Case 9 Epstein-Barr virus ‘A 20-year-old woman went to her doctor complaining of sore throat. It started 4 days previously with associated episodes of fever and chills. On examination her doctor noticed that her tonsils and uvula were red and slightly swollen and that she had cervical lymphadenopathy. Suspecting a bacterial infection her doctor prescribed a course of ampicilin and suggested that she took a couple of days off work. The patient returned a week later with worsening symptoms. She was now very lethargic with a rash as shown in Figure 1. (On the second visit to her doctor she had patches of white exudate on the tonsils (Figure 2), petechial hemorrhages on the soft palate, and generalized lymphadenopathy. The doctor could also palpate an enlarged spleen and noticed that she was slightly tender over the right hypochondrium, He suspected that she might have infectious mononucleosis and sent her for hematological and antibody tests. temperature of 38.5°C and a widespread maculopapular Figure 1. Infectious mononucleosis: ampicillin-induced rash, Note the resemblance to measles. Figure 2. Infectious ‘mononucleosis: follicular ‘exudate on the tonsil, which is very swollen; the uvula is red and edematous. 1. What is the causative agent, how does it enter the body and spread a) within the body and b) from person to Causative agent ‘The patient has the clinical symptoms of primary Epstein-Barr virus (EBV) infection — infectious mononucleosis or glandular fever as it is commonly called because of the concomitant swollen lymph nodes. EBV, first discov- ered in 1964, is one of the most common human viruses. It belongs to the Herpewiridae family, of which there are eight identified to date as being human pathogens (Table 1). They include herpes simplex virus (HSV-1 and HSV-2) cytomegalovirus (CMV), varicella-zoster virus (VZV), and others. EBV is a gamma herpesvirus and is also called human herpesvirus 4 (HEV4). All herpesviruses are enveloped with a linear dsDINA genome of about 175 kbp. The icosahedral capsid is approximately 100-110 nm in6 CASE9 + EPSTEIN-BARR VIRUS EUCeernien) Herpes simplex virus type 1 Herpes simplex virus type 2 Varicella-zoster virus Epstein-Barr virus cytomegalovirus Human herpesvirus type 6 Human herpesvirus type 7 Human herpesvirus type 8 (also known as Kaposts sarcoma-associated herpesvirus) diameter, containing 162 tubular (ie. with a hole running down the long axis) capsomeres. ‘The virus envelope has glycoprotein spikes on its surface ~ these envelope proteins include gp42, gH, gL, and gp350. Entry and spread within the body Primary infection. The virus is transmitted to an uninfected from an infected person via saliva. Although the precise cellular route of infection has not yet been elucidated, it appears that either tonsillar B cells or the overlying squa- ‘mous epithelial cells ae probably the first cells to be infected. Most evidence points to the tonsil as the primary site of infection. Here virus replication involves a lytic cycle producing many more virions, which then pass via the afferent lymphatics into the cervical lymph nodes where further B cells are infected. For entry into B cells, gp350 on the viral envelope binds to a com- plement receptor (CR2, also called CD21), on the surface of B cells. gp42 binds MHC class II, which serves as co-receptor on the cell surface and is responsible for the fusion between the virus envelope and the host cell mem- brane. The virus is also carried by B cells through the bloodstream to the spleen and other lymphoid tissues where EBV causes B-lymphocyte prolif- ration (proliferating EBV-infected lymphocytes are sometimes referred to as transformed B cells see later) resulting in lymphadenopathy at both cer- vical and other sites of the body and splenomegaly. The incubation time of this infection (i. time from initial infection to development of symptoms ~ if they occur; see later, is usually 4-8 weeks. Even after resolution of symp toms the virus is not cleared from the body and remains latent throughout life in some of the memory B lymphocytes leading to a permanent carrier state. These memory B cells contain the latent EBV genome as an episome that expresses only part of its genetic information and serves upon reactiva- tion of the vieus from its latent state (see later) as a seed for further lytic infection at mucosal sites. This results in shedding of EBV in saliva but itis unclear whether the source of EBV in saliva is infected B or epithelial cells ‘Whatever the exact mechanism, most, if not all long-term carriers continue to shed low levels of virus throughout their life. Natural killer (NK) cells and T cells may occasionally be the targets of EBV during primary infection but the molecules used for entry are at present unknown. Infection might be responsible for the rare develop- ment of NK-cell and possibly T-cell lymphomas (see complications of EBV infection).Person to person spread [As described above, EBV is present in saliva throughout life. Spread of the infection is usually through intimate contact between an infected and an uninfected person ~ often through kissing. Hence this disease is known as the ‘kissing disease.’ EBV has also been shown to be present in both vagi rnal and male genital secretions, This, together with recent evidence that penetrative sex increases the frequency of seroconversion suggests that EBV is also sexually transmitted, Spread of the virus in children is probably mainly through fingers contaminated with saliva and other close contact. Epidemiology of EBV infection and infectious mononucleosis Globally the majority of adults are infected with EBV (95-98%). In devel- oping countries children become infected with the virus early in life and the infection is usually asymptomatic or so mild that it is undiagnosed. In developed countries, infection with EBV occurs relatively late and infec~ ‘ious mononucleosis is most common in young adults such as college stu- dents; recent studies in Europe show that at least 75% of school leavers are EBV seropositive but only about 30% develop the symptoms of infectious mononucleosis. The incidence of infectious mononucleosis shows no consistent seasonal peak and the disease is rare in older adults. 2, What is the host response to the infection and what is the disease pathogenesis? Following primary infection with EBV several virus-encoded molecules are produced, which induce an antibody response. These include the fol- lowing. © Early antigens EA complex ‘© Late antigens. virus capsid antigens (VCA complex) ~ membrane especially gp 350 ‘© Latency antigens some EB nuclear antigens (EBNAs) three latent membrane proteins (LMPS). In the infected cell, EA complex is produced early in the EBV replication cycle, whereas the VCA complex, a virus structural protein, is produced later. EBNA-I is an important lateney factor (a latent DNA replication factor), EBNA-2 is a viral oncogene and EBNAs 3 and C are transcrip- tional regulators that regulate the function of EBNA 2. These are not expressed during the establishment of latency. LMPI is a viral oncogene that initiates B-cell activation and proliferation and also plays a role in the establishment of latency by inhibiting B-cell apoptosis, whereas LMP2 plays a major role in the maintenance of latency. Both antibody and T-cell responses are induced against EBV antigens Antibody responses Figure 3 shows the typical sequence of appearance of antibodies made to some of the EBV-encoded antigens in a primary response. IgM to VCA is the first to appear followed by IgG. Antibodies of the IgM class to VCA are indicative of recent EBV infection, whereas IgG alone suggests infec~ tion some time previously. IgG VCA antibodies are present throughout CASE9 + EPSTEIN-BARR VIRUS ww118 CASES + EPSTEIN-BARR VIRUS Figure 3. Basic pattern of serum antibodies to Epstein-Barr virus- associated antigens before, during, and after primary infection. HA, heterophil antibody; EA(D), ciffuse form of early antigen: VA, vitus capsid antigen; EBNA, Epstein-Barr nuclear antigen, antibody titer aPIHEBNA T IgG dass ores ae ra eT or) fr) cin the life of individuals infected with EBV and are used to determine the sta- tus of an individual regarding prior infection with the virus. Antibodies to the viral membrane glycoprotein gp350 are neutralizing since they block binding of the virus to CD21 on the B-cell surface and therefore have the potential to protect an individual from primary infection, Antibodies to EA are highest during the acute phase of infection but are often detectable at varying levels thereafter and are thus not a reliable indicator of acute infection. Antibody responses to EBNAs arise approximately 4 weeks after onset of symptoms, and persist for life. Nk-cell and T-cell responses “The role of NK cells in primary infection is unclear but there is evidence that these cells are ‘activated’ by virus-infected cells in the oropharynx. Cytotoxic CD8+ T cells are the main cells that deal with primary EBV infection and their strong antiviral response determines the clinical fea- tures of the disease. Figure 4 shows the virus-cell interactions and the virus-induced CD8+ ‘T-cell response in primary EBV infection as seen in