What is the treatment for Epstein-Barr Virus (EBV) infection?

Treatment for Epstein-Barr Virus (EBV) Infection

The primary treatment for Epstein-Barr Virus (EBV) infection is supportive care, as there are no approved antiviral drugs effective against EBV infection. 1

Supportive Care for Uncomplicated EBV Infection

• First-line management:

  • Adequate hydration
  • Rest as tolerated
  • Antipyretics (acetaminophen or NSAIDs) for fever and pain
  • Analgesics for sore throat

• Activity restrictions:

  • Avoid contact sports or strenuous exercise for at least 3-4 weeks from symptom onset
  • Continue restrictions for up to 8 weeks if splenomegaly persists to prevent splenic rupture 1, 2

• Monitoring:

  • Follow up for resolution of symptoms, particularly fatigue
  • Monitor for potential complications (hepatitis, splenomegaly)

Special Circumstances

Airway Compromise

• Corticosteroids may be indicated for significant tonsillar hypertrophy causing airway obstruction 1
• This is the most common cause of hospitalization from infectious mononucleosis, particularly in children

Immunocompromised Patients

For patients with immunosuppression who develop EBV infection:

1. Reduce or discontinue immunomodulator therapy when possible 3, 1
2. Monitor EBV viral load weekly in high-risk patients 1
3. For significant EBV DNA-emia without clinical symptoms:
   • Rituximab 375 mg/m², once weekly (typically 1-4 doses) until EBV DNA-emia negativity 3, 1
   • Reduction of immunosuppression when possible 1

EBV-Related Post-Transplant Lymphoproliferative Disorders (PTLD)

For patients who develop PTLD:

1. First-line therapy:

   • Reduce immunosuppression 3, 1
   • Rituximab 375 mg/m², once weekly 1
   • EBV-specific cytotoxic T lymphocytes (CTLs) if available 1

2. Second-line therapy:

   • Cellular therapy (EBV-specific CTLs or donor lymphocyte infusion) 1
   • Chemotherapy ± rituximab after failure of other methods 1

What Is NOT Recommended

• Antiviral drugs (aciclovir, ganciclovir, foscarnet, cidofovir) are ineffective against latent EBV and not recommended for routine treatment 3, 1

  • Exception: In severe primary EBV infection in immunocompromised patients, ganciclovir or foscarnet may be considered despite limited evidence 3

• Routine use of corticosteroids is not recommended for uncomplicated infectious mononucleosis 1, 4

Important Clinical Considerations

• EBV IgG screening should be considered before initiation of immunomodulator therapy in patients with inflammatory bowel disease 3

• Anti-TNF monotherapy could be used in preference to thiopurines in EBV seronegative patients with inflammatory bowel disease 3

• The Paul–Bunnell and monospot tests are suboptimal for diagnosis. Primary EBV infection is diagnosed by detection of IgM and IgG directed against the EBV viral capsid antigen (VCA) with negative EBNA1 IgG 3

• Biopsy with EBER in situ hybridization is required to differentiate infectious mononucleosis from lymphoproliferative disease, non-Hodgkin's lymphoma, and Hodgkin's disease 3, 1

By following these guidelines, clinicians can provide appropriate care for patients with EBV infection while monitoring for potential complications, especially in high-risk populations.