Epstein-Barr Virus - EBV

Diagnosis

Indications for Testing

  • Acute persistent pharyngitis and lymphadenopathy with negative strep testing

Laboratory Testing

  • EBV diagnosis and testing information (CDC)
  • CBC with differential – elevated white blood cells with atypical lymphocytes
  • Rapid strep test and/or culture – negative
  • Positive heterophile antibody (IgM antibodies not specific for EBV) – point of care testing (eg, Monospot)
    • Heterophile test is often negative in children <5 years; misses 50-70% of cases
    • Antibodies develop after about day 5 of illness; do not test before 4-5 days
  • Diagnosis of acute disease due to EBV depends mostly on testing for an immune response to the virus
    • Immune response during acute infection may be significantly delayed, especially in children and immunocompromised hosts
    • Extensive workup appropriate in markedly febrile patient with enlarged nodes and for whom prior testing was negative
    • Initial antibody testing should include EBV anti-viral capsid antigen (VCA) IgM and IgG
    • Interpretation of serologic results
    • InfectionVCA GVCA MEAEBNA
      No previous----
      Acute++±-
      Recent+±±±
      Past+--+
      *Reactivation+±++
      * Antibody to the early antigen in the presence of a positive EBNA does not automatically indicate that a patient's current medical condition is caused by EBV reactivation. Healthy individuals with no symptoms can have antibodies to early antigen for years after initial EBV infection. Reactivation can occur subclinically.
    • If testing is negative for EBV, consider serologies for cytomegalovirus (CMV) IgM, human herpesvirus 6 (HHV6) IgM and HIV testing
  • PCR, ELISA, probe testing – all usually reserved for immunocompromised patients or those with EBV-related tumors
    • PCR – standard of care for diagnosing EBV infection in CSF

Histology

  • Paraffin evaluation of tissue may be used for virus identification of EBV
  • Immunohistochemistry – stain for EBV  latent membrane protein

Differential Diagnosis

Monitoring

  • EBV quantitative viral load testing may be indicated in transplant patients who develop primary mononucleosis or in new transplant patients
  • Inability to clear viral load after primary mononucleosis may be surrogate for PTLD 
  • Increasing titers may signal reason to decrease immunosuppressive therapy to abort PTLD

Clinical Background

Epstein-Barr virus (EBV) is the cause of a variety of disorders, including mononucleosis.

Epidemiology

  • Age – usually <21 years
    • 50% seropositive <5 years
  • Transmission – salivary contact

Organism

  • Gamma herpesvirus that belongs to the Herpesviridae family
  • Like other herpes viruses, may remain dormant for years as a latent infection
    • Infects B lymphocytes, which can then be reactivated

Clinical Presentation

  • Primary infection often manifests as infectious mononucleosis (IM)
    • IM usually self-limiting and characterized by the following
      • Fever
      • Sore throat
      • Myalgias
      • Lymphadenopathy
      • Hepatosplenomegaly
  • Rare complications – hemolytic anemia and splenic rupture
  • Other serious symptoms may occur in extremes of age and among immunocompromised patients
    • Thrombocytopenia
    • Bulky adenopathy (cervical and axillary most common)
    • Hemolytic anemia
    • Hepatitis
    • Meningitis
    • Myocarditis
  • Disorders associated with EBV
    • Infectious mononucleosis
    • Endemic Burkitt lymphoma
      • Primarily in Africa; less common in developed countries
      • High grade B-cell lymphoma
      • >80% of nonendemic Burkitt lymphomas are EBV-negative
    • Nasopharyngeal carcinoma (endemic in China)
      • Malignant nasopharyngeal tumor of the squamous epithelium
    • Other cancers
    • X-linked lymphoproliferative syndrome (Duncan disease)
      • Often results in fatal, polyclonal B-cell proliferation
    • Progressive lymphoproliferative diseases
      • Children with primary immunodeficiencies
      • Post-transplant lymphoproliferative disorders (PTLD)
      • Immunosuppressed or AIDS patients
    • No good evidence to implicate EBV in chronic fatigue syndrome

Indications for Laboratory Testing

  • Tests generally appear in the order most useful for common clinical situations
  • Click on number for test-specific information in the ARUP Laboratory Test Directory
Test Name and Number Recommended Use Limitations Follow Up
CBC with Platelet Count and Automated Differential 0040003
Method: Automated Cell Count/Differential

Nonspecific testing in mononucleosis

   
Heterophile Antibody (Infectious Mononucleosis) by Latex Agglutination, Qualitative 0050385
Method: Qualitative Latex Agglutination

Initial serologic test to detect acute Epstein-Barr virus infectious mononucleosis

Negative Monospot test is common in children and immunocompromised adults

If test results are negative but a strong clinical suspicion exists, repeat testing in 7-14 days
Epstein-Barr Virus Antibody to Viral Capsid Antigen, IgM 0050240
Method: Semi-Quantitative Chemiluminescent Immunoassay

Evaluation of equivocal or negative Monospot test, especially in patients at risk for splenic rupture (contact sports)

Discriminate EBV from other IM-like diseases (eg, CMV, toxoplasmosis)

 

Rule out other causes of lymphadenopathy by ordering antibody tests for toxoplasmosis and CMV

