Epstein Barr Virus (EBV) - PowerPoint Presentation

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Epstein Barr Virus (EBV)

Frances A. Rosario FNP-S

Suny Poly

Slide2

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 Hodgkin lymphoma

T Cell lymphoma

N

asopharyngeal carcinomas

(Sullivan, 2013)

Slide3

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)

Slide4

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)

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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)

Slide6

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 daycaresPredominant age: All ages are effected by EBVAges 10-19 manifest as infectious mononucleosisEqually effects males & femalesBy 20 yrs of age 60-90 % of individuals have a life-long anti-EBV antibody present (5 Minute Clinical Consult, 2014)

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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

gp350 antigen is being studied as a possibility(Odumade, Hogquist & Balfour, 2011). Risk FactorsAge Sociohygienic levelGeographic locationClose, intimate contact

Immunocompromised

(The 5 Minute Clinical Consult, 2014)

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Transmission

Transmitted mainly by contact with infected oropharyngeal secretions

such as:

Sharing of toothbrushes or kissing: the

kissing disease

Sharing drinks, cups, eating utensils & foodsContact with tools that have saliva on them (CDC, 2014)EBV is also transmitted via Blood Blood derivative transfusionOrgan and Tissue transplantsEBV can be present in breast milk and is present in the genital tract(Gequelin, Riediger, Nakatani, Biondo & Bonfim, 2011)

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Clinical Findings

Sx of EBV include

Fever

&

Fatigue

Inflamed throatSwollen lymph nodes in the neckEnlarged spleen and/or Swollen liverSx usually only last about 2-4 wks, but some may continue to experience fatigue for several months or monthsAfter EBV infections (ex. IM) the virus become latent. Reactivation of the virus does not always cause sx-- unless immunocompromised (CDC, 2014a)

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Differential Dx

Streptococcal Pharyngitis

Diphtheria

Blood

dyscrasias

Rubella MeaslesViral hepatitis MononucleosisCytomegalovirus(The 5 Minute Clinical Consult, 2014)

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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)

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Laboratory/ Diagnostics

Viral Capsid antigen (VCA)

Anti-VCA

IgM

appears early in EBV infection- disappears within 4-6 wks.

+ IgM=Active InfectionAnti-VCA IgG is present in the acute stage of EBV infection & peaks at wks 2-4---persist for lifeIf VCA antibodies are not present then pt is susceptible to EBVA 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)

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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 MononucleosisA + monospot may indicate that the pt has a typical case of IM, but it does not confirm an EBV infection(CDC, 2014b)

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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 appropriateAdequate rest, but bed rest is unnecessaryTylenol & NSAIDS are recommended for fever, throat pain, and general malaise(CDC, 2014a)

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EBV Complications

Primary complication is

infectious mononucleosis

EBV complications include lymphoma’s such as:

Hodgkin's & non-Hodgkin's lymphoma

Burkett's lymphomaPost transplant lymphoproliferative diseaseNasopharyngeal carcinoma(Gequelin, Riediger, Nakatani, Biondo & Bonfim, 2011)

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Symptoms of mononucleosis

(Hellwig

, Jude & Meyer, 2013)

Site

Central

ThroatTonsilsLymph nodesAbdominalSystemicSymptomsFatigue, malaise, anorexiaSoreness, reddening Swelling & exudateSwellingSplenomegaly, enlarged liverFever, aches, & fatigue

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Antiviral used to tx IM

Antiviral: Acyclovir

I

nhibits 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 placeboOropharyngeal shedding of virus greatly decreased by end of therapy in pts using acyclovir, but replication started again after tx ended(Hellwig, Jude & Meyer, 2013)

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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 PharyngitisSwollen lymph nodes in the neckEnlarged spleen and/or Swollen liver(Hellwig, Jude & Meyer, 2013)

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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)

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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 requiredMay return to work/school when pt feels able to. It may wks to more than a month to feel back to normalCaution with return to sports: avoid splenic rupture. If possibility of enlarged spleen aviod contact sports till cleared by MD (Bennett, 2014)

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10 Multiple questions

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Question # 1

Epstien

-Barr is cause by which herpes virus ?

Herpes simplex 1

Herpes simplex 2

Herpes virus 3 Herpes virus 4

Slide23

Question # 2

2. The Epstein-Barr virus is spread via?

Blood

Oropharyngeal

secretions

SalviaAll of the above

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Question # 3

3. A complication of EBV includes multiple lymphoma?

True

False

Hodgkin’s &

non-Hodgkin’s lymphoma Burkett's lymphomaPost transplant lymphoproliferative diseaseNasopharyngeal carcinoma

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Question # 4

4. The most common complication of EBV is?

Hodgkin's lymphoma

Nasopharyngeal carcinomas

Viral hepatitis

Mononucleosis

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Question # 5

5. There is a vaccine for the EBV virus

True

False

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Question # 6

6. IM is most often seen in what age groups?

Young children

Elderly

Middle-aged

Adolescents

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Question # 7

7. Symptoms of EBV include?

Fever & Fatigue

Pharyngitis

Nausea/Vomiting

A & B

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Question # 8

8. A definitive diagnosis for EBV can be made by testing for?

Monospot- heterophile

Viral Capsid

Antigen (VCA)

EBV Nuclear Antigen (EBNA)B & C

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Question # 9

9. When does a positive Anti

-VCA

IgM

appear?

4-6 wks after infectionVery early in infection2- 4 months after infectionLate in the infection

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Question # 10

10. The

presence of VCA &

EBNA indicates?

Acute infection

Immunity None of the aboveD. Past infection from months to years

Slide32

References

Bennett, J. (

2014a)

.

Pediatric mononucleosis and

epstein-barr virus infection: Background. Retrieved from http://emedicine.medscape.com/article/963894-overviewBennett, 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/about-ebv.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

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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/clinical-manifestations-and-treatment-of-epstein-barr-virus-infection?source=search_result&search=epstein barr&selectedTitle=1~150The 5 Minute Clinical Consult Stanard 2015. (2014). Epstein-barr virus infections

. (23rd ed.). Lippincott Williams & Wilkins

.