infectious mononucle- sis patients and healthy virus carriers. cells initially respond to the EBV-infected cells by proliferation, firstly CD4+ T cells and then CD8+ T cells and outnumber the B cells by a factor of about 50 to 1. These “T cells appear in the circulation as ‘atypical lymphocytes’ and are used in diagnosis (see Section 4). During the early response to the virus, up to 50% of the CD8+ T cells in the circulation can be specific for EBV anti- gens, Infectious mononucleosis is an immunopathological disease with the immune response itself being responsible for the clinical symptoms and pathogenesis. The symptoms of infectious mononucleosis result from the intense immunological activity of CD8+ T cells specifically recognizing EBY-encoded antigens expressed by infected cells, This results in a strong inflammatory response. It has been suggested that the almost complete absence of this disease in young children (although not proven) is due to less mature T-cell responses, thus resulting in a weaker but still effectiveprimary infection transmitted —@ reactivation tolytic cycle CASES + EPSTEINBARRVIRUS 119 ius carer state Ini anes 4 Ne 87 ret yea @ co een epithelium pene “pect Speci epithelium Ene Pn immune response. Exposure to lower viral doses in this age group might also play a role. In infectious mononucleosis the cytolytic CD8+T cells are able to control the infection by killing most of the virus-infected cells (transformed B cells) but note that the high-level shedding of virus in the throat of infec~ tious mononucleosis patients continues. This might be because of the poor recruitment of the cytolytic CD8+ T cells to the tonsillar tissue. A few ‘memory B cells containing the latent virus evade the immune response by down-regulation of EBV antigens. These B cells enter a resting state as members of a long-lived memory cell pool, with about 1-50 cells per mil- lion circulating B cells latently infected with EBV, some 1000-fold below that typically seen in acute infectious mononucleosis. Following recovery from the primary infection, cytotoxic memory CD8+ cells persist in the blood at a frequency of 0.2-2% of cytotoxic CD8+ T cells, which increases with age. Some individuals aged over 60 years can have up to 40% of their CD8+ T cells specific for EBV antigens, Virus evasion mechanisms “The virus has several strategies that help it to evade the immune system and in particular to avoid attack by CD8+T cells, These include the following. 1. EBVisable to ‘switch off’ expression of viral antigens by all B cells con- stituting the latent reservoir of FBV and thus removes the targets for CD8+ T cells. 2. ‘The envelope protein gp? is actively shed as a soluble truncated mol- ‘cule during lytic infection and binds directly to MLIC class I/peptide complexes and inhibits activation of CD T cells that are required for the generation of CD8+ cytolytic T cell. Figure 4. Diagrammatic representation (of virus-cell interactions and of virus- induced CD8+ T-cell responses in primary EBV infection, as seen in infectious mononucleosis patients, and inhealthy virus carriers, Red arrows denote transmission of virus; black arrows denote movement of cells (where the arrow is dotted, this reflects uncertainty as to the level of cell movernent via this route); broad shaded arrows denote effector Teel function. Adapted from the article‘Cellular Responses to Viral Infection in Humans: Lessons from Epstein-Barr Virus’ by Andrew D, Hislop, Graham S, Taylor, Delphine Sauce and Alan 8. Rickinson, Reprint permission kindly given by the Annual Review of immunology, Volume 25 © by Annual Reviews woannualreviews.org. Additional reprint permission given by the lead author, Alan BRickinson,120 CASE9 + EPSTEIN-BARR VIRUS 3. A late antigen, BCRFI (the viral homologue of I-10) secreted actively during the lytic cycle is also thought to inhibit cytolytic CD8+ T-cell generation by either driving the response into a CD4+ Th2 type of Fesponse, or activating regulatory T cells. It might also act by enhane- ing survival of newly infected B lymphocytes. Nevertheless the presence of the cytolytic CD8+ T-cell memory pool keeps the EBV-infected lymphocytes in control and itis only if the patient becomes immunosuppressed (leading to a reduction in the CD8+ T-cell pool) that these cells can begin to proliferate in an uncontrolled manner. ‘This can happen in patients who are immunosuppressed prior to and fol- owing transplantation (see below). 