Can Epstein-Barr Virus (EBV) cause pericardial effusion?

Epstein-Barr Virus as a Cause of Pericardial Effusion

Yes, Epstein-Barr virus (EBV) can cause pericardial effusion as part of viral pericarditis, and in rare cases, can lead to serious complications including cardiac tamponade. 1

Pathophysiology and Diagnosis

EBV is specifically identified in the European Society of Cardiology (ESC) guidelines as one of the DNA viruses that can cause pericarditis and subsequent pericardial effusion 1. Unlike RNA viruses which are more commonly found in pericardial fluid, EBV (along with other herpesviruses) is typically detected at higher viral DNA copy numbers in pericardial tissue 1.

The diagnostic approach for EBV-associated pericardial effusion includes:

• Definitive diagnosis requires comprehensive workup of pericardial fluid and/or pericardial/epicardial biopsies with:

  • Histological examination
  • Cytological analysis
  • Immunohistological investigations
  • Molecular testing (PCR) specifically for EBV 1

• Serology alone is insufficient - A four-fold rise in serum antibody levels is only suggestive but not diagnostic for viral pericarditis (Class IIb indication) 1

• Routine viral serology is not recommended by ESC guidelines, with exceptions only for HIV and HCV 1

Clinical Presentation and Complications

EBV-associated pericardial effusion can present with:

• Typical symptoms of pericarditis (chest pain relieved by leaning forward, dyspnea)
• Pericardial effusion of variable size
• In severe cases, cardiac tamponade requiring urgent intervention 2, 3

Case reports document that EBV can cause:

• Hemorrhagic pericardial effusion 2
• Pericardial tamponade even in immunocompetent patients 3

Management Considerations

For EBV-associated pericardial effusion:

1. First-line treatment includes NSAIDs combined with colchicine 4

2. Specific antiviral treatment for EBV pericarditis may include:

   • Intravenous immunoglobulin (IVIG) therapy in acute systemic EBV infection 1, 4
   • These treatments remain under evaluation and are rarely used in clinical practice 1

3. Important caution: Corticosteroids are generally contraindicated in viral pericarditis, including EBV, as they can reactivate viral infections and lead to ongoing inflammation (Class III recommendation) 1

4. Drainage procedures:

   • Pericardiocentesis may be necessary for large effusions or if tamponade develops 5, 2, 3
   • Recurrent effusions may require consideration of pericardial window or pericardiectomy 5

5. Infectious disease consultation is recommended for management of viral pericarditis 1

Prognosis

• Most cases of EBV-associated pericardial effusion in immunocompetent patients are self-limited 2
• Complete resolution without specific antiviral treatment has been documented 2
• However, close monitoring is essential as progression to tamponade can occur 3

Clinical Pearls and Pitfalls

• Pitfall: Failing to consider EBV in the differential diagnosis of pericardial effusion, especially in young patients with recent viral symptoms
• Pitfall: Using corticosteroids in viral pericarditis, which can worsen outcomes with EBV and other viral infections
• Pearl: PCR analysis of pericardial fluid is more sensitive and specific than serological testing for diagnosing EBV pericarditis
• Pearl: EBV can cause localized pericardial infection without detectable systemic EBV infection, highlighting the importance of direct pericardial fluid analysis 2