# 88 - 199 Epstein-Barr Virus Infections, Including Infectious Mononucleosis ### 199 Epstein-Barr Virus Infections, Including Infectious Mononucleosis TABLE 198-1  Recommendations for VZIG Administration Exposure Criteria 1. Significant exposure to a person with chickenpox or zoster a. Household: residence in the same household b. Playmate: face-to-face indoor play c. Hospital Varicella: same 2- to 4-bed room or adjacent beds in a large ward, face-toface contact with an infectious staff member or patient, visit by a person deemed contagious Zoster: intimate contact (e.g., touching or hugging) with a person deemed contagious d. Newborn infant: onset of varicella in the mother ≤5 days before delivery or ≤48 h after delivery; VZIG not indicated if the mother has zoster 2. Patient should receive VZIG as soon as possible but not >96 h after exposure. Candidates (Provided They Have Significant Exposure) Include 1. Immunocompromised susceptible children without a history of varicella or varicella immunization 2. Susceptible pregnant women 3. Newborn infants whose mother had onset of chickenpox within 5 days before or within 48 h after delivery 4. Hospitalized premature infant (≥28 weeks of gestation) whose mother lacks a reliable history of chickenpox or serologic evidence of protection against varicella 5. Hospitalized premature infant (<28 weeks of gestation or ≤1000-g birth weight), regardless of maternal history of varicella or VZV serologic status Abbreviation: VZIG, varicella-zoster immune globulin. Source: Table is adapted from the American Academy of Pediatrics Red Book. PART 5 Infectious Diseases ■ ■FURTHER READING Arvin A: Aging, immunity, and the varicella-zoster virus. N Engl J Med 352:2266, 2005. Arvin A, Abendroth A: Varicella-zoster virus, in Fields Virology: DNA Viruses. Vol 2. 7th ed, Howley P et al (eds). Philadelphia, PA, Wolters Kluwer, 2021, pp 445-488. Cohen JI: A new vaccine to prevent herpes zoster. N Engl J Med 372: 2149, 2015. Gershon AA et al: Varicella zoster virus infection. Nat Rev Dis Primers 1:15016, 2015. Gnann JW, Whitley RJ: Herpes zoster. N Engl J Med 347:340, 2002. Kimberlin DW et al (eds): Redbook: 2021-2024 Report of the Committee on Infectious Diseases, 32nd ed. Itasca, IL, American Academy of Pediatrics, 2021. Lai H et al: Efficacy of an adjuvanted herpes zoster subunit vaccine in older adults. N Engl J Med 372:2087, 2015. Marin M et al: Monitoring varicella vaccine impact on varicella inci­ dence in the United States: Surveillance challenges and changing epidemiology, 1995-2019. J Infect Dis 226:S392, 2022. Morrison VA et al: Long-term persistence of zoster vaccine efficacy. Clin Infect Dis 60:900, 2015. Shaw J, Gershon AA: Varicella virus vaccination in the United States. Viral Immunol 31:96, 2018. Whitley RJ, Arvin A: Chickenpox and herpes zoster (varicella-zoster virus), in Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases, 10th ed. Blaser MJ, Cohen JI, Holland SM (eds). Philadelphia, PA, Elsevier Press. In press. Wutzler P et al: Varicella vaccination: The global experience. Expert Rev Vaccines 16:833, 2017. Jeffrey I. Cohen Epstein-Barr Virus Infections, Including Infectious Mononucleosis ■ ■DEFINITION Epstein-Barr virus (EBV) is the cause of heterophile-positive infec­ tious mononucleosis (IM), which is characterized by fever, sore throat, lymphadenopathy, and atypical lymphocytosis. EBV is also associated with several tumors, including nasopharyngeal and gastric carcinoma, Burkitt’s lymphoma, Hodgkin’s lymphoma, T-cell lymphoma, and (in patients with immunodeficiencies) B-cell lymphoma and smooth muscle tumors. Large epidemiology studies show a strong association of EBV with multiple sclerosis. The virus is a member of the family Herpesviridae. The two types of EBV that are widely prevalent in nature are not distinguishable by conventional serologic tests. ■ ■EPIDEMIOLOGY EBV infections occur worldwide. These infections are most common in early childhood, with a second peak during late adolescence. By adulthood, >90% of individuals have been infected and have antibodies to the virus. IM is usually a disease of young adults. In lower socio­ economic groups and in areas of the world with deficient standards of hygiene (e.g., developing regions), EBV tends to infect children at an early age, and IM is