3.What is the typical clinical presentation and what complications can occur? ‘The majority of individuals infected with EBV do not show the clinical symptoms of infectious mononucleosis. However, around 98% of patients presenting with the disease have a triad of symptoms - pharyngitis, pyrexia, and enlargement of cervical lymph nodes and tonsils. Fatigue is common and may persist for months after the initial presentation. Myalgia is also common. Splenomegaly is frequent and some studies show an inci: dence of up to 100% in patients with infectious mononucleosis but usually resolving by 4 weeks after onset of symptoms. Splenic ruprure is @ rare but a potentially life-threatening complication. Other complications that are less common for these patients include encephalitis, upper airway obstruc tion (due to massive lymphoid hyperplasia of the tonsil) ~ tracheostomy may be required to relieve this, abdominal pain, and liver involvement including hepatomegaly and jaundice ~ although an increase in hepato- cellular enzymes is relatively common. Older patients are less likely to have sore throat and lymphadenopathy but more likely to have liver involvement. Platelet abnormalities are relatively common with patients having mild thrombocytopenia. Autoantibodies induced by EBV are believed to be the cause of the thrombocytopenia and in some cases this can develop into the more severe idiopathic thrombocytic purpura with hemorrhagic consequences. Aplastic anemia (pancytopenia) has also been described following EBV infection with a similar autoimmune etiol- ogy proposed. Rashes occur in about 5% of patients and may be macular, petechial, scar- latiniform, urticarial, or erythema multiforme. Also, 90-10% of patients with infectious mononucleosis who receive ampicillin develop a pruritic maculopapular rash usually 7-10 days after administration. ‘This ‘was seen in the patient described here (see Figure 1). Itis not caused by an allergy to penicillin but rather a transient hypersensitivity reaction, since ampicillin-binding antibodies have been detected in patients with infec- tious mononucleosis. Clinical consequences of EBV infection As already indicated, recovery is the norm after infectious mononucleosis. However, in addition to the complications already mentioned above, thereare a number of serious clinical consequences that can result from EBV infection, X-linked bymphoproliferative disease (XLPD) is a rare familial condition affecting young boys and characterized by extreme susceptibility to EBV infection. Primary infection results in a particularly severe form of infee~ tious mononucleosis with a large expansion of infected B cells and cells infiltrating the organs of the body, especially the liver. Patients with this condition have several abnormalities of the immune system including defects in NK cell activity, overactivity of ThI cells, and poor Th2 responses leading to overexpansion of CD8+ T cells and overproduction of Thl inflammatory eytokines and hence macrophage activation and hemophagocytosis. The primary defect has been mapped to a small cyto- plasmie protein, SAP, involved in NK and T lymphocyte signaling. In 60% of cases, the disease is fatal. Patients with XLPD generally dic of acute liver necrosis or multi-organ failure. Survivors are also at high risk of developing B-cell lymphoma, Cancers ncer is the uncontrolled proliferation of cells in the body. When EBV infects B cells they are induced to proliferate presumably to increase the amount of virus during primary infection but also increase the number of B cells that can harbor the latent virus. ‘The process that results in B-cell ‘transformation’ is mediated by some EBV proteins interfering with the control of the cell cycle. Persistent lack of cell cycle control and the result of additional unknown factors are believed to lead to ‘malignant transfor~ ‘mation’ resulting in a B-cell tumor. Burkitts ympboma (BL) is a malignant tumor associated with EBV. This is based on finding the EBV genome in tumor cells and the frequent associ- ation of this tumor with an elevated antibody titer against EBV VCA. It is endemic to central parts of Africa and New Guinea and has an annwal inci= dence of 6-7 cases per 100 000 and a peak incidence at 6 or 7 years of age. BL is most frequently found in the ‘lymphoma belt,’ a region extending from West to East Africa ‘The region is characterized by high temperature and humidity ideal for the malaria parasite, and is probably the reason why malaria was initially suspected to be associated with BL. In Uganda, the association of BL with EBV is very strong (97%), but is weaker outside the ‘lymphoma belt’ (85% in Algeria; only 10-15% in France and the USA). Other B-cell malignancies. EBN has also