Post on 19-Dec-2015
Epstein Barr Virus in Immunosuppressed Host
Epstein Barr Virus = Human herpesvirus 4 Infects more than 95% of the world's population. Humans are the only known reservoir of Epstein-Barr virus. EBV is present in oropharyngeal secretions and is most commonly
transmitted through saliva. The virus replicates in nasopharyngeal epithelial cells. Viral replication viremia lymphoreticular system, including the
liver, spleen, and B lymphocytes in peripheral blood. Host immune response to the viral infection includes activation of
CD8+ T lymphocytes = atypical lymphocytes found in the peripheral blood.
The T lymphocytes kill EBV-infected B cells and eventually reduce the number of Epstein-Barr virus–infected B lymphocytes to less than 1 per 106 circulating B cells.
Latent viral infection of memory B cells
Clinical Manifestations
Most commonly associated with infectious mononucleosis Classically affects adolescents and young
adults Children often asymptomatic Self-limited course Classic triad of symptoms
Sore throat +/- tonsillar
Exudate(85% of pts)
Lymphadenopathy
(usually posterior cervical chain)
Present in ~100% of pts
Fever! – 98% of pts
** e.g. Saturday Night Fever
Splenomegaly – seen in 50% pts
Rash!
Generalized maculopapular, urticarial or petechial rash
Erythema nodosum has been reported, but is rare
Rash more common in pts treated with antibiotics (esp. ampicillin or amoxicillin)
Reactive Lymphocytes!
Lymphocytosis = most common lab finding Absolute count >
4500 Differential count >
50% Most pt’s have >10%
atypical lymphocytes on peripheral smear
= CD8+ Tcells
Less common manifestations of EBV
“EBV can affect virtually any organ.”
Hepatitis Fulminant liver failure Jaundice is rare
Glomerulonephritis/ Acute Kidney Injury Pneumonia/Pleural effusion Myocarditis Pancreatitis Myositis
Hepatitis!
Increased infiltration by CD8+ T cells Inflammation of the liver Transaminitis
Neurologic syndromes
Guillian-Barre Cranial nerve palsies Encephalitis Aseptic meningitis Transverse myelitis Optic neuritis
Oral Hairy Leukoplakia!
Vs. Oral Candidiasis
Epstein-Barr virus serology
Antibodies to Epstein-Barr virus antigens Antibodies to viral capsid antigen (VCA), early antigens (EAs) Epstein-Barr nuclear antigen (EBNA).
Primary acute Epstein-Barr virus infection is associated with VCA-IgM, VCA-IgG, and absent EBNA antibodies.
The antibody pattern in recent infection (3-12 mo) includes positive findings for VCA-IgG and EBNA antibodies, negative VCA-IgM antibodies, and, usually, positive EA antibodies.
Patients who are immunocompromised and have persistent or reactivated Epstein-Barr virus infections often have high levels of antibodies to EA/D or EA/R.
Monospot
Rapid slide agglutination tests, including Monospot assays, have been developed to measure acute infectious mononucleosis heterophile antibodies in a rapid qualitative fashion. Slide tests use either horse RBCs or bovine RBCs.
All commercial kits for rapid diagnosis of acute infectious mononucleosis heterophile antibodies have low sensitivity (63-84%), with a negative predictive value of more than 10%.
Spot tests rarely yield false-positive results in patients with lymphoma or hepatitis.
Treatment
In most cases, no treatment is necessary
---------------------------------------------------- Corticosteroids for tonsillar edema /
respiratory distress In vitro trials of acyclovir
Our patient was treated with Valcyte 900mg po q day
IVIG for immune-mediated thrombocytopenia
THE END