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Epstein barr virus mononucleosis

Infectious mononucleosis (also known as mono, the kissing disease, Pfeiffer's disease, and glandular fever) is a disease seen most commonly in adolescents and young adults, characterized by fever, sore throat and fatigue. It is caused by the Epstein-Barr virus (EBV) or the cytomegalovirus (CMV). It is typically transmitted through saliva or blood, often through kissing, or by sharing a drinking glass, eating utensil or needle. Contrary to common belief, the disease is relatively non-contagious. The causative virus is also found in the mucus of the infected person, so it is also easily spread through coughing or sneezing. more...

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It is estimated that 95% of adults in the world have EBV-antibodies, having been infected with the Epstein-Barr virus at some point in their lives. The virus infects B cells (B-lymphocytes), producing a reactive lymphocytosis and the atypical T cells (T-lymphocytes) which give the disease its name.

Symptoms and physical signs

A person can be infected with the virus for weeks or months before any symptoms begin to appear. Symptoms usually begin to appear 4-7 weeks after infection and may resemble strep throat or other bacterial or viral respiratory infections. These first signs of the disease are commonly confused with cold and flu symptoms. The typical symptoms and signs of mononucleosis are:

Fever - this varies from mild to severe, but is seen in nearly all cases.
Enlarged and tender lymph nodes - particularly the posterior cervical lymph nodes, on both sides of the neck.
Sore throat (throat infection) - nearly all patients with EBV-mononucleosis have symptoms similar to tonsillitis.
Fatigue (sometimes extreme fatigue)

Some patients may also display:

Enlarged spleen (splenomegaly) or liver (hepatomegaly), which may later rupture
Abdominal pain
Aching muscles
Headache
Loss of appetite
Jaundice
Sinus infection
Depression
Weakness
Skin rash

The symptoms of infectious mononucleosis usually last 1-2 months, but the virus can remain dormant in the B cells indefinitely after symptoms have disappeared, and resurface at a later date. Many people exposed to the Epstein-Barr virus do not show symptoms of the disease, but carry the virus and can transmit it to others. This is especially true in children, in whom infection seldom causes more than a very mild illness which often goes undiagnosed. This feature, along with mono's long incubation period, makes epidemiological control of the disease impractical. About 6% of people who have had mono will relapse.

Since mononucleosis can cause the spleen to swell, it may in rare cases lead to a ruptured spleen. Rupture may occur without trauma, but impact to the spleen is usually a factor. Other complications include hepatitis (inflammation of the liver) causing jaundice, and anaemia (a deficiency of red blood cells). In rare cases, death may result from severe hepatitis or splenic rupture.

Usually, the longer the infected person experiences the symptoms the more the infection weakens the person's immune system and the longer he/she will need to recover. Cyclical reactivation of the virus, although rare in healthy people, is often a sign of immunological abnormalities in the small subset of organic disease patients in which the virus is active or reactivated.

Definition

The Epstein-Barr virus test is a blood test, or group of tests, to determine the presence or absence of antibodies in the blood stream directed against proteins of the Epstein-Barr virus, the cause of infectious mononucleosis.

Purpose

The test is primarily used to detect whether first time infection (called primary infection) with the Epstein-Barr virus is currently occurring, or has occurred within a short period of time. The pattern of the antibodies detected can, however, tell if the person has never been infected with the Epstein-Barr virus, or if the infection occurred in the more distant past. These tests are mostly utilized in the diagnosis of Epstein-Barr virus-associated infectious mononucleosis when the more common diagnostic test, the heterophile antibody, is negative, or in situations where the infection is manifesting unusual symptoms. Therefore, the tests are often not needed in a situation where a doctor believes that a person has mononucleosis and the heterophile test (also called the monospot test) is positive.

In addition, Epstein-Barr virus testing is usually not needed in the evaluation of a patient who has long-lasting fatigue, and may have the chronic fatigue syndrome. Initially, it was thought that discovering a particular pattern of antibodies to this virus was helpful in the diagnosis of chronic fatigue syndrome , but this no longer appears to be the case.

