Transcript Epstein-barr virus and infectious mononucleosis

Epstein Barr Virus
(EBV)
Frances A. Rosario FNP-S
Suny Poly
Epstein Barr Virus (EBV)
• Epstein-Barr Virus is a herpesvirus that is transmitted
via intimate contact between at risk individuals and
asymptomatic EBV shedders
• EBV is the primary agent in pts with infectious
mononucleosis (IM)
• EBV is assoc. with the development of several
lymphomas such as
• B Cell lymphoma
• T Cell lymphoma
•
Hodgkin lymphoma
Nasopharyngeal carcinomas
(Sullivan, 2013)
Pathophysiology
• The only reservoir for Epstein-Barr virus are humans. Animals are not
carriers
• HBV is present in oropharyngeal secretions & is most commonly spread
via salvia. After infected the virus replicates within the nasopharyngeal
epithelial cells.
• Cell lysis causes release of virions which spreads to the salivary glands
and oropharyngeal lymphoid tissues.
• Continued viral replication results in worsening viremia affecting the
lymphoreticular system: liver, spleen, & B lymphocytes in the peripheral
blood.
• This results in a host response and the appearance of atypical
lymphocytes in the peripheral.
(Bennett, 2014b)
Pathophysiology
• The bodies host response includes CD8+ T lymphocytes
with suppressor & cytotoxic functions
• T-lympocytes are cytotoxic to the EBV and will eventually
decrease the no# of EBV (infected B-Cells)
• Primary infection is succeed by a latent infection during
which the virus is found in lymphocytes & oropharyngeal
epithelial cells as epitomes in the nucleus.
• Episomes seldom integrate into cell genome but some to
replicate. Reactivation during latently is low
• (Bennett, 2014b)
Etiology
• More than 95% of the worlds population have been infected with
EBV/ human herpesvirus 4.
• The most common complication of EBV is mononucleosis (IM)
• Adolescents and young adults are most commonly effected by IM
• EBV in young children is usually asymptomatic
•
(Bennett, 2014a)
Incidence
• 90% of all adults have antibodies to EBV indicating they have
been infected at some point in their lives (Gequelin, Riediger, Nakatani,
Biondo & Bonfim, 2011).
• Common in crowded populations such as military, college, and
daycares
• Predominant age: All ages are effected by EBV
• Ages 10-19 manifest as infectious mononucleosis
• Equally effects males & females
• By 20 yrs of age 60-90 % of individuals have a life-long anti-EBV
antibody present
•
(5 Minute Clinical Consult, 2014)
Screening & Risk Factors
Screening
• Currently there is no vaccine
or specific tx for EBV (CDC,
2014a).
• Studies are being conducted
to develop a vaccine for the
EBV virus
•
Risk Factors
• Age
• Sociohygienic level
• Geographic location
• Close, intimate contact
• Immunocompromised
gp350 antigen is being
studied as a possibility
• (Odumade, Hogquist &
Balfour, 2011).
(The 5 Minute Clinical Consult, 2014)
Transmission
• Transmitted mainly by contact with infected oropharyngeal
secretions such as:
• Sharing of toothbrushes or kissing: the kissing disease
• Sharing drinks, cups, eating utensils & foods
• Contact with tools that have saliva on them (CDC, 2014)
• EBV is also transmitted via
• Blood
• Blood derivative transfusion
• Organ and Tissue transplants
• EBV can be present in breast milk and is present in the genital
tract
•
(Gequelin, Riediger, Nakatani, Biondo & Bonfim, 2011)
Clinical Findings
• Sx of EBV include
• Fever & Fatigue
• Inflamed throat
• Swollen lymph nodes in the neck
• Enlarged spleen and/or Swollen liver
• Sx usually only last about 2-4 wks, but some may continue to
experience fatigue for several months or months
• After EBV infections (ex. IM) the virus become latent. Reactivation
of the virus does not always cause sx-- unless immunocompromised
•
(CDC, 2014a)
Differential Dx
• Streptococcal Pharyngitis
• Diphtheria
• Blood dyscrasias
• Rubella
• Measles
• Viral hepatitis
• Mononucleosis
• Cytomegalovirus
• (The 5 Minute Clinical Consult, 2014)
Social/Environmental
Considerations
• EBV is more prevalent in low socioeconomic groups,
occurs at an earlier age and is not as likely to result in
acute infectious mononucleosis
• In developed nation EBV usually develops in
adolescence and 50% results in acute mononucleosis
• EBV has no racial predictor and is equal found in men
and women
• (Hellwig, Jude & Meyer, 2013)
Laboratory/ Diagnostics
• Viral Capsid antigen (VCA)
•
Anti-VCA IgM appears early in EBV infection- disappears within 4-6 wks.