uncommon. In areas with higher standards of hygiene, infection with EBV is often delayed until adulthood, and IM is more prevalent. EBV is spread by contact with oral secretions. The virus is frequently transmitted from asymptomatic adults to infants and among young adults by transfer of saliva during kissing. Transmission by less inti­ mate contact is rare. EBV has been transmitted by blood transfusion and by bone marrow transplantation. More than 90% of asymptomatic seropositive individuals shed the virus in oropharyngeal secretions. Shedding is increased in immunocompromised patients and those with IM. ■ ■PATHOGENESIS EBV is transmitted by salivary secretions. The virus infects the epithe­ lium of the oropharynx and the salivary glands and is shed from these cells. While B cells may become infected after contact with epithelial cells, studies suggest that lymphocytes in the tonsillar crypts can be infected directly. The virus then spreads through the bloodstream. The proliferation and expansion of EBV-infected B cells along with reactive T cells during IM result in enlargement of lymphoid tissue. Polyclonal activation of B cells leads to the production of antibodies to host-cell and viral proteins. During the acute phase of IM, up to 1 in every 100 B cells in the peripheral blood is infected by EBV; after recovery, 1–50 in every 1 million B cells is infected. During IM, there is an inverted CD4+/CD8+ T-cell ratio. The percentage of CD4+ T cells decreases, while there are large clonal expansions of CD8+ T cells; up to 40% of CD8+ T cells are directed against EBV antigens during acute infection. Memory B cells, not epithelial cells, are the reservoir for EBV in the body. When patients are treated with acyclovir, shedding of EBV from the oropharynx stops but the virus persists in B cells. The EBV receptor (CD21) on the surface of B cells is also the recep­ tor for the C3d component of complement. Another EBV receptor (CD35) on B cells binds to CD21. Human leukocyte antigen class II serves as a co-receptor for EBV entry into B cells. EBV infection of epithelial cells occurs by virus binding to ephrin A2 and results in viral replication and production of virions. When B cells are infected by EBV in vitro, they become transformed and can proliferate indefinitely. During latent infection of B cells, the EBV nuclear antigens (EBNAs), latent membrane proteins (LMPs), multiple microRNAs, and small EBV RNAs (EBERs) are expressed in vitro. EBV-transformed B cells secrete immunoglobulin; only a small fraction of these cells produce virus. Cellular immunity is more important than humoral immunity in controlling EBV infection. In the initial phase of infection, suppressor T cells, natural killer (NK) cells, and nonspecific cytotoxic T cells are important in controlling the proliferation of EBV-infected B cells. Lev­ els of markers of T-cell activation and serum interferon γ are elevated. Later in infection, human leukocyte antigen–restricted cytotoxic T cells that recognize EBNAs and LMPs and destroy EBV-infected cells are generated. If T-cell immunity is compromised, EBV-infected B cells may begin to proliferate. When EBV is associated with lymphoma in immuno­ competent persons, virus-induced proliferation is but one step in a multistep process of neoplastic transformation. In many EBV-containing tumors, LMP-1 mimics members of the tumor necrosis factor receptor family (e.g., CD40), transmitting growth-proliferating signals. ■ ■CLINICAL MANIFESTATIONS Signs and Symptoms  Most EBV infections in infants and young children either are asymptomatic or present as mild pharyngitis with or without tonsillitis. In contrast, ~75% of infections in adolescents pres­ ent as IM. IM in the elderly often presents with nonspecific symptoms, including prolonged fever, fatigue, myalgia, and malaise. In contrast, pharyngitis, lymphadenopathy, splenomegaly, and atypical lympho­ cytes are relatively rare in elderly patients. The incubation period for IM in young adults is ~4–6 weeks. A pro­ drome of fatigue, malaise, and myalgia may last for 1–2 weeks before the onset of fever, sore throat, and lymphadenopathy. Fever is usually low-grade and is most common in the first 2 weeks of the illness; how­ ever, it may persist for >1 month. Common signs and symptoms are listed along with