Precautions

As in any blood test, standard precautions should be performed to prevent infection at the site where the blood is obtained, and to prevent excess bleeding. Normally, the site is cleaned with an antiseptic liquid prior to the blood being obtained; a sterile non-reusable needle and syringe are used; and, once the needle is removed, pressure is placed at the site until bleeding has stopped.

Description

These tests are more often performed in a consulting laboratory than at a physician's office or in a hospital laboratory. Like most antibody tests, they are performed on serum, the liquid part of the blood obtained after the whole blood is allowed to clot in a tube. Antibodies can be detected against several components of the Epstein-Barr virus (EBV). These components are the EBV early antigen (EA), the viral capsid antigen (VCA), and the nuclear antigen (EBNA). These several antigens are different proteins that are produced in the process (stages) of the virus' growth.

At the time of infection with Epstein-Barr virus, antibodies to EA are found and usually last for four to six months only. This antibody, however, persists substantially longer in about 10% of persons who have had EBV infection in the more remote past. The absence of antibody to EA when other EBV antibodies are present strongly suggests that first time infection with EBV occurred in the past.

Antibody to VCA is found both early and late in EBV infection. At the time of infection, antibody of both the IgM and IgG types are detectable. After 4-6 months, usually, only the IgG antibody against VCA can be found.

Unlike antibodies to EA and VCA, antibody to EBNA does not usually develop until recovery from first time infection of this virus. Therefore, finding detectable amounts of antibody to EBNA during an illness which might be caused by EBV makes the causal relationship very unlikely.

Preparation

The skin area from which the blood sample will be obtained is wiped with an antiseptic such as alcohol or iodine.

Aftercare

The aftercare is similar to that for any blood test. Usually, pressure is applied to the area for several moments until bleeding stops. If the results are difficult to interpret, it may be necessary to re-test later, after waiting one to three weeks. The change in the amounts of antibody detected between the two tests can be particularly useful, at times, in helping to make a diagnosis.

Risks

There are no risks over and above those of having blood drawn for any other purpose. These tests are more expensive than many other blood tests but are usually covered by medical insurance.

Normal results

The pattern of the three antibodies can be used to determine whether the person has not had infection with EBV to this point (is susceptible to infection); is currently, or recently, infected with EBV for the first time; or has had first time infection with EBV sometime in the past (more than six months ago).

If one defines "normal" results as either not having EBV in the past, and call that category one; or having had it in the past, and call that category two. Most young children below the age of 5 will fall into category one, while most adults over the age of 20 years will fall into category two.

The results for susceptibility are:

Antibody to EA = Negative
Antibody to VCA (either IgM or IgG) = Negative
Antibody to EBNA = Negative.

The results for past infection are:

Antibody to EA = Negative (90% of time)
Antibody to VCA IgM = Negative
Antibody to VCA IgG = Positive
Antibody to EBNA = Positive.

It is important to realize that the Epstein-Barr virus, like all the human herpes viruses, does not totally leave the body after the patient recovers from illness. With EBV, the virus will intermittently recur in the saliva of people without any symptoms. Such people will have a test pattern of previous infection. It is this group of people who can transmit EBV to others without themselves being ill.

Abnormal results

The results for current or recent infection are:

Antibody to EA = Positive
Antibody to VCA IgM = Positive
Antibody to VCA IgG = Positive
Antibody to EBNA = Negative.

Without the pattern of the three antibodies, it can be difficult to be accurate in interpretation. The presence of antibody to VCA IgM is the best single test for current or recent first time infection.

For Your Information

Books

Bailey, R. Eugene. "Infectious Mononucleosis." In Current Diagnosis, edited by Rex B. Conn, William Z. Borer, and Jack W. Snyder. Philadelphia: W. B. Saunders, 1997.
Fleischer, Gary R. "Epstein-Barr Virus." In Textbook of Human Virology, edited by Robert B. Belshe. St. Louis, MO: Mosby Year Book, 1991.
Periodicals
Henle, G., W. Henle, and C. A. Horowitz. "Epstein-Barr Virus Specific Diagnosis: Tests in Infectious Mononucleosis." Human Pathology 5 (1997): 551-558.

Gale Encyclopedia of Medicine. Gale Research, 1999.

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