Epstein-Barr Virus Infection (Infectious Mononucleosis)

Pediatric Infectious Diseases Fellow Queen Sirikit National Institute of Child Health Sep21, 2007

Pranee Sitaposa, M.D.

Epstein-Barr Virus : History

In 1889, German physician Pfeiffer fever lymphadenopathy malaise hepatosplenomegaly abdominal discomfort in adolescents and young adults In England, Drsenfieber, or glandular fever In the early 1900s
numerous case descriptions of illnesses epidemiologically and clinically compatible with IM.
FEIGIN et al. Textbook of Pediatric Infectious Diseases5th ed;2004:1952-1957.

Epstein-Barr Virus : History

In 1920, Sprunt and Evans published cases of spontaneously resolving acute leukemia associated with blast-like cells in the blood In 1923, Downey and McKinlay detailed description of the lymphocyte morphology. In 1932, Paul and Bunnell Identified heterophile antibodies in serum during acute IM.
FEIGIN et al. Textbook of Pediatric Infectious Diseases5th ed;2004:1952-1957.

Epstein-Barr Virus : History

In 1958, Dennis Burkitt described 38 cases of round-cell sarcoma in children and adolescent living in Uganda, Africa. (Lymphoma) In 1964, Epstein described the first human tumor virus in a Burkitt lymphoma cell line by EM; herpes simplex virus (HSV). human herpesvirus type 4 In 1968, Henle reported the relationship between acute IM and EBV. Yale University showed EBV-transformed B-lymphoblastoid cell lines in tissue culture.
FEIGIN et al. Textbook of Pediatric Infectious Diseases5th ed;2004:1952-1957.

Virology : Structure and Genome

The structure of EBV is typical for a member of herpesvirus family : Inner core of DNA surrounded by a nucleocapsid, tegument, and an envelope. The entire EBV genome : short and long sections of unique sequences (Us and UL)

Molecular Biology : Replication

To infect cells, EBV uses a cell surface receptor (CR2,CD21) found primarily on B lymphocytes and nasopharyngeal epithelial cells. MHC class II protein functions as a cofactor for this virus-receptor interaction. After infection of epithelial cells, active replication occurs and leads to lysis and death of the cell.

Molecular Biology : Replication

Viral capsid antigens (VCAs) are the primary structure protiens in viral capsids and are found in replicating cells. EBV early antigens (EAs) consist of >15 protiens codes by genes distributed throughout the genome. EBV nuclear antigen (EBNA) corresponds to six virally encoded protiens found in the nucleus of an EBV-infected cell.

Viral capsid antigens (VCAs)

Molecular Biology : Latency

Latently infected B cells are the primary reservoir of EBV in the body. >100 gene products may be expressed during active viral replication, only 11 are expressed during viral latency. In this way, the virus limits cytotoxic T-cell recognition of EBV-infected cells.

Molecular Biology : Transformation

EBV generally transforms relatively mature B lymphocytes secreting a complete immunoglobulin product. EBV : infect and transform B cells in earlier stages of development (e.g. pre-B cells and lymphoid precusors lacking immunoglobulin gene rearrangement)

Molecular Biology : EBV Subtype

2 subtypes EBV-1 (type A): Western countries EBV-2 (type B): less virulence In immunocompromised persons : co-infection both type 1 and type 2 strains No one subtype is responsible for specific lymphoproliferative diseases (geographic differences)

Immunopathogenesis : IM

In a normal host, both cellular and humoral immunity develops in response to EBV infection. Diagnosis of acute infection : viral capsid and nuclear proteins. 2-7 wks after exposure, up to 20% of circulating B lymphocytes become infected during primary EBV infection.

Immunopathogenesis : IM

In acute stage, proliferating EBV-infected B cells are controlled principally by NK cells, CD4 and CD8 cells. After T-cell response, number of EBV-infected B cells falls dramatically. Convalescence : EBNA-3 protein.

Immunopathogenesis : IM

Primary EBV infection, like herpesviruses, is able to persist in a latent state in a human host throughout that persons lifetime. This ability indicates that EBV exerts some influence on the immune response to prevent its complete eradication.