their frequencies in Table 199-1. Lymphadenopathy and pharyngitis are most prominent during the first 2 weeks of the illness, while splenomegaly is more prominent during the second and third weeks. Lymphadenopathy most often affects the posterior cervi­ cal nodes but may be generalized. Enlarged lymph nodes are frequently tender and symmetric but are not fixed in place. Pharyngitis, often the most prominent sign, can be accompanied by enlargement of the tonsils with an exudate resembling that of streptococcal pharyngitis. A morbilliform or papular rash, usually on the arms or trunk, devel­ ops in ~5% of cases (Fig. 199-1). Earlier studies reported that many patients treated with penicillin derivatives develop a macular rash; penicillin-associated rashes are not predictive of future adverse reac­ tions to penicillins. More recent studies suggest that EBV-associated rashes may occur with similar frequency in those exposed to penicillin When CNS complications develop, they usually do so during the first 2 weeks of EBV infection; in some patients, especially children, TABLE 199-1  Signs and Symptoms of Infectious Mononucleosis MEDIAN PERCENTAGE OF PATIENTS (RANGE) MANIFESTATION Symptoms Sore throat 75 (50–87) Malaise 47 (42–76) Headache 38 (22–67) Abdominal pain, nausea, or vomiting 17 (5–25) Chills 10 (9–11) Signs Lymphadenopathy 95 (83–100) Fever 93 (60–100) Pharyngitis or tonsillitis 82 (68–90) Splenomegaly 51 (43–64) Hepatomegaly 11 (6–15) Rash 10 (0–25) Periorbital edema 13 (2–34) Palatal enanthem   7 (3–13) Jaundice   5 (2–10) FIGURE 199-1  Rash in a patient with infectious mononucleosis due to Epstein-Barr virus. (Courtesy of Maria Turner, MD; with permission.) derivatives and those not taking these drugs. Erythema nodosum (Fig. A1-39) and erythema multiforme (Fig. A1-24) also have been described (Chap. 61). The severity of the disease correlates with the levels of CD8+ T cells and EBV DNA in the blood. Most patients have symptoms for 2–4 weeks, but nearly 10% have fatigue that persists for ≥6 months. CHAPTER 199 Laboratory Findings  The white blood cell count is usually ele­ vated and peaks at 10,000–20,000/μL during the second or third week of illness. Lymphocytosis is usually demonstrable, with >10% atypical lymphocytes. The latter cells are enlarged lymphocytes that have abun­ dant cytoplasm, vacuoles, and indentations of the cell membrane (Fig. 199-2). CD8+ T cells predominate among the atypical lympho­ cytes. Low-grade neutropenia and thrombocytopenia are common during the first month of illness. Liver function is abnormal in >90% of cases. Serum levels of aminotransferases and alkaline phosphatase are usually mildly elevated. The serum concentration of bilirubin is elevated in ~40% of cases. Epstein-Barr Virus Infections, Including Infectious Mononucleosis Complications  Most cases of IM are self-limited. Deaths are very rare and are most often due to central nervous system (CNS) complications, splenic rupture, upper-airway obstruction, or bacterial superinfection. FIGURE 199-2  Atypical lymphocytes from a patient with infectious mononucleosis due to Epstein-Barr virus. they are the only clinical manifestations of acute infection. Hetero­ phile antibodies and atypical lymphocytes may be absent. Meningitis and encephalitis are the most common neurologic abnormalities, and patients may present with headache, meningismus, or cerebellar ataxia. Acute hemiplegia and psychosis also have been described. The cerebro­ spinal fluid contains mainly lymphocytes, with occasional atypical lym­ phocytes. Most cases resolve without neurologic sequelae. Acute EBV infection has also been associated with cranial nerve palsies (especially those involving cranial nerve VII), Guillain-Barré syndrome, acute transverse myelitis, and peripheral neuritis. Autoimmune hemolytic anemia occurs in ~2% of cases during the first 2 weeks. In most cases, the anemia is Coombs-positive, with cold agglutinins directed against the red blood cell i antigen. Most patients with hemolysis have mild anemia that lasts for 1–2 months, but some patients have severe disease with hemoglobinuria and jaundice. Nonspecific antibody responses may also include rheumatoid factor, antinuclear antibodies, anti–smooth muscle antibodies, antiplatelet antibodies, and cryoglobulins. IM has been