Frances A Rosario FNPS Suny Poly Epstein Barr Virus EBV EpsteinBarr 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 ID: 934268
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Slide1
Epstein Barr Virus (EBV)
Frances A. Rosario FNP-S
Suny Poly
Slide2Epstein 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)
Slide3Pathophysiology
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)
Slide4Pathophysiology
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)
Slide5Etiology
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)
Slide6Incidence
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)
Slide7Screening & 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)
Slide8Transmission
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)
Slide9Clinical 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)
Slide10Differential Dx
Streptococcal Pharyngitis
Diphtheria
Blood
dyscrasias
Rubella MeaslesViral hepatitis MononucleosisCytomegalovirus(The 5 Minute Clinical Consult, 2014)
Slide11Social/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)
Slide12Laboratory/ 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)
Slide13Laboratory/ 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)
Slide14treatment 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)
Slide15EBV 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)
Slide16Symptoms of mononucleosis
(Hellwig
, Jude & Meyer, 2013)
Site
Central
ThroatTonsilsLymph nodesAbdominalSystemicSymptomsFatigue, malaise, anorexiaSoreness, reddening Swelling & exudateSwellingSplenomegaly, enlarged liverFever, aches, & fatigue
Slide17Antiviral 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)
Slide18Corticosteroids 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)
Slide19Follow 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)
Slide20Counseling/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)
Slide2110 Multiple questions
Slide22Question # 1
Epstien
-Barr is cause by which herpes virus ?
Herpes simplex 1
Herpes simplex 2
Herpes virus 3 Herpes virus 4
Slide23Question # 2
2. The Epstein-Barr virus is spread via?
Blood
Oropharyngeal
secretions
SalviaAll of the above
Slide24Question # 3
3. A complication of EBV includes multiple lymphoma?
True
False
Hodgkin’s &
non-Hodgkin’s lymphoma Burkett's lymphomaPost transplant lymphoproliferative diseaseNasopharyngeal carcinoma
Slide25Question # 4
4. The most common complication of EBV is?
Hodgkin's lymphoma
Nasopharyngeal carcinomas
Viral hepatitis
Mononucleosis
Slide26Question # 5
5. There is a vaccine for the EBV virus
True
False
Slide27Question # 6
6. IM is most often seen in what age groups?
Young children
Elderly
Middle-aged
Adolescents
Slide28Question # 7
7. Symptoms of EBV include?
Fever & Fatigue
Pharyngitis
Nausea/Vomiting
A & B
Slide29Question # 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
Slide30Question # 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
Slide31Question # 10
10. The
presence of VCA &
EBNA indicates?
Acute infection
Immunity None of the aboveD. Past infection from months to years
Slide32References
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
Slide33References
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
.