Makindo Medical Notes Comprehensive Medical Encyclopedia | Education for Healthcare Professionals

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Epstein-Barr Virus infection

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💡 90% of patients with Infectious Mononucleosis develop a rash if given ampicillin or amoxicillin – a classic diagnostic clue.

📖 About

One of the main causes of Infectious Mononucleosis (Glandular Fever).
Very common infection – 90% of adults show past EBV exposure.
Clinical picture can mimic CMV or Toxoplasmosis → always check, especially in pregnancy or immunocompromised.

🦠 Virology

EBV = a gamma herpesvirus.
Spread via saliva droplets → classically “the kissing disease” 😘.
Often subclinical in childhood; symptomatic illness more likely in adolescents/young adults.
50% of infections cause clinical symptoms.
Not highly contagious → isolation not required.

🩺 Clinical Features

Often subclinical.
Non-specific flu-like illness: headache, malaise, fever 🤒.
Severe sore throat + tonsillar enlargement.
Generalised tender lymphadenopathy (cervical, axillary, inguinal).
Hepatitis → jaundice, raised LFTs.
Splenomegaly (⚠️ risk of rupture).
Skin features: erythema multiforme, petechiae, periorbital oedema.
Rare CNS: encephalitis, meningitis. Disease severity ↑ with age.

🤰 Pregnancy

If heterophile antibodies negative → check CMV serology.
CMV can mimic EBV, but active CMV in pregnancy can cause congenital abnormalities.
Toxoplasmosis also mimics – must exclude.

📌 Causes of Infectious Mononucleosis-like Syndrome

Epstein-Barr virus (EBV)
Cytomegalovirus (CMV)
Human Herpesvirus-6 (HHV-6)
HIV seroconversion
Toxoplasmosis

⚠️ Long-Term Complications

Nasopharyngeal carcinoma 🎭
Burkitt’s lymphoma
Post-transplant lymphoproliferative disease
HIV-related immunoblastic lymphoma
Chronic fatigue syndrome
Duncan’s syndrome (X-linked lymphoproliferative syndrome due to SAP gene mutation)

🔎 Differentials

Streptococcal sore throat (no hepatosplenomegaly or atypical lymphocytes).
CMV infection.
Toxoplasmosis.
Viral hepatitis.
HIV seroconversion.
Lymphoma / Leukaemia.

🧪 Investigations

FBC: mononuclear lymphocytosis with atypical lymphocytes, neutropenia, thrombocytopenia.
LFT: raised ALT, raised bilirubin.
Atypical CD8+ T lymphocytes → can mimic acute leukaemia.
Monospot (Paul-Bunnell test): detects heterophile antibodies. Positive in week 2, may need repeat if negative initially.
EBV serology: IgM EBV EA (early antigen) + negative IgG EBV confirms acute infection.
Viral PCR (if needed).

📊 Causes of Atypical Lymphocytosis

EBV
HIV seroconversion
Viral hepatitis
Mumps
Rubella

💊 Management

Supportive: rest, fluids, paracetamol/NSAIDs. Fatigue may last 6 weeks.
⚠️ Avoid ampicillin/amoxicillin → rash in 90% of cases.
Advise against contact sports until splenomegaly resolves (risk of rupture).
For airway compromise / severe pharyngeal oedema → prednisolone 30–60 mg OD × 5 days.
Treat streptococcal superinfection with IV benzylpenicillin or erythromycin (not amoxicillin).
No role for antivirals against EBV.

📌 Key Exam Pearls

Ampicillin rash = diagnostic clue 🎯.
Splenomegaly → avoid contact sports.
Monospot test = heterophile antibodies (Paul-Bunnell).
Consider CMV/toxoplasmosis in pregnancy.

Cases — Epstein–Barr Virus (EBV) Infection

Case 1 — Infectious Mononucleosis (Glandular Fever): An 18-year-old university student presents with sore throat, fever, malaise, and cervical lymphadenopathy. Exam: tonsillar enlargement with exudates, splenomegaly. Bloods: lymphocytosis with atypical lymphocytes. Monospot test positive. Diagnosis: EBV infectious mononucleosis. Management: Supportive (hydration, rest, paracetamol/NSAIDs). Avoid amoxicillin (rash risk) and contact sports for 4 weeks due to splenic rupture risk.
Case 2 — EBV-Associated Malignancy (Burkitt Lymphoma): A 9-year-old boy from East Africa presents with a rapidly enlarging jaw mass. Biopsy shows “starry sky” appearance with medium-sized B-cells. EBV DNA detected in tumour tissue. Diagnosis: EBV-associated endemic Burkitt lymphoma. Management: Intensive multi-agent chemotherapy; supportive care; oncology referral.
Case 3 — EBV-Driven Lymphoproliferation in Immunosuppressed Host: A 45-year-old renal transplant patient on immunosuppressants develops fever, night sweats, weight loss, and lymphadenopathy. Lymph node biopsy shows EBV-positive B-cell proliferation consistent with post-transplant lymphoproliferative disorder (PTLD). Diagnosis: EBV-associated PTLD. Management: Reduction of immunosuppression, rituximab-based therapy, possible chemotherapy in refractory cases.

Teaching Commentary 🧾

EBV is a gamma-herpesvirus transmitted via saliva (“kissing disease”). Primary infection in adolescents/young adults → infectious mononucleosis. Complications: splenic rupture, hepatitis, haemolytic anaemia. EBV is oncogenic, associated with Burkitt lymphoma, Hodgkin lymphoma, nasopharyngeal carcinoma, and PTLD. Diagnosis: heterophile antibody test (Monospot), EBV-specific serology, PCR. Treatment: usually supportive, except in EBV-driven malignancies or PTLD where chemotherapy, immunotherapy, or reduction of immunosuppression is required.

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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