When should Epstein-Barr Virus (EBV) testing occur?

When to Perform EBV Testing

EBV testing should be performed when a patient presents with clinical features suggestive of infectious mononucleosis but has a negative heterophile antibody (Monospot) test, or when evaluating for EBV-associated lymphoproliferative disease in immunocompromised patients. 1

Primary Indications for EBV Testing

• Initial evaluation should include a heterophile antibody test (Monospot) in patients with suspected infectious mononucleosis presenting with fever, pharyngitis, and lymphadenopathy 1, 2
• Perform specific EBV antibody testing when heterophile antibody tests are negative but clinical suspicion remains high, especially in children under 10 years who commonly have false-negative heterophile results 1, 2
• Test for EBV in immunocompromised patients (transplant recipients, HIV-infected individuals, those with congenital immunodeficiencies) who are at risk for EBV-associated lymphoproliferative disease 1
• Consider EBV testing when evaluating patients with cerebrospinal fluid abnormalities and suspected CNS lymphoma, particularly in immunocompromised patients 1

Specific EBV Serologic Testing Approach

• When heterophile tests are negative but EBV infection is still suspected, order EBV-specific antibody panel including IgG and IgM to viral capsid antigen (VCA) and antibodies to Epstein-Barr nuclear antigen (EBNA) 1, 2
• The presence of VCA IgM (with or without VCA IgG) antibodies in the absence of EBNA antibodies indicates recent primary EBV infection 1, 3
• The presence of EBNA antibodies indicates infection occurring more than 6 weeks prior to testing, making EBV unlikely as the cause of current symptoms 1

Testing in Special Populations

• In children under 10 years, heterophile antibody tests have higher false-negative rates (approximately 10%), making EBV-specific antibody testing more important 1, 4
• In elderly patients with prolonged fever, sore throat, and myalgia with or without significant lymphadenopathy, consider EBV testing as infectious mononucleosis can present atypically in this population 5
• For immunocompromised patients with suspected EBV-associated lymphoproliferative disease, quantitative EBV viral load testing by nucleic acid amplification test (NAAT) in peripheral blood is recommended 1

Specimen Collection and Timing

• For serologic testing, collect serum specimens as soon as possible after symptom onset 1
• For EBV DNA detection, appropriate specimens include whole blood, peripheral blood lymphocytes, or plasma (EDTA tube, room temperature, transported within 2 hours) 1
• For CNS involvement, cerebrospinal fluid should be collected in a sterile tube and transported at room temperature within 2 hours 1

Common Pitfalls to Avoid

• Relying solely on heterophile antibody tests early in the course of illness (first week) when false-negative rates can be as high as 25% 4
• Failing to consider other causes of mononucleosis-like illnesses (CMV, adenovirus, HIV, Toxoplasma gondii) when EBV tests are negative 6, 1
• Misinterpreting isolated positive EBV IgG results, which typically indicate past infection rather than acute illness 3
• Overlooking the possibility of EBV infection in patients with atypical presentations, particularly in children and elderly patients 5, 7