From the Guidelines
The treatment for Epstein-Barr Virus (EBV) infection in immunocompromised patients primarily involves reduction of immunosuppression, rituximab, and EBV-specific cytotoxic T-cell therapy.
First Line Therapy
- Rituximab, 375 mg/m², once weekly, is recommended as first-line therapy 1.
- Reduction of immunosuppressive therapy combined with rituximab should always be considered, if possible 1.
- EBV-specific cytotoxic T-cell therapy is also recommended as first-line therapy, if available 1.
Management
- Monitoring of high-risk patients for EBV by nucleic acid testing (NAT) is suggested, with frequency depending on the post-transplant period 1.
- Reduction or cessation of immunosuppressive medication is recommended for patients with EBV disease, including post-transplant lymphoproliferative disease (PTLD) 1.
- In cases of severe primary EBV infection, antiviral therapy with ganciclovir or foscarnet may be considered, despite the lack of supporting evidence 1.
- Discontinuation of immunosuppressive therapy may result in spontaneous regression of EBV-associated lymphoproliferative disease 1.
General Considerations
- Immunosuppressive therapy should be discontinued in severe cases of varicella infection, disseminated HSV and VZV, symptomatic infectious mononucleosis, EBV-related mucocutaneous ulceration, and severe influenza 1.
- The decision to restart immunosuppression after treatment for viral infections should be made on a case-by-case basis, considering the risk of disease flare and the risk of infection 1.
From the Research
Treatment Options for EBV Infection in Immunocompromised Patients
- There are no approved antivirals active in Post-transplant Lymphoproliferative Disorder (PTLD) nor in any other malignancy associated with EBV infection 2.
- Current therapies for EBV-associated malignancies include radiotherapy and chemotherapy 3.
- Adoptive therapy through infusions of human leukocyte-associated antigen-matched EBV cytotoxic T cells may form a novel strategy for both prophylaxis and treatment of EBV-induced lymphoproliferative disorders 3.
- Immunological-based approaches targeted at EBV-infected cells, as well as improvement in the treatment of the underlying and predisposing disease, are being explored as potential therapeutic strategies 4.
- Antiviral drugs such as acyclovir and ganciclovir have been used with limited impact, except when used with drugs that induce EBV lytic cycle 5.
Emerging Therapies
- Novel therapeutics developed that show anti-EBV activity are being discussed as potential treatment options for EBV infection in immunocompromised patients 2.
- Emerging therapies targeting the EBV-infected cells are being explored, including those that target the viral DNA polymerase 5.
- A vaccine based on immunization with a structural antigen, gp350, is under evaluation as a potential prophylactic strategy for EBV infection 3.
Challenges in Treatment
- The management and/or prevention of EBV primary infections or reactivations remains difficult due to the lack of approved antivirals and the complexity of the disease 2.
- The development of new anti-herpes drugs that can inhibit infection by both wild-type viruses and acyclovir-resistant strains is crucial, especially in immunocompromised patients 5.