•
•
•
+ IgM=Active Infection
Anti-VCA IgG is present in the acute stage of EBV infection & peaks at
wks 2-4---persist for life
If VCA antibodies are not present then pt is susceptible to EBV
•
A high or rising anti VCA IgG without a + EBNA = Strongly suggest primary
infection after 4 wks of illness
• EBV Nuclear Antigen (EBNA):
•
•
•
Antibody to EBNA: determined by the standard immunofluorescent test
Not seen in acute infection, but appears 2-4 months after pt is
symptomatic and is present life long
The presence of VCA & EBNA= past infection from months to years
•
(CDC, 2014b)
Laboratory/ Diagnostics
• Monospot Test – used to test for mononucleosis
• Is testing for heterophile antibodies.
• Heterophile is not always present in children with IM
• Antibodies (heterophile) detected by the Monospot can
be caused by conditions other than EBV or
Mononucleosis
• A + monospot may indicate that the pt has a typical case
of IM, but it does not confirm an EBV infection
• (CDC, 2014b)
treatment of EBV:
• Primary EBV is usually self-limiting and rarely requires
more than symptom management
• Non pharmacological treatments include:
• Adequate fluids & nutritional intake is appropriate
• Adequate rest, but bed rest is unnecessary
• Tylenol & NSAIDS are recommended for fever, throat pain,
and general malaise
• (CDC, 2014a)
EBV Complications
• Primary complication is infectious mononucleosis
• EBV complications include lymphoma’s such as:
•
•
•
•
Hodgkin's & non-Hodgkin's lymphoma
Burkett's lymphoma
Post transplant lymphoproliferative disease
Nasopharyngeal carcinoma
•
(Gequelin, Riediger, Nakatani, Biondo & Bonfim, 2011)
Symptoms of mononucleosis
(Hellwig, Jude & Meyer, 2013)
Site
Symptoms
• Central
• Fatigue, malaise, anorexia
• Throat
• Soreness, reddening
• Tonsils
• Swelling & exudate
• Lymph nodes
• Swelling
• Abdominal
• Splenomegaly, enlarged liver
• Systemic
• Fever, aches, & fatigue
Antiviral used to tx
IM
• Antiviral: Acyclovir
• Inhibits the EBV infection by inhibition of EBV DNA
polymerase (no effect on latent infection).
• Both PO & IV acyclovir have been studied
• A meta-analysis of 5 randomized controlled trials including
2 trials with IV acyclovir therapy, failed to show clinical
benefit when compared to placebo
• Oropharyngeal shedding of virus greatly decreased by end
of therapy in pts using acyclovir, but replication started
again after tx ended
• (Hellwig, Jude & Meyer, 2013)
Corticosteroids tx for
Infectious mononucleosis (IM)
• Corticosteroids: controversial
• Corticosteroids have traditionally been used to tx the sx of IM, but studies
have shown no clinical significance
• Studies that have focused on steroid therapy alone have not perfect, but they
indicated that steroids tx is able to induce modest improvement of lymphoid
& mucosal swelling
• Steroid use not recomm. for routine cases of IM but have been used to
manage the following sx:
•
Severe Pharyngitis
• Swollen lymph nodes in the neck
• Enlarged spleen and/or Swollen liver
•
(Hellwig, Jude & Meyer, 2013)
Follow up &
Consultation/Referral
• Normally referrals or follow- up are not needed unless
complication such as
• Severe inflamed throat/ Pharyngitis that results in
airway obstruction
• Swollen lymph nodes in the neck/ lymphoma’s
• Enlarged spleen and/or swollen liver
• (Hellwig, Jude & Meyer, 2013)
Counseling/education
• The EBV virus lives in saliva and commonly spread via kissing
• Do not share items such as eating utensils, drinking glasses,
• You can be tested for EBV or IM, but testing too early may result in a false
negative.
