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

Treatment for Epstein-Barr Virus (EBV) Infection

There is no specific antiviral treatment for EBV infection, and management primarily consists of supportive care, with antiviral agents only considered in severe cases of primary infection in immunocompromised patients. 1

Clinical Presentation and Diagnosis

Signs and Symptoms

• Infectious mononucleosis (most common symptomatic presentation):
  • Fever
  • Sore throat/pharyngitis
  • Lymphadenopathy (particularly cervical)
  • Fatigue
  • Hepatosplenomegaly
• In immunocompromised patients:
  • Prolonged or intermittent fever
  • Persistent lymphadenopathy
  • Debilitating fatigue
  • Potential complications affecting hematological, neurological, pulmonary, and cardiovascular systems 2

Diagnostic Approach

• EBV-specific antibody panels (VCA-IgG, EA-IgG)
• Heterophile antibody testing (Monospot)
• Complete blood count with differential (atypical lymphocytes)
• Liver function tests
• In severe cases or immunocompromised patients: EBV DNA quantification by PCR 1, 2

Treatment Algorithm

1. Immunocompetent Patients with Uncomplicated EBV Infection

• Supportive care only:
  • Adequate hydration
  • Rest
  • Analgesics/antipyretics for symptom relief
  • Avoid contact sports (risk of splenic rupture)
  • No role for antiviral medications 1

2. Severe EBV Infection in Immunocompromised Patients

• Reduce immunosuppression if possible 1, 2
• Consider antiviral therapy in severe cases:
  • Ganciclovir or foscarnet may be considered despite limited supporting evidence
  • These agents are more potent than aciclovir for replicative EBV infection but more toxic 1
• For EBV-related lymphoproliferative disorders:
  • Rituximab 375 mg/m² IV weekly until EBV DNA-emia negativity (typically 1-4 doses) 2
  • Discontinuation of immunosuppressive therapy may result in spontaneous regression 1

3. EBV Reactivation in Transplant Recipients

• Weekly EBV DNA monitoring by quantitative PCR for at least 4 months post-transplant 2
• Preemptive therapy when viral load exceeds threshold (varies between centers):
  • Reduction of immunosuppression if possible
  • Rituximab 375 mg/m² IV weekly until EBV DNA-emia negativity 2
• Second-line options:
  • EBV-specific cytotoxic T lymphocytes
  • Donor lymphocyte infusion 2

Important Considerations

Limitations of Antiviral Therapy

• Standard antiviral drugs (acyclovir, ganciclovir) have limited efficacy against latent EBV
• Antiviral therapy primarily targets lytic viral replication, which represents only a small portion of the viral lifecycle 1, 2

Prevention

• No EBV vaccine is currently available 1
• In transplant recipients, EBV IgG testing pre-transplant can identify susceptible patients 1

Monitoring for Complications

• Monitor for development of lymphoproliferative disorders in immunocompromised patients
• Consider EBV DNA monitoring in high-risk patients 2

Special Caution

• Primary EBV infection during immunosuppressive therapy (particularly thiopurines) carries increased risk of lymphoproliferative disorders
• Fatal infectious mononucleosis has been reported in patients on azathioprine 1