associated with red-cell aplasia, severe granulocytopenia, thrombocytopenia, pancytopenia, and hemophagocytic lymphohistiocytosis. The spleen ruptures in <0.5% of cases. Splenic rupture is more common among male than female patients and may manifest as abdominal pain, referred shoulder pain, or hemodynamic compromise. Hypertrophy of lymphoid tissue in the tonsils or adenoids can result in upper-airway obstruction, as can inflammation and edema of the epiglottis, pharynx, or uvula. About 10% of patients with IM develop streptococcal pharyngitis after their initial sore throat resolves. Other rare complications associated with acute EBV infection include hepatitis (which can be fulminant), myocarditis or pericarditis, pneumonia with pleural effusion, interstitial nephritis, genital ulcer­ ations, and vasculitis. PART 5 Infectious Diseases EBV-Associated Diseases Other Than IM  EBV-associated lymphoproliferative disease has been described in patients with con­ genital or acquired immunodeficiency, including those with severe combined immunodeficiency, patients with AIDS, and recipients of bone marrow or organ transplants who are receiving immunosuppres­ sive drugs (especially cyclosporine). Proliferating EBV-infected B cells infiltrate lymph nodes and multiple organs, and patients present with fever and lymphadenopathy or gastrointestinal symptoms. Pathologic studies show B-cell hyperplasia or poly- or monoclonal lymphoma. X-linked lymphoproliferative disease is a recessive disorder of young boys who have a normal response to childhood infections but develop fatal lymphoproliferative disorders after infection with EBV. The protein associated with most cases of this syndrome (SAP, encoded by SH2D1A) binds to a protein that mediates interac­ tions of B and T cells. Most patients with this syndrome die of acute IM. Others develop hypogammaglobulinemia, malignant B-cell lym­ phomas, aplastic anemia, or agranulocytosis. Disease resembling X-linked lymphoproliferative disease, but with more prominent hemo­ phagocytosis, has also been associated with mutations in BIRC4. Muta­ tions in ITK, MAGT1, CORO1A, TNFRSF9, IL27RA, CD70, or CD27 are associated with inability to control EBV and lymphoma. Mutations in other genes, such as GATA2, PIK3CD, CTPS1, RLTPR, RSGRP1, TNFRSF9, and several genes associated with severe combined immu­ nodeficiency, also can predispose to severe or fatal EBV disease as well as other infections. Moreover, IM has proved fatal to some patients with no obvious preexisting immune abnormality. Oral hairy leukoplakia (Fig. 199-3) is an early manifestation of infection with HIV in adults (Chap. 208). Most patients present with raised, white corrugated lesions on the tongue (and occasionally on the buccal mucosa) that contain EBV DNA. Children infected with HIV can develop lymphoid interstitial pneumonitis; EBV DNA is often found in lung tissue from these patients. Patients with chronic fatigue syndrome may have titers of antibody to EBV that are elevated but are not significantly different from those in healthy EBV-seropositive adults. These patients do not have elevated levels of EBV DNA in the blood. While some patients have malaise and fatigue that persist for weeks or months after IM, persistent EBV FIGURE 199-3  Oral hairy leukoplakia often presents as white plaques on the lateral surface of the tongue and is associated with Epstein-Barr virus infection. infection is not a cause of chronic fatigue syndrome. EBV reactivation (largely based on viral serology) has been associated with post-acute COVID-19 syndrome (PACS), but it is unclear that EBV is a cause of the symptoms of PACS. Chronic active EBV infection is very rare and is distinct from chronic fatigue syndrome. The affected patients have an illness lasting >3 months, with elevated levels of EBV DNA in the blood (in T or NK cells); high titers of antibody to EBV; and evidence of organ involvement, including hepatosplenomegaly, lymphadenopathy, and hepatitis, pneumonitis, uveitis, or neurologic disease. Some have somatic mutations in DD3X and other tumor driver genes. EBV is associated with several malignancies. About 15% of cases of Burkitt’s lymphoma in the United States and ~90% of those in Africa are associated with EBV (Chap. 113). African patients with Burkitt’s lymphoma have