been associated with 50% of Hodgkin's lymphomas (HL) and causes 90% of lymphoproliferative disease in immunosuppressed transplant patients ~ post transplant lymphoprolifer ative disease (PTLD) — and sometimes in XLPD patients. EBV-associated B-cell lymphomas also occur in patients with AIDS. Non-B-cell malignancies ‘Nasopharyngeal cancer (NPC), 2 malignancy of epithelial cells, is relatively rare (less than 1 per 100000 in most populations) except in southern ina, where there is an annual incidence of more than 20 cases per 100 000. ‘There is also a high incidence in isolated northern populations such as Inuit and Greenlanders, while the incidence is moderate in North CASE9 + EPSTEIN-BARR VIRUS a122 CASE9 + EPSTEIN-BARR VIRUS “ @ Bas REED Be i pet Figure 5. Photomicrographs of peripheral blood films stained by the Giemsa method (x40; insets x100). (A) From a patient with infectious mononucleosis; numerous large atypical mononuclear cells are present (arrows and insets) in addition to the normal cell (8) From a normal individual showing four neutrophils (detail in let inset) and one lymphocyte (arrow and right inset) among amass ofred cells, Africa, Israel, Kuwait, the Sudan, and parts of Kenya and Uganda. ‘The rate of incidence generally inereases from ages 20 to around 50 and men are twice as likely to develop NPC as women. In the USA, Chinese Americans comprise the majority of NPC patients, together with workers exposed to fumes, smoke, and chemicals, implying a role for chemical car- cinogenesis. There appears to be an association between eating highly salted foods and the incidence of NPC. Genetic studies have indicated an HLA association, which may account for the higher disease incidence in Southern China, EBV is also thought to cause some T- and NK-cell lymphomas and other epithelial tumors such as gastric cancers (10%). 4. How is this disease diagnosed and what is the differential diagnosis? Diagnosis of infectious mononucleosis is made on presentation with pharyngitis, pyrexia, and cervical lymphadenopathy and is confirmed by Taboratory tests Hematological tests ‘The white blood cell count (WBC) is moderately raised by the second week and a blood film will contain ‘atypical lymphocytes’ Figure 5A). Figure 5B shows a normal blood film for comparison. The large atypical cells make up to 10-20% of the blood mononuclear cells (hence mononu- cleosis), are characterized by the presence of bean-shaped or lobulated nuclei, and may persist in the blood for several months. They are eytotoxic CDB8+ T cells, produced to control the EBV-induced B-cell proliferation. Hoagland’s criteria are most widely used for the diagnosis of infectious ‘mononucleosis. These are: at least 50% of the WBC being lymphocytes; at least 10% of them being atypical lymphocytes; the presence of fever, pharyngitis, and lymphadenopathy; and confirmed by a positive antibody test (see below). These criteria while quite specific are not extremely sen- sitive and only about half of the patients with infectious mononucleosis meet all of Hooagland’s criteria Antibody tests ‘Tests for heterophil antibodies are often used for diagnosis. In primary infection, some of the EBV-activated B cells are induced to differentiate into plasma cells. As a result of this polyclonal activation they secrete a variety of unrelated antibodies, including the so-called heterophil anti- Dodies and these form the basis of the Paul-Bunnell test. Heterophil anti- bodies (produced in 90% of patients with infectious mononucleosis) are able to agglutinate sheep, horse, or ox erythrocytes. The classic Monospot test uses horse erythrocytes and newer tests use heterophil antigens attached to latex beads. Heterophil antibodies are often absent in children, espe- cially under age 4. EBV-specific antibody tests may also be employed for the diagnosis of infectious mononucleosis (see Figure 3). The most useful ofthese antibody assays is that which detects IgM against the Epstein-Barr VCA. Anti-VCA of the TgM class develops early in the illness and declines rapidly over thefollowing 3 months. Enzyme immunoassays (ELISAs) can be used to quantitate IgM anti-VCA but detection is often by indirect immunofluo~ rescence assay using EBV-infected lymphoblastoid cell lines as the anti- genic substrate. Patients also seroconvert to IgG anti-VCA antibodies primary infection and these serum antibodies persist for life. Antibodies against EBNA are absent early in typical infectious mononucleosis but persist indefinitely thereafter. They may therefore be helpful in differenti- ating EBV reactivation from primary infection. Differential