Download Disseminated Epstein

Epstein Barr Virus in
Immunosuppressed Host
Epstein Barr Virus
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= Human herpesvirus 4
Infects more than 95% of the world's population.
Humans are the only known reservoir of Epstein-Barr virus.
EBV is present in oropharyngeal secretions and is most commonly
transmitted through saliva.
The virus replicates in nasopharyngeal epithelial cells.
Viral replication  viremia  lymphoreticular system, including the
liver, spleen, and B lymphocytes in peripheral blood.
Host immune response to the viral infection includes activation of
CD8+ T lymphocytes
 = atypical lymphocytes found in the peripheral blood.
The T lymphocytes kill EBV-infected B cells and eventually reduce
the number of Epstein-Barr virus–infected B lymphocytes to less
than 1 per 106 circulating B cells.
Latent viral infection of memory B cells
Clinical Manifestations
 Most commonly associated with infectious
mononucleosis
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Classically affects adolescents and young
adults
Children often asymptomatic
Self-limited course
Classic triad of symptoms
Sore throat
+/- tonsillar
Exudate
(85% of pts)
Lymphadenopathy
(usually posterior
cervical chain)
Present in ~100% of pts
Fever! – 98% of pts
** e.g. Saturday Night Fever
Splenomegaly – seen in 50% pts
Rash!
 Generalized
maculopapular,
urticarial or petechial
rash
 Erythema nodosum has
been reported, but is
rare
 Rash more common in
pts treated with
antibiotics (esp.
ampicillin or amoxicillin)
Reactive Lymphocytes!
 Lymphocytosis = most
common lab finding
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Absolute count >
4500
Differential count >
50%
 Most pt’s have >10%
atypical lymphocytes
on peripheral smear
 = CD8+ Tcells
Less common manifestations of EBV
“EBV can affect virtually any organ.”
 Hepatitis  Fulminant liver failure
 Jaundice is rare
 Glomerulonephritis/ Acute Kidney Injury
 Pneumonia/Pleural effusion
 Myocarditis
 Pancreatitis
 Myositis
Hepatitis!
Increased infiltration by CD8+ T cells 
Inflammation of the liver  Transaminitis
Neurologic syndromes
 Guillian-Barre
 Cranial nerve palsies
 Encephalitis
 Aseptic meningitis
 Transverse myelitis
 Optic neuritis
Oral Hairy Leukoplakia!
Vs. Oral Candidiasis
Epstein-Barr virus serology
 Antibodies to Epstein-Barr virus antigens
 Antibodies to viral capsid antigen (VCA),
 early antigens (EAs)
 Epstein-Barr nuclear antigen (EBNA).
 Primary acute Epstein-Barr virus infection is
associated with VCA-IgM, VCA-IgG, and absent
EBNA antibodies.
 The antibody pattern in recent infection (3-12 mo)
includes positive findings for VCA-IgG and EBNA
antibodies, negative VCA-IgM antibodies, and,
usually, positive EA antibodies.
 Patients who are immunocompromised and have
persistent or reactivated Epstein-Barr virus
infections often have high levels of antibodies to
EA/D or EA/R.
Monospot
 Rapid slide agglutination tests, including Monospot
assays, have been developed to measure acute
infectious mononucleosis heterophile antibodies in a
rapid qualitative fashion. Slide tests use either horse
RBCs or bovine RBCs.
 All commercial kits for rapid diagnosis of acute
infectious mononucleosis heterophile antibodies have
low sensitivity (63-84%), with a negative predictive
value of more than 10%.
 Spot tests rarely yield false-positive results in patients
with lymphoma or hepatitis.
Treatment
 In most cases, no treatment is necessary
--------------------------------------------------- Corticosteroids for tonsillar edema /
respiratory distress
 In vitro trials of acyclovir
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Our patient was treated with Valcyte 900mg po
q day
 IVIG for immune-mediated thrombocytopenia
THE END