Epstein-Barr Virus (EBV) Infection

Key Features

• Lymphadenopathy: Often bilateral, with posterior cervical chain involvement suggestive of EBV

• Pharyngitis: Severe sore throat, frequently exudative and can mimic strep throat

• Rash: Frequently emerges 1–2 weeks after infection, particularly if the patient has been given amoxicillin or ampicillin

• Fatigue: Can persist for weeks, typically resolving within 2–3 weeks

• Splenomegaly: Occurs in about 50% of cases, necessitating avoidance of contact sports for at least 3–4 weeks to reduce risk of splenic rupture

• Tonsillar hypertrophy: May be severe, potentially causing difficulty swallowing or even airway compromise

Diagnostic Tests

• Infectious Mononucleosis (IM) Test (Monospot)

  • Detects heterophile antibodies

  • Positive in 70–80% of cases after 2 weeks of infection

  • Less commonly used now, as EBV-specific serology is more accurate

• EBV Serology (IgM, IgG)

  • IgM positive indicates acute or recent infection

  • IgG positive indicates past infection or immunity

  • Preferred for its higher specificity and sensitivity

• Other Laboratory Findings

  • Mildly elevated liver enzymes (AST/ALT)

  • Raised ESR (less likely in simple strep pharyngitis)

  • Atypical lymphocytes on FBC supportive of EBV but non-specific

• Differential Diagnosis

  • CMV, acute HIV, toxoplasmosis, strep throat

  • Consider alternative causes if fever persists >4 weeks (malignancy, other infections)

Management

• Supportive Care

  • Typically self-limiting: most symptoms improve by 2–3 weeks, though fatigue can last longer

  • Rest and adequate hydration

  • Analgesics and antipyretics (NSAIDs, paracetamol)

  • Soft diet if odynophagia due to tonsillar enlargement

• Antibiotics

  • Not indicated for EBV alone

  • Avoid amoxicillin or ampicillin (increased risk of rash)

  • If strep co-infection is confirmed, use alternative antibiotics like penicillin V or cephalosporins

• Activity Restriction

  • Avoid contact sports for at least 3–4 weeks if splenomegaly is present

  • Ultrasound can confirm spleen size if uncertain

Complications

• Neurological: Encephalitis, Guillain-Barré syndrome, Bell’s palsy

• Hepatic: Hepatitis, transaminitis

• Cardiac: Myocarditis, pericarditis

• Haematological: Splenic rupture, neutropenia, thrombocytopaenia

• Airway: Significant tonsillar hypertrophy can cause airway obstruction in severe cases

Notes:

• Always consider EBV in adolescents or young adults with persistent sore throat, cervical lymphadenopathy, and marked fatigue

• Co-infection with strep can occur, so a throat swab may be warranted

• EBV-specific serology helps confirm diagnosis when Monospot or clinical findings are inconclusive

• Emphasise rest and gradual return to normal activity, especially in contact sports

• Reinforce avoidance of alcohol if liver enzymes are elevated

• Monitor for complications such as prolonged jaundice, significant hepatic involvement, or severe thrombocytopaenia