high levels of antibody to EBV, and their tumor tissue usually contains viral DNA. Malaria in African patients may impair cellular immunity to EBV and induce polyclonal B-cell activation with an expansion of EBV-infected B cells. In addition, malaria may target B cells and result in expansion of germinal centers, with consequently increased activity of activation-induced cytidine deaminase, which can mutate DNA. These changes may enhance the proliferation of B cells with elevated EBV DNA in the bloodstream, thereby increasing the likelihood of a c-myc translocation—the hallmark of Burkitt’s lym­ phoma. EBV-containing Burkitt’s lymphoma also occurs in patients with AIDS. Anaplastic nasopharyngeal carcinoma is common in southern China and is uniformly associated with EBV; the affected tissues con­ tain viral DNA and antigens. Patients with nasopharyngeal carcinoma often have elevated titers of antibody to EBV (Chap. 82). Antibody to an EBV protein, BNLF1, in serum is a useful screening marker. Measurement of EBV DNA in plasma is useful for early detection of nasopharyngeal carcinoma. High levels of EBV plasma DNA before treatment or detectable levels of EBV DNA after radiation therapy correlate with lower rates of overall survival and relapse-free survival among patients with nasopharyngeal carcinoma. Worldwide, the most common EBV-associated malignancy is gastric carcinoma. About 9% of these tumors are EBV-positive including >90% of gastric lymphoepithelioma-like carcinomas (Chap. 85). EBV has been associated with Hodgkin’s lymphoma, especially the mixed-cellularity type (Chap. 114). Patients with Hodgkin’s lymphoma often have elevated titers of antibody to EBV. In about half of cases in the United States, viral DNA and antigens are found in Reed-Sternberg cells. The risk of EBV-positive Hodgkin’s lymphoma is significantly increased in young adults for several years after EBV-seropositive IM. About 50% of non-Hodgkin’s lymphomas in patients with AIDS are EBV-positive. EBV is present in B cells of lesions from patients with lymphomatoid granulomatosis. In some cases, EBV DNA has been detected in tumors from immunocompetent patients with angiocentric nasal NK/T-cell lym­ phoma, aggressive NK leukemia/lymphoma, T-cell lymphoma, and CNS lymphoma. Studies have demonstrated viral DNA in leiomyosarcomas from AIDS patients and in smooth-muscle tumors from organ transplant recipients. Virtually all CNS lymphomas in AIDS patients are associated Antibody titer Anti-VCA IgM Anti-VCA IgG Anti-EBNA 1 week 1 month 2 months 3 months Time of symptoms FIGURE 199-4  Pattern of Epstein-Barr virus (EBV) serology during acute infection. EBNA, Epstein-Barr nuclear antigen; VCA, viral capsid antigen. (Reproduced with permission from JI Cohen, in NS Young et al [eds]: Clinical Hematology. Philadelphia, Mosby, 2006.) with EBV. EBV has been associated with multiple sclerosis; an epidemi­ ology study of over a million military personnel found that the risk of multiple sclerosis was 32-fold higher after primary EBV infection, but not after other virus infections. In addition, a history of IM and higher levels of antibodies to EBNA before the onset of disease is more common in persons with multiple sclerosis than in the general population; additional research on the role of EBV in multiple sclerosis is needed. ■ ■DIAGNOSIS Serologic Testing (Fig. 199-4)  The heterophile test is used for the diagnosis of IM in children and adults. In the test for this antibody, human serum is absorbed with guinea pig kidney, and the heterophile titer is defined as the greatest serum dilution that agglutinates sheep, horse, or cow erythrocytes. The heterophile antibody does not interact with EBV proteins. A titer of ≥40 is diagnostic of acute EBV infec­ tion in a patient who has symptoms compatible with IM and atypical lymphocytes. Tests for heterophile antibodies are positive in 40% of patients with IM during the first week of illness and in 80–90% during the third week. Therefore, repeated testing may be necessary, espe­ cially if the initial test is performed early. Tests usually remain positive for 3 months after the onset of illness, but heterophile antibodies can persist for up to 1 year. These antibodies usually are not detectable in children <5 years of age, in the elderly, or in patients