diagnosis Patients with streptococcal pharyngitis or one of several other viruses can present with sore throat, fatigue, and adenopathy. In the case presented here the doctor attempted treatment with ampicillin on the supposition of a streptococcal infection. Unfortunately the patient responded adversely to this antibiotic with a rash (see Section 3), This is an idiosyncratic response peculiar to infectious mononucleosis. Acute CMV infection, toxoplasmosis, and acute TIIV infection share many clinical and laboratory features of infectious mononucleosis, including splenomegaly, hepatomegaly. lymphocytosis, atypical lymphocytosis, and even (but rarely) false-positive results in the heterophil antibody test Distinguishing clinically between infectious mononucleosis caused. by EBV infection and an infectious mononucleosis-like syndrome caused by toxoplasmosis or CMV may not be possible, or perhaps not useful, since the management of these syndromes is the same. Iowever, diagnostic test- ing is needed in pregnant women because toxoplasmosis and CMV infec~ tions may cause congenital infection resulting in severe damage to the unborn child. If acute HIV infection is suspected, tests for antibody and viral nucleic acid should be performed. The differential diagnosis for sus- pected infectious mononucleosis is summarized in “Table 2 Diagnosis Key distinguishing features Streptococcal pharyngitis Absence of splenomegaly or hepatomegaly; fatigue less prominent. Other viral pharyngitis Patients are less likely to have (eg. adenoviruses, lymphadenopathy, tonsillar exudates, fever patients withenteroviruses) of absence of cough than streptococcal pharyngitis or infectious mononucleosis. Cytomegalovirus (CMV) Sore throatess severe, lymphadenopathy may be minimal or absent. Confirm by specific antibody tests. Toxoplasmosis Sore throat less severe; confirm by specific antibody tests Acute HIV infection Mucocutaneous lesions, rash, nausea, ‘vomiting, diarrhoea and weightloss. CASE9 + EPSTEIN-BARR VIRUS 12314 CASE9 + EPSTEIN-BARR VIRUS The differential diagnosis also includes leukemia/lymphoma although these would be less likely. 5. How is the disease managed and prevented? Management Usually there is no treatment given for infectious mononucleosis other than good supportive care, including adequate hydration and throat lozenges or sprays, or gargling with a 2% lidocaine (Xylocaine®) solution to relieve pha- ryngeal discomfort, Nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen are given for fever and myalgias; aspirin should not be given to children because it may cause Reye’s syndrome. Patients are recommended to rest and return to usual activities based on their energy levels. Although the exact period of increased risk is unknown, patients might also be advised to avoid contact sports or other activities that may lead to splenic rupture for a period of several weeks. Corticosteroids may be considered in patients with significant pharyn- geal edema that might cause or threaten respiratory compromise. Prevention There is currently no approved vaccine for EBV but one is eagerly awaited. It would be useful to protect adolescents and young adults against infectious mononucleosis. A vaccine could also be used to prevent primary infection in all age groups and hence presumably reduce the burden of EBV-associated eancers. It could be used in FBV seronegative individuals with XLPD, seronegative individuals receiving a seropositive transplant, those children at risk of BL. and individuals at risk of developing NPC, especially in southern China. ‘The principal target of EBV neutralizing antibodies is the major virus sur- face glycoprotein gp350 and several vaccine candidates based on this mol ecule have been developed. Live recombinant vaccinia virus vectors have been used to express the gp350 antigen and were found to confer protec- tion in primates and induce antibodies in EBV seronegative Chinese infants. Recent results (2007) from two double-blind randomized (phase I and phase I/II) trials using a recombinant subunit gp350 trial carried out on 148 healthy adult volunteers in Belgium showed that the vaccine formula: tions had a good safety profile, were immunogenic, and induced gp350- specific antibody responses including neutralizing antibodies, Clinical trials of an EBNA-3A peptide are being conducted in Australia,CASES + EPSTEIN-BARRVIRUS 125 SUMMARY 1. What is the causative agent, how does it enter the body and how does it spread a) within the body and b) from person to person? Epstein-Barr virus (also called human herpesvirus 4) is a gamma herpesvirus