Infectious Mononucleosis

NEJM;343:481-492.

Serum EBV antibodies

Nelson 17 edition, Textbook of Pediatrics

Serum Epstein-Barr Virus (EBV) Antibodies in EBV Infection

Infection VCA IgG VCA IgM EA(D) EBNA

No previous infection
Acute infection

+/-

Recent infection
Past infection

+
+

+/-

+/+/-

+/+

AAP. Red book2006;286-288.

EBV-associated tumors

In normal hosts, cellular immune : adequate for control and sequestration of EBV-infected cells. In cellular immune deficiency : excess EBV-associated B-cell production -histologically pleomorphic (B-cell lymphoproliferative disease) -relatively uniform (monomorphic, B-cell lymphomas)

EBV-associated tumors

Life-threatening EBV infections strong virus-induced T-cell proliferation cause autoaggressive activity producing hypogammaglobulinemia or other major organ dysfunctions multifactorial : mixture of virology genetic environmental factors

EBV-associated lymphoproliferative diseases

The most common form of non-Hodgkin lymphoma (NHL) is Burkitt lymphoma, which consists of sheets of small noncleaved cells that are histologically uniform. HD tissues : presence of Reed-Sternberg cells admixed with lymphocytes and other reactive cells. Reed-Sternberg cells are large (15-45 m), multinucleated cells probably derived from B or T cells.

EBV-associated lymphoproliferative diseases

Reed-Sternberg cells

Other EBV-associated diseases

The hemophagocytic lymphohistiocytosis (HLH) typically include the bone marrow, spleen, liver, lymph nodes, skin and brain. In BM -hypocellularity -activated macrophages (histiocytes) are egulfing all bone marrow cellular element

Other EBV-associated diseases

Three histopathologic categoies of epithelial tumors in nasopharynx, most common form is the undifferentiated variety, which is associated most strongly with EBV.

Malignant cells consistently contain multiple copies of monoclonal EBV DNA within episomes and several EBV proteins are expressed.

Epidemiology : Seroprevalence

In the mid-1960s : detection of antibodies to - VCA (long lasting, early in infection) - EA (short duration, early in infection) EBV-VCA antibodies : 100% in BL patients 85% in normal adults 80-95% of adults have serologic evidence, most infections occuring during infancy and children.

Primary EBV infection : Seroprevalence

In developing countries -80-100% of children becoming infected by 3-6 yrs of age -clinically silent or mild disease.

In developed countries -occurs later in life, 10-30 years of age -induce clinically mononucleosis syndrome (U.S.college students : 50-75% associated with primary EBV infection)

Hickey SM et al. Pediatr Clin North Am. Dec 1997;44(6):1541-56.

Epidemiology : Incidence

Population-based studies ; 50-100 : 100,000 population. Highest incidence rates : 15-19 years. No seasonal predilection. Higher rate in persons of white race than in other ethnic groups.

Epidemiology : viral shedding

In 1971, Chang and Golden : identified a leukocyte-transforming agent in oropharyngeal secretions. Studies in healthy populations indicating 1) most children and adults with acute IM shed EBV in their oropharynx 2) 6 20% of general population shed EBV in the oropharynx 3) oropharyngeal shedding may be intermittent or continuous 4) high concentrations of EBV in oropharyngeal secretions are associated with high concentrations of EBV in B lymphocytes in peripheral blood but not with concentrations of EBV-specific serum antibodies

Epidemiology : Transmission

Incubation period : 30 50 days. (shorter in young children) Oral secretion : major role but occur slowly Blood products,Transplanted organs : less commonly than CMV Intrauterine : infrequently : if infected; no adverse fetal outcomes and no viral transmission to the fetus.
Fleisher, et al. J. Pediatr.98:16-19, 1981.

