From the Guidelines
The management of Epstein-Barr Virus (EBV) infection primarily involves supportive care, with a focus on symptom relief and monitoring for potential complications, as the infection is typically self-limiting. Treatment focuses on symptom relief with acetaminophen or NSAIDs like ibuprofen for fever and pain, adequate hydration, and rest until symptoms resolve, which usually takes 2-4 weeks 1. Patients should avoid contact sports and strenuous activity for at least 3-4 weeks to prevent splenic rupture, particularly if splenomegaly is present. Corticosteroids are not routinely recommended but may be considered in severe cases with significant tonsillar swelling causing airway obstruction, severe thrombocytopenia, or hemolytic anemia. Antiviral medications like acyclovir have not shown significant benefit for uncomplicated EBV infections.
In cases of chronic active EBV (CAEBV) or EBV-associated hemophagocytic lymphohistiocytosis (EBV-HLH), more aggressive treatment may be necessary, including the use of rituximab, etoposide, and corticosteroids, with consideration of stem cell transplantation (SCT) in severe cases 1. The prognosis for EBV-HLH has improved greatly when treated promptly using HLH-94 protocols, but the variable severity of EBV-HLH demands graded intensity and length of treatment. Monitoring of ferritin, sCD25, cell counts, and EBV DNA in affected patients aids in assessing treatment response.
Some key points to consider in the management of EBV infection include:
- Avoiding alcohol consumption for at least 6 weeks to reduce liver stress, as EBV can cause hepatitis
- Regular follow-up to monitor for resolution of symptoms and potential complications
- Consideration of more aggressive treatment in cases of CAEBV or EBV-HLH, including the use of rituximab, etoposide, and corticosteroids, with consideration of SCT in severe cases
- Monitoring of EBV DNA levels, as levels above 10^3 copies per milliliter have been reported to be relevant for the development of EBV-HLH 1.
From the Research
Management of Positive EBV Infection
The management of a patient with a positive Epstein-Barr Virus (EBV) infection can vary depending on the severity of the symptoms and the presence of any complications.
- Mild Cases: In most cases, EBV infection runs a mild self-limiting course, and treatment is primarily focused on relieving symptoms such as fever, headache, and general fatigue 2.
- Severe Cases: For severe manifestations of EBV infections, such as CNS involvement, peripheral nervous system involvement, hepatitis, and other afflictions, antiviral medications may be considered as an adjunct to steroid treatment 3.
- Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): NSAIDs, such as tiaramide or loxoprofen, have been shown to quickly resolve symptoms associated with EBV-induced infectious mononucleosis in patients with atopic predispositions 2.
- Splenic Rupture or Infarction: In cases of splenic rupture or infarction associated with EBV infectious mononucleosis, the goal of management is to preserve the spleen, thereby eliminating the risk of post-splenectomy infections 4.
- Surgical Management: Splenectomy may be necessary in some cases of splenic rupture, particularly those with a severe World Society of Emergency Surgery splenic rupture score 4.
- Conservative Management: Splenic infarction is typically managed conservatively without any fatal outcomes 4.
Considerations
It is essential to be aware of the possibility of spontaneous splenic rupture in patients with EBV infection and abdominal pain, and to provide appropriate counseling 5, 6.