Can Epstein-Barr Virus (EBV) cause thrombocytopenia?

Epstein-Barr Virus and Thrombocytopenia

Yes, Epstein-Barr Virus (EBV) can cause thrombocytopenia, which can range from mild to severe and potentially life-threatening in some cases. 1, 2

Mechanism and Presentation

• EBV-associated thrombocytopenia is a recognized hematological complication that can occur during both acute and chronic EBV infections 2
• Severe thrombocytopenia is an uncommon but serious complication of EBV infection that can lead to bleeding diathesis 3, 4
• Thrombocytopenia may occur as an isolated finding or as part of the spectrum of hematological abnormalities in EBV infection 5
• In chronic active EBV infection (CAEBV), thrombocytopenia is associated with poorer outcomes and is considered a negative prognostic indicator 1

Clinical Significance

• While mild decreases in platelet counts are common in uncomplicated EBV infections, severe thrombocytopenia (platelet count <20 × 10^9/L) is rare but potentially dangerous 5, 3
• Complications due to severe thrombocytopenia occur in approximately 27% of patients with EBV-associated thrombocytopenia 6
• Mortality has been reported in approximately 5.4% of patients with EBV-associated severe thrombocytopenia 6
• EBV should be considered in the differential diagnosis for any patient presenting with acute thrombocytopenia, regardless of age 5

Diagnostic Approach

• Testing for EBV should be considered in patients with unexplained thrombocytopenia, particularly when accompanied by other features suggestive of EBV infection 2, 7
• Diagnostic workup should include:
  • Complete blood count with peripheral blood smear examination 2
  • EBV serology (VCA-IgM, VCA-IgG, EA-IgG, EBNA) 1
  • Quantitative EBV PCR to detect viral load in peripheral blood 1
  • Assessment for other cytopenias that may suggest more severe disease 2

Management

• For mild to moderate thrombocytopenia without significant bleeding, observation may be sufficient as the condition often resolves spontaneously with resolution of the EBV infection 3
• For severe thrombocytopenia with bleeding manifestations, treatment options include:
  • Corticosteroids (intravenous methylprednisolone) as first-line therapy 3, 4
  • Intravenous immunoglobulin (IVIg) for cases refractory to steroid treatment or with significant bleeding 8, 4
  • Combination therapy with both corticosteroids and IVIg may be necessary in severe cases 4
• Platelet transfusions may be required in cases of life-threatening hemorrhage 1
• In chronic active EBV infection with persistent thrombocytopenia, more aggressive immunomodulatory therapy may be necessary 7

Important Clinical Considerations

• Thrombocytopenia may be the presenting feature of EBV infection, even without the classic triad of fever, pharyngitis, and lymphadenopathy 5, 4
• The presence of thrombocytopenia in chronic EBV infection is associated with poorer outcomes, particularly when EBV infects T cells 1
• Response to treatment is generally favorable, with normalization of platelet counts typically occurring within 1-2 weeks with appropriate therapy 5, 3
• Relapse of thrombocytopenia can occur upon discontinuation of corticosteroids, requiring reinstitution of therapy 3

EBV should be included in the differential diagnosis of acute or chronic thrombocytopenia, and appropriate testing should be performed, especially in patients with other clinical features suggestive of viral infection 2, 5.