Clinical Syndromes Associated with EBV Infection

Silent, nonspecific infections : in children - prolonged low-grade fever + lymphadenopathy - cough - rhinorrhea - pharyngitis Infectious mononucleosis (IM) - prodrome 2 5 days malaise, fatigue, possibly fever - acute phase fever (last 45 wks), lymphadenopathy (24 wks), tonsillopharyngitis, splenomegaly, hepatomegaly, rash, abdominal pain, eyelid edema 15% - resolution phase : organomegaly may persist 13 m

IM : Pathophysiology

Reservoir of EBV : Humans only. EBV founds in the saliva for the first 12-18 months after acquisition.

Viral replication lymphoreticular system liver spleen B lymphocytes in peripheral blood.

IM : Pathophysiology

Host immune response to the viral infection atypical lymphocytes. After acute EBV infection, latently infected lymphocytes and epithelial cells persist and are immortalized. During latent infection, the virus is present in the lymphocytes and oropharyngeal epithelial cells as episomes in the nucleus.

IM : Pathophysiology

A low rate of viral reactivation occurs within the population of latently infected cells. Primary source of new virus in latently infection Epithelial cells. Virus can be isolated from oral secretions of 2030% of healthy latently infected individuals at anytime.

IM : Pathophysiology

NEJM;343:481-492.

Infectious Mononucleosis

In Africa, the virus is associated with endemic Burkitt lymphoma. NP cacinoma : numerous EBV episomes Most common CA in adult men in southern China North American Inuits North African whites.

Infectious Mononucleosis

Infectious Mononucleosis

No racial and sexual difference. The peak incidence occurs 2 years earlier in females. Report in middle-aged and elderly adults heterophile antibody negative. Most clinical symptoms are a consequence of T cell proliferation and organ infiltration.

Infectious Mononucleosis

Acute infectious mononucleosis fatique and malaise 1-2 wks sore throat, pharyngitis retro-orbital headache fever myalgia nausea abdominal pain generalized lymphadenopahy hepatosplenomegaly

Infectious Mononucleosis

Pharyngitis is the most consistent physical finding. 1/3 of patients : exudative pharyngitis. 25-60% of patients : petechiae at the junction of the hard and soft palates. Tonsillar enlargement can be massive, and occasionally it causes airway obstruction.

Infectious Mononucleosis

Lymphadenopathy : 90% symmetrical enlargement. mildly tender to palpation and not fix. posterior cervical lymph nodes.

anterior cervical and submandibular nodes. axillary and inguinal nodes.

Enlarged epitrochlear nodes are very suggestive of infectious mononucleosis.

Infectious Mononucleosis

Hepatomegaly : 60% jaundice is rare. Percussion tenderness over the liver is common. Splenomegaly : 50% palpable 2-3 cm below the left costal margin and may be tender. rapidly over the first week of symptoms, usually decreasing in size over the next 7-10 days. spleen can rupture from relatively minor trauma or even spontaneously.

Infectious Mononucleosis

Maculopapular rash : 15% usually faint, widely scattered, and erythematous occurs in 3-15% of patients and is more common in young children. 80% of patients, treatment with amoxicillin or ampicillin is associated with rash Circulating immunoglobulin G (IgG) and immunoglobulin M (IgM) antibodies to ampicillin are demonstrable.

Infectious Mononucleosis

IM with rash after treatment with amoxicillin or ampicillin

NEJM;343:481-492.

Infectious Mononucleosis

Eyelid edema : 15% may be present, especially in the first week Children younger than 4 years : more commonly splenomegaly or hepatomegaly rash symptoms of an upper respiratory tract infection

Clinical manifestation of IM in children and adults

Frequency (%)
Sign or symptom
Lymphadenopathy Fever Sore throat or tonsillopharyngitis Exudative tonsillopharyngitis Splenomegaly Hepatomegaly Cough or rhinitis Rash Abdominal pain or discomfort Eyelid edema

Age < 4 yr
94 92 67 45 82 63 51 34 17 14

Age 4 16 yr
95 100 75 59 53 30 15 17 0 14

Adults (range)
93 100 63 100 70 91 40 74 32 51 6 24 5 31 0 15 2 14 5 34

Sumaya, et al. J Infect Dis.131:403-408,1975.

Infectious Mononucleosis

NEJM;343:481-492.