Repeat testing in 10-14 days may be helpful if results are equivocal

Epstein-Barr Virus Antibody to Viral Capsid Antigen, IgG 0050235
Method: Semi-Quantitative Chemiluminescent Immunoassay

Evaluation of equivocal or negative Monospot test, especially in patients at risk for splenic rupture (contact sports)

 

Rule out other causes of lymphadenopathy by ordering antibody tests for toxoplasmosis and CMV

Repeat testing in 10-14 days may be helpful if results are equivocal

Epstein-Barr Virus Antibody to Nuclear Antigen, IgG 0050245
Method: Semi-Quantitative Chemiluminescent Immunoassay

Confirm previous infection with EBV

 

Rule out other causes of lymphadenopathy by ordering antibody tests for toxoplasmosis and CMV

Repeat testing in 10-14 days may be helpful if results are equivocal

Epstein-Barr Virus by PCR 0050246
Method: Qualitative Polymerase Chain Reaction

Standard of care for detecting EBV in CSF

Diagnose EBV-related diseases in immunocompromised patients or patients with lymphoproliferative tumors

Do not use to confirm acute mononucleosis

Negative result does not rule out the presence of PCR inhibitors in patient specimen or EBV DNA in concentrations below assay detection

 
Epstein-Barr Virus, Quantitative PCR 0051352
Method: Quantitative Polymerase Chain Reaction

Monitor disease – usually in immunocompromised patients (plasma, serum or CSF specimens)

Do not use to confirm acute mononucleosis

The limit of quantification for this DNA assay is 2.6 log copies/mL (390 copies/mL); if the assay DID NOT DETECT the virus, the test result will be reported as “<2.6 log copies/mL (<390 copies/mL)”

If the assay DETECTED the presence of the virus but was not able to accurately quantify the number of
copies, the test result will be reported as “Not Quantified"

Inhibition may also lead to underestimation of viral quantitation

 
Epstein-Barr Virus, Quantitative PCR, Whole Blood 0051353
Method: Quantitative Polymerase Chain Reaction

Monitor disease – usually in immunocompromised patients (whole blood specimens)

Do not use to confirm acute mononucleosis

The limit of quantification for this DNA assay is 2.6 log copies/mL (390 copies/mL); if the assay DID NOT DETECT the virus, the test result will be reported as “<2.6 log copies/mL (<390 copies/mL)”

If the assay DETECTED the presence of the virus but was not able to accurately quantify the number of
copies, the test result will be reported as “Not Quantified"

Inhibition may also lead to underestimation of viral quantitation

 
Epstein-Barr Virus Antibody to Early D Antigen (EA-D), IgG 0050225
Method: Semi-Quantitative Chemiluminescent Immunoassay

Confirm chronic active mononucleosis, post-transplant lymphoproliferative disease and nasopharyngeal carcinoma

This antibody test is more useful and appropriate than early antigen R for mononucleosis assessment

 

Rule out other causes of lymphadenopathy by ordering antibody tests for toxoplasmosis and CMV

Repeat testing in 10-14 days may be helpful if results are equivocal

Epstein-Barr Virus Antibody to Viral Capsid Antigen, IgA 0051626
Method: Semi-Quantitative Enzyme-Linked Immunosorbent Assay

May be used in conjunction with Epstein-Barr Virus Antibody to Early D Antigen (EA-D), IgG to confirm chronic active mononucleosis, post-transplant lymphoproliferative disease, Burkitt lymphoma, nasopharyngeal carcinoma

IgA is variably seen; levels are not consistently elevated

Results vary in acute infectious mononucleosis, chronic active mononucleosis and post-transplant lymphoproliferative disease

Rule out other causes of lymphadenopathy by ordering antibody tests for toxoplasmosis and CMV

Repeat testing in 10-14 days may be helpful if results are equivocal

Epstein-Barr Virus (EBV) By in situ Hybridization, Paraffin 2002902
Method: In situ Hybridization

Virus identification of EBV

   
Cytomegalovirus Rapid Culture 0065004
Method: Cell Culture/Immunofluorescence

Test for CMV if EBV testing is negative

Recommended for specimens other than CSF

   
Herpesvirus 6 (HHV6) (A and B), Quantitative PCR 0060071
Method: Quantitative Polymerase Chain Reaction

Test for HHV6 if EBV testing is negative

   
Additional Tests Available
 
Click the plus sign to expand the table of additional tests.
Test Name and NumberComments
Epstein-Barr Virus Antibody to Viral Capsid Antigen, IgG and IgA 0051627
Method: Enzyme-Linked Immunosorbent Assay/Semi-Quantitative Chemiluminescent Immunoassay
Epstein-Barr Virus Antibody Panel I 0050600
Method: Semi-Quantitative Chemiluminescent Immunoassay
Epstein-Barr Virus Antibody Panel II 0050602
Method: Semi-Quantitative Chemiluminescent Immunoassay
Heterophile Antibody (Infectious Mononucleosis) by Latex Agglutination with Reflex to Titer 2007697
Method: Qualitative Latex Agglutination/Semi-Quantitative Latex Agglutination

Initial serologic test to detect acute Epstein-Barr virus infectious mononucleosis

Viral Culture, Non-Respiratory 2006498
Method: Cell Culture

Viruses that can be isolated by culture – adenovirus, CMV, enterovirus, HSV, and VZV

Virus-specific tests are recommended