Can Epstein-Barr virus (EBV) cause tonsils with white patches?

Epstein-Barr Virus Can Cause White Patches on Tonsils

Yes, Epstein-Barr virus (EBV) infection commonly causes white patches on the tonsils, typically presenting as exudative tonsillitis in the context of infectious mononucleosis. 1, 2

Clinical Presentation of EBV Tonsillitis

EBV infection affecting the tonsils typically presents with:

• Tonsillar enlargement with characteristic white exudative patches/coats 2
• Fever, fatigue, and malaise
• Cervical lymphadenopathy (particularly posterior cervical chain)
• Possible hepatosplenomegaly 2
• Symptoms may persist for weeks, unlike most bacterial tonsillitis

The white patches on tonsils in EBV infection represent an inflammatory exudate and are clinically similar to those seen in bacterial tonsillitis, particularly streptococcal pharyngitis, creating a common diagnostic challenge 3.

Diagnostic Considerations

When evaluating white patches on tonsils that might be EBV-related:

1. Serological testing is the standard diagnostic approach:

   • The recommended EBV antibody panel includes VCA IgM, VCA IgG, and EBNA IgG 4
   • Positive VCA IgM with positive VCA IgG but negative EBNA IgG indicates acute primary infection within 6 weeks 4
   • Heterophile antibody tests (Monospot) become detectable 6-10 days after symptom onset 5

2. Differential diagnosis is crucial:

   • Bacterial tonsillitis (particularly Group A Streptococcus)
   • Other viral causes (CMV, adenovirus)
   • Tonsillar candidiasis

3. Warning signs requiring further investigation:

   • Failure to respond to appropriate therapy
   • Asymmetric tonsillar enlargement
   • Persistent symptoms beyond expected timeframe

Common Pitfalls in Diagnosis

1. Misdiagnosis as bacterial tonsillitis leading to unnecessary antibiotic use 6

   • Up to 75% of acute exudative tonsillitis cases may be associated with EBV 1
   • Patients with EBV who receive amoxicillin/ampicillin often develop a characteristic maculopapular rash 6

2. Incomplete serological testing

   • Relying solely on heterophile antibody tests can miss approximately 10% of cases 5
   • False-negative results are especially common in children under 10 years 5

3. Failure to consider dual infection

   • EBV and bacterial co-infections can occur due to synergistic effects on inflamed tonsillar tissue 3

Management Approach

The management of EBV-related tonsillitis with white patches is primarily supportive:

• Rest, adequate hydration, and symptomatic relief 4
• Avoid contact sports for at least 8 weeks or while splenomegaly is present 4
• Avoid unnecessary antibiotics unless bacterial co-infection is confirmed
• Monitor for complications such as airway obstruction from severe tonsillar enlargement

In cases of persistent or severe symptoms, consider:

• Quantitative EBV viral load by PCR to confirm active viral replication 4
• Evaluation for chronic active EBV infection if symptoms persist beyond 6 months 5

Conclusion

White patches on tonsils are a common manifestation of EBV infection during infectious mononucleosis. The clinical presentation can mimic bacterial tonsillitis, making appropriate diagnostic testing crucial for correct management and avoiding unnecessary antibiotic use.