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

Treatment of Epstein-Barr Virus (EBV) Infection

For most EBV infections in immunocompetent individuals, supportive care is the mainstay of treatment as antiviral therapy has not shown efficacy against EBV in these patients. 1

Treatment Approach Based on Patient Status

Immunocompetent Patients (Typical Infectious Mononucleosis)

• Supportive Care

  • Adequate hydration
  • Rest
  • Antipyretics for fever
  • Analgesics for pain relief
  • Activity restrictions for 3-4 weeks from symptom onset to prevent splenic rupture
  • Avoid contact sports until symptoms resolve and splenomegaly subsides

• Important Note: Antiviral medications (acyclovir, ganciclovir) are not recommended for routine EBV infections in immunocompetent hosts due to lack of efficacy 1

Immunocompromised Patients with EBV-PTLD (Post-Transplant Lymphoproliferative Disorder)

• First-line Treatment:

  • Rituximab 375 mg/m², once weekly (typically up to 4 doses) 2
  • Reduction of immunosuppressive therapy combined with rituximab whenever possible 2
  • Monitor EBV viral load during treatment - look for decrease of at least 1 log10 in the first week 2

• Second-line Treatment (if rituximab fails):

  • Cellular therapy: EBV-specific cytotoxic T lymphocytes (CTLs) or donor lymphocyte infusion (DLI) 2
  • Chemotherapy ± rituximab for refractory cases 2

• Not Recommended:

  • Surgery, IVIG, interferon, and antiviral agents are not recommended for PTLD treatment 2

Special Situations

CNS EBV Disease

Therapeutic options include:

• Rituximab ± chemotherapy (high-dose methotrexate and/or cytarabine or hydroxyurea) 2
• Rituximab systemic or intrathecal monotherapy 2
• Anti-EBV T-cell therapy 2
• Radiotherapy 2

Chronic Active EBV Disease (CAEBV)

• Requires confirmation of high EBV genome copy number (≥10,000 IU/mL in whole blood) 3
• Hematopoietic stem cell transplantation (HSCT) is considered the only curative treatment 3
• Chemotherapy may be used to control disease activity before HSCT 3

Monitoring and Prevention

• Regular follow-up to assess symptom resolution
• In immunocompromised patients:
  • Regular monitoring of EBV viral load
  • Pre-transplant EBV serology screening
  • Post-transplant monitoring of EBV DNA levels in high-risk patients
  • Screening should begin no later than 4 weeks after HSCT 1

Common Pitfalls to Avoid

• Don't prescribe antivirals for routine EBV infections in immunocompetent patients - they have not shown efficacy
• Don't allow early return to contact sports - wait at least 3-4 weeks from symptom onset to prevent splenic rupture
• Don't delay treatment in EBV-PTLD - therapy should be started as soon as possible due to risk of rapidly growing high-grade lymphoid tumor
• Don't rely solely on reduction of immunosuppression for PTLD - it should be combined with rituximab for better outcomes
• Don't miss monitoring response to rituximab therapy - look for decrease in EBV DNA-emia of at least 1 log10 in the first week

Prognosis Factors for Rituximab Therapy

Positive prognostic factors include:

• Age below 30 years
• Underlying non-malignant disease
• No acute GvHD
• Reduction of immunosuppression at EBV-PTLD diagnosis
• Decrease of EBV DNA-emia after initial therapy 2