Infectious Mononucleosis

Exudative pharyngotonsillitis

Infectious Mononucleosis

Cervical lymphadnopathy

Hepatosplenomegaly

Infectious Mononucleosis : Cause

EBV 90% of acute IM Etiology of most EBV-negative IM : unknown Other Herpesviruses : Cytomegalovirus (CMV) herpes simplex 1 and simplex 2 human herpesvirus 6 Other viruses : adenovirus hepatitis A, hepatitis B, or hepatitis C rubella primary human immunodeficiency virus in adolescents or young adults.

Infectious Mononucleosis : Lab

The 3 classic criteria for laboratory confirmation 1 lymphocytosis 2 the presence of at least 10% atypical lymphocytes on peripheral smear 3 a positive serologic test for Epstein-Barr virus (EBV).

Infectious Mononucleosis : Lab

Complete blood count 40-70%, Leukocytosis (WBC 10,000-20,000 cells per cm3) By the second week of illness, approximately 10% have a WBC count > 25,000 per cm3. 80-90% of patients have lymphocytosis, with greater than 50% lymphocytes. Lymphocytosis is greatest during 2-3 weeks of illness and lasts for 2-6 weeks. 20-40% of the lymphocytes : atypical lymphocytes > 10% ; Downey types 25-50%, Mild thrombocytopenia

Infectious Mononucleosis

atypical lymphocytes : Downey types

Infectious Mononucleosis : Lab

Liver function tests 80-100% of patients : elevated LFT Alkaline phosphatase, AST and bilirubin peak 5-14 days after onset GGT peaks at 1-3 weeks. Occasionally, GGT remains mildly elevated for up to 12 months 95% of patients : elevated LDH most liver function test results are normal by 3 months.

Infectious Mononucleosis : Lab

Heterophile antibodies 50% in first week of illness 60-90% in the second or third weeks begins to decline during the fourth or fifth week and often is less than 1:40 by 2-3 months after symptom onset 20% of patients have positive titers 1-2 years after acquisition children < 2 years : 10-30% children 2-4 years : 50-75%

Infectious Mononucleosis : Lab

EBV serology
EAs

(early antigens) : early in the lytic cycle VCA (Viral capsid antigen) and membrane antigens : late in the lytic cycle EBNA (Epstein-Barr nuclear antigen) : latent infection
Antibodies

to membrane antigens : usually are not measured

Infectious Mononucleosis : Lab

EA/D (diffuse-staining

component of EA) : 80% EA/R (restricted component of early antigens) measurable in children younger than 4 years with primary EBV infection or in asymptomatic infection.
nasopharyngeal

carcinoma antibodies to EA/R are high in individuals with EBV-associated Burkitt lymphoma.

immunocompromised

patient persistent or reactivated EBV infections often have high antibody levels to EA/D or EA/R.

Infectious Mononucleosis : Lab

Time course of antibody production
EA

is rising at symptom onset : rise for 3-4 weeks, then quickly decline to undetectable levels by 3-4 months, although low levels may be detected intermittently for years. VCA-IgM usually is measurable at symptom onset, peaks at 2-3 weeks, then declines and unmeasurable by 3-4 months. VCA-IgG rises shortly after symptom onset, peaks at 2-3 months, then drops slightly but persists for life.
EBNA

: convalescence and remain present for life.

IM Treatment
Medical Care : self-limited illness : not require specific therapy.

Inpatient therapy of medical and surgical complications may be required.

Acyclovir (10 mg/kg/dose IV q8h for 7-10 d) inhibit viral shedding from the oropharynx clincal course is not significantly IVIG (400 mg/kg/d IV for 2-5 d) immune thrombocytopenia associated with
Andersson J et al. J Infect Dis. Feb 1986;153(2):283-90. Cyran EM et al. Am J Hematol. Oct 1991;38(2):124-9.

IM Treatment
Medical Care : Short-course corticosteroids : prednisolone (1 mg/kg/d, max 60 mg/d for 7 d and tapered over another 7 d) Marked tonsillar inflammation with impending airway obstruction Massive splenomegaly Myocarditis Hemolytic anemia Hemophagocytic syndrome Seizure and meningitis Surgical Care : Splenic rupture. AAP. Red book2006;286-288.

