What is the recommended treatment for an acute Epstein‑Barr virus infection in a patient in their late 80s, including supportive care, use of antivirals, and management of complications?

Treatment of EBV Infection in Patients in Their Late 80s or Older

For immunocompetent elderly patients with acute EBV infection, supportive care alone is the recommended treatment—antivirals are completely ineffective and should not be prescribed. 1, 2

Primary Management Approach

Supportive care is the cornerstone of treatment for uncomplicated EBV infections in elderly patients, focusing on:

• Symptom relief through antipyretics and analgesics for fever and pharyngeal pain 1
• Adequate hydration to prevent dehydration from fever and reduced oral intake 1
• Rest until the self-limiting infection resolves, typically over weeks to months 3

Critical Caveat: Antivirals Are Ineffective

Antiviral medications including acyclovir, valacyclovir, and ganciclovir are completely ineffective against EBV and should never be prescribed for acute or past EBV infections. 1, 2, 4 These drugs do not work because latently infected B cells do not express the EBV thymidine kinase enzyme required for antiviral activity. 5 Even in clinical trials of acute infectious mononucleosis, acyclovir showed minimal effects on clinical symptoms despite inhibiting oropharyngeal viral replication. 6

When to Consider Corticosteroids

Corticosteroids should be reserved for specific severe complications only:

• Upper airway obstruction from massive tonsillar enlargement (most clear indication) 3
• Severe immune-mediated hemolytic anemia or thrombocytopenia 3, 7
• Use judiciously as evidence for benefit in uncomplicated disease is lacking 3

Monitoring for Complications in Elderly Patients

Elderly patients warrant closer observation for complications given age-associated immunosenescence. Watch specifically for:

• Neurologic complications including meningoencephalitis, which may require hospitalization 3
• Hematologic complications such as autoimmune hemolytic anemia or thrombocytopenia 3, 7
• Hepatic complications with elevated transaminases or biliary stasis 7
• Splenic rupture (rare but life-threatening) 3, 7

Special Considerations for Immunocompromised Elderly

If the patient is immunocompromised (transplant recipient, on immunosuppressants, HIV-positive), the management paradigm changes completely:

• Monitor EBV DNA-emia in blood (not throat) by quantitative PCR weekly for at least 4 months 5, 1, 2
• Preemptive rituximab therapy (375 mg/m² weekly for 1-4 doses) is indicated for significant EBV DNA-emia without clinical symptoms 5, 1, 4
• Reduce immunosuppression when possible, always combined with rituximab 5, 1, 4

Management of EBV-Related Lymphoproliferative Disease

If EBV-PTLD develops (rare in immunocompetent elderly but possible with age-related immunosenescence):

• First-line treatment is rituximab 375 mg/m² once weekly for 1-4 doses until EBV DNA-emia negativity, achieving positive outcomes in approximately 70% of patients 5, 1, 4
• Reduction of immunosuppression should always accompany rituximab when applicable 5, 1, 4
• EBV-specific cytotoxic T-cell therapy should be considered if available 5, 1

Common Pitfalls to Avoid

• Do not prescribe antivirals based on positive EBV serology or PCR—this is ineffective and not evidence-based 1, 2, 4
• Do not use throat PCR for clinical decision-making; asymptomatic viral shedding is common and has no clinical significance 2
• Do not monitor EBV DNA levels serially in immunocompetent elderly patients—this leads to unnecessary interventions without benefit 2, 4
• Do not confuse uncomplicated acute infection with chronic active EBV (CAEBV), which requires persistent symptoms for >3 months and is exceedingly rare 4