Can Epstein-Barr Virus (EBV) cause upper respiratory symptoms?

Epstein-Barr Virus and Upper Respiratory Symptoms

Yes, Epstein-Barr Virus (EBV) can cause upper respiratory symptoms, particularly sore throat, nasal congestion, and cough as part of infectious mononucleosis syndrome. 1, 2

Clinical Presentation of EBV Infection

EBV infection commonly presents with the following upper respiratory and systemic symptoms:

• Upper respiratory manifestations:

  • Sore throat (pharyngitis, often exudative)
  • Tonsillar enlargement
  • Nasal congestion
  • Cough
  • Palatal petechiae

• Other common symptoms:

  • Fever
  • Fatigue
  • Cervical lymphadenopathy (particularly posterior)
  • Hepatosplenomegaly
  • Malaise

Evidence for EBV Causing Upper Respiratory Symptoms

The American Journal of Hematology guidelines for diagnosing chronic active EBV infection specifically mention that infectious mononucleosis-like symptoms include upper respiratory tract manifestations 1. These symptoms are part of the clinical presentation that may persist in chronic active EBV infection.

Recent case reports have documented more extensive upper respiratory involvement with EBV, including a 2023 case of acute extensive viral sinusitis secondary to EBV infection 3. This case demonstrated that EBV can directly affect the sinuses, presenting with:

• Frontal sinus pain
• Fever
• Nasal discharge
• CT findings showing extensive sinusitis

Distinguishing EBV from Other Upper Respiratory Infections

It's important to differentiate EBV-related upper respiratory symptoms from common viral URIs and bacterial infections:

1. Duration and pattern:

   • Common cold symptoms typically resolve within 7-10 days 1
   • EBV symptoms often persist longer and are accompanied by characteristic systemic features

2. Associated symptoms that suggest EBV:

   • Prominent fatigue lasting weeks
   • Posterior cervical lymphadenopathy
   • Hepatosplenomegaly
   • Atypical lymphocytosis on blood work
   • Palatal petechiae

3. Complications specific to EBV:

   • Upper airway obstruction (occurs in 1-3.5% of cases) 4
   • Splenic rupture (uncommon but serious)
   • Multiple organ involvement (hepatitis, nephritis) 5

Diagnostic Approach

When upper respiratory symptoms suggest possible EBV infection:

1. Initial testing: Heterophile antibody test (71-90% accuracy for diagnosing infectious mononucleosis) 2

   • Note: 25% false-negative rate in the first week of illness

2. Confirmatory testing: EBV-specific antibody panel

   • Presence of EBV-specific IgM antibodies confirms recent infection
   • EBV PCR viral load can help assess viral activity

3. Additional workup:

   • Complete blood count (lymphocytosis with atypical lymphocytes)
   • Liver function tests (elevated transaminases common)

Clinical Pearls and Pitfalls

• Pearl: Lymphocytosis with fever and sore throat should prompt consideration of EBV infection, even with atypical presentations 3

• Pitfall: Mistaking EBV pharyngitis for bacterial pharyngitis and inappropriately prescribing antibiotics

• Pearl: Upper airway obstruction is more common in children with EBV infection and is the most common cause of hospitalization 2

• Pitfall: Failing to recognize that EBV can cause sinusitis, which may be mistaken for bacterial sinusitis 3

Management Considerations

• Symptomatic relief is the mainstay of treatment for EBV-related upper respiratory symptoms

  • Adequate hydration
  • Analgesics for pain and fever
  • Rest

• Avoid unnecessary antibiotics unless secondary bacterial infection is suspected

• Monitor for complications:

  • Airway compromise requiring intervention
  • Splenic rupture (avoid physical activity for first three weeks)
  • Severe systemic disease in immunocompromised patients

• Activity restrictions: Athletic participation is not recommended during the first three weeks of illness due to risk of splenic rupture 2

In conclusion, while EBV is not typically considered a primary cause of isolated upper respiratory symptoms, it can and does cause significant upper respiratory manifestations as part of the infectious mononucleosis syndrome, and in rare cases, can directly affect the sinuses and upper airway.