• Treatment for EBV is geared toward symptoms management such as Tylenol
(fever) NSIADS (sore throat)
• Rest and adequate fluid intake required
• May return to work/school when pt feels able to. It may wks to more than a
month to feel back to normal
• Caution with return to sports: avoid splenic rupture. If possibility of enlarged
spleen aviod contact sports till cleared by MD
•
(Bennett, 2014)
10 Multiple questions
Question # 1
1. Epstien-Barr is cause by which herpes virus ?
A. Herpes simplex 1
B. Herpes simplex 2
C. Herpes virus 3
D. Herpes virus 4
Question # 2
2. The Epstein-Barr virus is spread via?
A. Blood
B. Oropharyngeal secretions
C. Salvia
D. All of the above
Question # 3
3. A complication of EBV includes multiple lymphoma?
A. True
B. False
Hodgkin’s & non-Hodgkin’s lymphoma
Burkett's lymphoma
Post transplant lymphoproliferative disease
Nasopharyngeal carcinoma
Question # 4
4. The most common complication of EBV is?
A. Hodgkin's lymphoma
B. Nasopharyngeal carcinomas
C. Viral hepatitis
D. Mononucleosis
Question # 5
5. There is a vaccine for the EBV virus
A. True
B. False
Question # 6
6. IM is most often seen in what age groups?
• Young children
• Elderly
• Middle-aged
• Adolescents
Question # 7
7. Symptoms of EBV include?
A. Fever & Fatigue
B. Pharyngitis
C. Nausea/Vomiting
D. A & B
Question # 8
8. A definitive diagnosis for EBV can be made by testing
for?
A. Monospot- heterophile
B. Viral Capsid Antigen (VCA)
C. EBV Nuclear Antigen (EBNA)
D. B & C
Question # 9
9. When does a positive Anti-VCA IgM appear?
A. 4-6 wks after infection
B. Very early in infection
C. 2- 4 months after infection
D. Late in the infection
Question # 10
10. The presence of VCA & EBNA indicates?
A. Acute infection
B. Immunity
C. None of the above
D. Past infection from months to years
References
•
Bennett, J. (2014a). Pediatric mononucleosis and epstein-barr virus infection: Background.
Retrieved from http://emedicine.medscape.com/article/963894-overview
•
Bennett, J. (2014b). Pediatric mononucleosis and epstein-barr virus infection: Pathophysiology.
Retrieved from http://emedicine.medscape.com/article/963894-overview
•
Center for Disease Control and Prevention (CDC). (2014a). Epstein-barr virus and
infectious mononucleosis. Retrieved from http://www.cdc.gov/epstein-barr/aboutebv.html
•
Center for Disease Control and Prevention (CDC). (2014b). Laboratory testing. Retrieved
from http://www.cdc.gov/epstein-barr/laboratory-testing.html
•
Gequelin, L., Riediger, I., Nakatani, S., Biondo, A., & Bonfim, C. (2011). Epstein-barr
virus: general factors, virus-related diseases and measurement of viral load after
transplant. US National Library of Medicine National Institutes of Health, 33(5), 383-388.
doi: 10.5581/1516-8484.20110103
•
Hellwig, T., Jude, K., & Meyer, B. (2013). Management options for infectious mononucleosis.
Retrieved from Hellwig, T., Jude, K., & Meyer, B. (2013). Management options for infectious mononucleosis. Retrieved
from http://www.medscape.com/viewarticle/805511_8
References
• Odumade, O., Hogquist, K., & Balfour, H. (2011). Progress and problems in
understanding and managing primary epstein-barr virus infections. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3021204/
• Sullivan, J. (2013). Clinical manifestations and treatment of epstein-barr virus
infection. Retrieved from http://www.uptodate.com/contents/clinicalmanifestations-and-treatment-of-epstein-barr-virusinfection?source=search_result&search=epstein barr&selectedTitle=1~150
• The 5 Minute Clinical Consult Stanard 2015. (2014). Epstein-barr virus
infections. (23rd ed.). Lippincott Williams & Wilkins.