Can a healthy teenager with a history of infectious mononucleosis (mono) experience a relapse of symptoms after testing positive for Epstein-Barr virus (EBV)?

Epstein-Barr Virus Reactivation in Healthy Teenagers with Prior Mono

Yes, a healthy teenager with a history of infectious mononucleosis can experience a relapse or reactivation of Epstein-Barr virus (EBV) symptoms, although it is uncommon in immunocompetent individuals. 1

Diagnosis of EBV Reactivation

When evaluating a teenager with a history of mono who is now testing positive for EBV:

1. Confirm EBV reactivation with appropriate testing:

   • EBV-specific antibody panel (VCA IgG, VCA IgM, EBNA) 2, 1
   • Heterophile antibody testing (Monospot) 2
   • Consider EBV DNA quantification by PCR in severe or persistent cases 1

2. Clinical features suggesting reactivation:

   • Persistent or intermittent fever
   • Recurrent lymphadenopathy (especially cervical)
   • Fatigue or malaise
   • Pharyngitis
   • Hepatosplenomegaly 1

Distinguishing Primary Infection from Reactivation

• Primary infection: VCA IgM positive, VCA IgG may be positive, EBNA antibodies negative 2
• Past infection: VCA IgG and EBNA antibodies positive, VCA IgM negative 2
• Reactivation: Rising VCA IgG titers, possible transient VCA IgM, EBNA antibodies positive 1

Management Approach

For a healthy teenager with EBV reactivation:

1. Supportive care is the mainstay of treatment:

   • Adequate hydration
   • Rest
   • Analgesics/antipyretics for symptom control 1

2. Activity restrictions:

   • Avoid contact sports until clinical recovery and resolution of splenomegaly (if present)
   • Athletes may require 3-6 months to regain full performance 3

3. Monitoring:

   • Complete blood count with differential
   • Liver function tests 1
   • Assess for complications including hematologic abnormalities, hepatitis, and neurological manifestations 4

Important Considerations

• Standard antiviral medications (acyclovir, ganciclovir) have limited efficacy against latent EBV and are not routinely recommended for immunocompetent patients 1

• Risk factors for complications in EBV infections include:

  • Female gender
  • Absence of tonsillopharyngitis
  • White blood cell count ≤10,000/mm³
  • AST ≥150 IU/L 4

• While rare in healthy teenagers, be alert for potential complications:

  • Hematologic abnormalities (thrombocytopenia, neutropenia)
  • Hepatitis
  • Neurological manifestations
  • Airway obstruction 4, 5

When to Consider Further Evaluation

Refer for specialist evaluation if:

• Symptoms persist beyond 4-6 weeks
• Severe or unusual manifestations develop
• Suspicion for chronic active EBV infection (CAEBV) 2, 1

CAEBV is diagnosed when patients have:

• Persistent/recurrent infectious mononucleosis-like symptoms
• Unusual patterns of anti-EBV antibodies
• Chronic illness unexplained by other known diseases 1

While EBV reactivation can occur in healthy teenagers with prior mono, persistent or severe symptoms warrant thorough evaluation to rule out underlying immunodeficiency or development of EBV-associated complications.