Epstein-Barr Virus - EBV

  • Diagnosis
  • Monitoring
  • Background
  • Lab Tests
  • References
  • Related Content

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
    • Infection VCA G VCA M EA EBNA
      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
    • EBV viral load (quantitative PCR) is used in routine monitoring for transplant patients for posttransplant lymphoproliferative disorder
    • Standard of care for diagnosing EBV infection in CSF – PCR

Histology

  • Evaluation of formalin-fixed, paraffin-embedded (FFPE) tissue may be used for virus identification of EBV
  • Immunohistochemistry – stains for EBV latent membrane protein

Differential Diagnosis

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 posttransplant lymphoproliferative disorder (PTLD)
  • Increasing titers may signal reason to decrease immunosuppressive therapy to abort PTLD

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

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

  • 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
      • EBV-associated Hodgkin lymphoma (mixed cellularity subtypes)
      • Tonsillar carcinoma
      • T-cell lymphomas (especially sinonasal NK-cell lymphomas)
      • B-cell lymphoma of the elderly (diffuse large cell)
    • X-linked lymphoproliferative syndrome (Duncan disease)
      • Often results in fatal, polyclonal B-cell proliferation
    • Progressive lymphoproliferative diseases (eg, plasmablastic lymphoma)
      • Children with primary immunodeficiencies
      • Post-transplant lymphoproliferative disorders (PTLD)
      • Immunosuppressed or AIDS patients
    • No good evidence to implicate EBV in chronic fatigue syndrome
  • Primary infection often manifests as IM
    • IM usually self-limiting and characterized by the following
      • Fever
      • Sore throat
      • Myalgias
      • Lymphadenopathy
        • Cervical site most common
      • 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

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

CBC with Platelet Count and Automated Differential 0040003
Method: Automated Cell Count/Differential

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

Limitations

Negative Monospot test is common in children and immunocompromised adults

Follow Up

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

Follow Up

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

Follow Up

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

Follow Up

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

Limitations

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

Limitations

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

Limitations

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

Follow Up

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

Limitations

IgA is variably seen; levels are not consistently elevated

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

Follow Up

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

Cytomegalovirus Rapid Culture 0065004
Method: Cell Culture/Immunofluorescence

Human Herpesvirus 6 (HHV-6A and HHV-6B) by Quantitative PCR 0060071
Method: Quantitative Polymerase Chain Reaction

Additional Tests Available

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

Comments

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

Viral Culture, Non-Respiratory 2006498
Method: Cell Culture

Comments

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

Virus-specific tests are recommended

Guidelines

Parker A, Bowles K, Bradley A, Emery V, Featherstone C, Gupte G, Marcus R, Parameshwar J, Ramsay A, Newstead C, Haemato-oncology Task Force of the British Committee for Standards in Haematology and British Transplantation Society. Diagnosis of post-transplant lymphoproliferative disorder in solid organ transplant recipients - BCSH and BTS Guidelines. Br J Haematol. 2010; 149(5): 675-92. PubMed

General References

Auerbach A, Aguilera N. Epstein-Barr virus (EBV)-associated lymphoid lesions of the head and neck. Semin Diagn Pathol. 2015; 32(1): 12-22. PubMed

Brady G, MacArthur G, Farrell P. Epstein-Barr virus and Burkitt lymphoma. J Clin Pathol. 2007; 60(12): 1397-402. PubMed

Gulley M, Tang W. Laboratory assays for Epstein-Barr virus-related disease. J Mol Diagn. 2008; 10(4): 279-92. PubMed

Gulley M, Tang W. Using Epstein-Barr viral load assays to diagnose, monitor, and prevent posttransplant lymphoproliferative disorder. Clin Microbiol Rev. 2010; 23(2): 350-66. PubMed

Lennon P, Crotty M, Fenton J. Infectious mononucleosis. BMJ. 2015; 350: h1825. PubMed

Luzuriaga K, Sullivan J. Infectious mononucleosis. N Engl J Med. 2010; 362(21): 1993-2000. PubMed

References from the ARUP Institute for Clinical and Experimental Pathology®

Gross T, Orjuela M, Perkins S, Park J, Lynch J, Cairo M, Smith L, Hayashi R. Low-dose chemotherapy and rituximab for posttransplant lymphoproliferative disease (PTLD): a Children's Oncology Group Report. Am J Transplant. 2012; 12(11): 3069-75. PubMed

Hayden R, Hokanson K, Pounds S, Bankowski M, Belzer S, Carr J, Diorio D, Forman M, Joshi Y, Hillyard D, Hodinka R, Nikiforova M, Romain C, Stevenson J, Valsamakis A, Balfour H, U.S. EBV Working Group. Multicenter comparison of different real-time PCR assays for quantitative detection of Epstein-Barr virus. J Clin Microbiol. 2008; 46(1): 157-63. PubMed

Herrmann M, Durtschi J, Bromley K, Wittwer C, Voelkerding K. Amplicon DNA melting analysis for mutation scanning and genotyping: cross-platform comparison of instruments and dyes. Clin Chem. 2006; 52(3): 494-503. PubMed

Martins T, Litwin C, Hill H. Evaluation of a multiplex fluorescent microsphere immunoassay for the determination of epstein-barr virus serologic status. Am J Clin Pathol. 2008; 129(1): 34-41. PubMed

Salama M, Perkins S, Mariappan R. Images in HIV/AIDS. Primary bone marrow presentation of Epstein-Barr virus-driven HIV-associated Hodgkin lymphoma. AIDS Read. 2007; 17(12): 604-5. PubMed

She R, Stevenson J, Phansalkar A, Hillyard D, Litwin C, Petti C. Limitations of polymerase chain reaction testing for diagnosing acute Epstein-Barr virus infections. Diagn Microbiol Infect Dis. 2007; 58(3): 333-5. PubMed

Medical Reviewers

Last Update: January 2016