presenting with symptoms not typical of IM. The commercially available monospot test for heterophile antibodies is somewhat more sensitive than the classic heterophile test. The monospot test is ~75% sensitive and ~90% spe­ cific compared with EBV-specific serologies (see below). False-positive monospot results are more common among persons with connective tissue disease, lymphoma, viral hepatitis, and malaria. EBV-specific antibody testing is used for patients with suspected acute EBV infection who lack heterophile antibodies and for patients TABLE 199-2  Differential Diagnosis of Infectious Mononucleosis   SIGN OR SYMPTOM   ETIOLOGY FEVER ADENOPATHY SORE THROAT ATYPICAL LYMPHOCYTES DIFFERENCES FROM EBV MONONUCLEOSIS EBV infection + + + + — CMV infection + ± ± + Older age at presentation, longer duration of fever HIV infection + + + ± Diffuse rash, oral/genital ulcers, aseptic meningitis Toxoplasmosis + + ± ± Less splenomegaly; exposure to cats or raw meat HHV-6 infection + + + + Older age at presentation Streptococcal pharyngitis + + + – No splenomegaly, less fatigue Viral hepatitis + ± – ± Higher aminotransferase levels Rubella + + ± ± Maculopapular rash, no splenomegaly Lymphoma + + + + Fixed, nontender lymph nodes Drugsa + + – ± Occurs at any age aMost commonly phenytoin, carbamazepine, sulfonamides, or minocycline. Abbreviations: CMV, cytomegalovirus; EBV, Epstein-Barr virus; HHV, human herpesvirus. with atypical infections. Titers of IgM and IgG antibodies to viral capsid antigen (VCA) are elevated in the serum of >90% of patients at the onset of disease. IgM antibody to VCA is most useful for the diagnosis of acute IM because it is present at elevated titers only during the first 2–3 months of the disease; in contrast, IgG anti­ body to VCA usually is not useful for diagnosis of IM but often is used to assess past exposure to EBV because it persists for life. Seroconversion to EBNA positivity also is useful for the diagnosis of acute infection with EBV. Antibodies to EBNA become detectable relatively late (3–6 weeks after the onset of symptoms) in nearly all cases of acute EBV infection and persist for the lifetime of the patient. These antibodies may be lacking in immunodeficient patients and in those with chronic active EBV disease. Titers of other antibodies also may be elevated in IM; however, these elevations are less useful for diagnosis. Antibodies to early antigens are detectable 3–4 weeks after the onset of symptoms in patients with IM. About 70% of individuals with IM have antibodies to early antigen diffuse (EA-D) during the illness; the presence of EA-D antibodies is especially likely in patients with relatively severe disease. These anti­ bodies usually persist for only 3–6 months. Levels of EA-D antibodies are elevated in patients with nasopharyngeal carcinoma or chronic active EBV infection. Antibodies to early antigen restricted (EA-R) are often found at elevated titers in patients with African Burkitt’s lym­ phoma or chronic active EBV infection; however, they are not useful for diagnosis. IgA antibodies to EBV antigens have proved useful for the identification of patients with nasopharyngeal carcinoma and of persons at high risk for the disease. Heterophile CHAPTER 199 Other Studies  Detection of EBV DNA, RNA, or proteins has been valuable in demonstrating the association of the virus with various malignancies. The polymerase chain reaction has been used to detect EBV DNA in the cerebrospinal fluid of some AIDS patients with CNS lymphomas and to monitor the amount of EBV DNA in the blood of patients with lymphoproliferative disease. Detection of high levels of EBV DNA in blood for a few days to several weeks after the onset of IM may be useful if serologic studies yield equivocal results. Culture of EBV from throat washings or blood is not helpful in the diagnosis of acute infection, since EBV persists in the oropharynx and in B cells for the lifetime of the infected individual. Epstein-Barr Virus Infections, Including Infectious Mononucleosis Differential Diagnosis  Whereas ~90% of cases of IM are due to EBV, 5–10% of cases are due to cytomegalovirus (CMV) (Chap. 200). CMV is the most common cause of heterophile-negative mononucleo­ sis; less common causes of IM and differences from IM due to EBV are shown in Table 199-2.