially)
- Scratch test: scratch finger on abdomen while the stethoscope is on the abdomen – the quality of sound will become duller along the edge of the spleen/liver
Differential Diagnosis
- Strep pharyngitis: No hepatosplenomegaly, URI sx are rare
- CMV: Uncommon in immunocompetent patients
Diagnosis
- Serological testing: Directly tests for antibodies to the viral capsid antigen.
- VCA IgM: + Suggests acute infection. Peaks quickly and typically drops after 2-4 weeks. If low positive, can repeat 2 weeks later to see if this is an emerging or resolving acute infection.
- VCA IgG: + Suggests current or prior infection.
- EBNA: + Suggests past infection. Shows up later in infection (6 weeks at the earliest, usually peaks around 6 months)
- Heterophile antibody test (e.g., monospot). Latex agglutination test that indirectly identifies the antibodies that are fighting the virus. False negatives are common in the first 1-2 weeks and for patients <4 years old. Overall sensitivity can vary from ~50-90%.
- PCR testing: Identifies residual virus circulating in the body – mostly used in immunocompromised patients.