Nelson. Textbook of Pediatrics17th ed;977-981.

Infectious Mononucleosis
Activity : depends on severity of the patient's symptoms. Extreme fatigue : bed rest for 1-2 weeks. Malaise may persist for 2-3 months. Patients should not participate in contact sports or heavy lifting for at least 2-3 weeks some authors recommend avoiding activities that may cause splenic trauma for 2 months.

IM : Complication

Hepatitis : > 90% of patients LFT : < 2-3 times of NUL in the second and third weeks of illness 45% of patients : elevated bilirubin, but jaundice occurs in only 5%. Mild thrombocytopenia occurs in approximately 50% of patients with infectious mononucleosis. Platelet count : nadir approximately 1 week after symptom onset (100,000-140,000/cm3. ), then gradually improves over the next 3-4 weeks. Mild thrombocytopenia occurs in approximately 50% of patients with infectious mononucleosis.

IM : Complications

Hemolytic anemia 0.5-3%, associated with cold-reactive antibodies, anti-I antibodies, and with autoantibodies to triphosphate isomerase mild and is most significant during the second and third weeks of symptoms. Upper airway obstruction 0.1-1%, due to hypertrophy of tonsils and other lymph nodes of Waldeyer ring treatment with corticosteroids may be beneficial

IM : Complications

Splenic rupture : 0.1-0.2% Spontaneous or history of some antecedent trauma. occur during the second and third weeks. mild-to-severe abdominal pain below the left costal margin, sometimes with radiation to the left shoulder and supraclavicular area. Massive bleeding : Shock

IM : Complications

Hematologic complications hemophagocytic syndrome. Immune thrombocytopenic purpura occurs and may evolve to aplastic anemia. accelerate hemolytic anemia in congenital spherocytosis or hereditary elliptocytosis. Disseminated intravascular coagulation associated with hepatic necrosis has occurred.

IM : Complications

Neurologic complications : < 1% during the first 2 weeks. negative for the heterophile antibody. Severe (fatal), complete recovery aseptic meningitis, acute viral encephalitis, coma, meningitis, and meningoencephalopathy. Hypoglossal nerve palsy, Bell palsy, hearing loss, brachial plexus neuropathy, multiple cranial nerve palsies, Guillain-Barr syndrome, autonomic neuropathy, gastrointestinal dysfunction secondary to selective cholinergic dysautonomia, acute cerebellar ataxia, transverse myelitis.

IM : Complications

Cardiac and pulmonary complications

rare chronic interstitial pneumonitis. myocarditis and pericarditis.

IM : Complications

Autoimmune complications

Autoimmune diseases and Reye syndrome have been associated with EBV infection.
Infectious mononucleosis stimulates production of many antibodies not directed against EBV. These include autoantibodies, antiI antibodies, cold hemolysins, antinuclear antibodies, rheumatoid factors, cryoglobulins, and circulating immune complexes. These antibodies may precipitate autoimmune syndromes.

IM : Complications

Miscellaneous complications Renal disorders : immune deposit nephritis, renal failure, paroxysmal nocturnal hemoglobinuria. After cardiac bypass or transfusion, an infectious mononucleosislike syndrome : primary CMV infection > EBV. A syndrome of chronic fatigue, myalgias, sore throat, and mild cognitive dysfunction occurring primarily in young adult females initially was attributed to EBV. Current data suggest that EBV is not the etiologic agent.

IM : Prognosis

Immunocompetent : full recovery in several months.

The common hematologic and hepatic complications resolve in 2-3 months.

Neurologic complications Children : resolve quickly Adults : neurological deficits All individuals develop latent infection asymptomatic.

IM : Prevention

Isolation is not required : low transmission. Avoid contact with saliva. Do not kiss children on the mouth. Maintain clean conditions : day care, avoid sharing toys. EBV can be transmitted by blood transfusion and by bone marrow transplantation. Vaccine development is proceeding, although the role of a vaccine is unclear.

FEIGIN et al. Textbook of Pediatric Infectious Diseases5th ed;2004:1952-1957.

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