with linear dsDNA, an icosahedral capsid containing 162 capsomeres, which is approximately 100-110 nm in diameter. © During primary infection the virus probably infects pharyngeal squamous epithelial cells and undergoes a lytic cycle producing many more virions that directly infect B cells in transit through the tonsil, For entry into B cells, gp350 on the viral envelope binds to a complement receptor CD21 (CR2) on the surface of B cells. Another envelope glycoprotein, gp42, is responsible for the fusion between the virus envelope and the host cell ‘membrane. EBV causes proliferation of the B cells (B-cell transformation) resulting in lymphadenopathy at both cervical and other sites of the body and splenomegaly. ¢ Memory B cells maintain the latent EBV genome as an episome that expresses only part ofits genetic information. EBV virions are shed into the saliva at high level for several months after primary infection and spread of the infection is usually through intimate contact with an uninfected person. Spread of the virus in children is probably mainly through fingers and close contact. The majority of adults globally are infected with EBV (95-98%). In developing countries more children may become infected with the virus early in life. In developed countries around 50-70% of adolescents and young adults undergo primary infection with EBV but only about 30% develop the symptoms of infectious mononucleosis 2. What is the host response to the infection and what is the disease pathogenesis? In primary infection EBV antibodies are produced at different times as they are recognized by the immune system of the host. These include: carly antigens, FA; late antigens such as virus capsid antigens (VCA); and latency antigens including EBNAs and LMPs, IgM antibody to VCA is the first to appear followed by IgG. Antibodies to the latency antigens, for example EBNA, are seen later. «Cytotoxic CD8+ T cells are the main cells that control EBV infections. During the early response to the virus, up to 50% of the CD8+ T cells in the circulation can be specific for FBV antigens. ‘The symptoms of infectious mononucleosis are attributable to the activation of B cells through polyclonal activation and the intense immunological response to them mounted by CDB+ T cells «The cytotoxic T cells are able to control the primary infection but a few resistant B cells, containing the latent EBV enter a resting state as members of a long-lived memory cell pool Strategies that help EBV to evade the immune system include: ‘switching off’ the expression of viral antigens during latency; shedding of gp42, which binds to MHC class II/peptide complexes and inhibits CD4+T cell activity; late antigen BCRFI inhibits CD8 T-cell activity. 3. What is the typical clinical presentation and what complications can occur? «The majority of individuals infected with EBV do not show clinical symptoms of infectious mononucleosis. Nearly all patients with the disease have a triad of symptoms ~ pharyngitis, pyrexia, and cervical lymph node and tonsillar enlargement. © Older adults are less likely to have sore throat and adenopathy but more likely to have hepatitis and jaundice (9% of cases). Hepatocellular enzymes are mildly increased in 90% of infectious mononucleosis cases. Encephalitis coceurs rarely ‘Patients with X-linked Iymphoproliferative disease (XLPD), a rare familial condition affecting young boys, have extreme sensitivity to EBV. In 60% of cases, the disease is fatal resulting from macrophage activation, hemophagocytosis, and destruction ofall of the Iymphoid tissue. © Burkitt’s lymphoma (BL), a malignant tumor associated with EBY, is endemic to central parts126 CASES - EPSTEIN-BARR VIRUS of Africa and New Guinea, with an annual incidence of 6-7 cases per 100000 and a peak incidence at 6 or 7 years of age. In African ‘countries such as Uganda, in the lymphoma belt, the association of BL with EBV is very strong (97%), but is weaker elsewhere (85% in Algeria; only 10-15% in France and the USA). ‘© Nasopharyngeal cancer (NPC) is relatively rare (less than 1 per 100000 in most populations) ‘except in populations in southern China, where there is an annual incidence of more than 20 ceases per 100000. The rate of incidence generally increases from age 20 to around 50 and men are twice as likely to develop NPC as women. «EBV causes PTLD and has been shown to be associated with Hodgkin’s lymphoma (HL) as well as with some T- and NK-cel lymphomas and other epithelial tumors such as gastric iagnosed and what is the ‘¢ Diagnosis of infectious mononucleosis includes persistent pharyngitis with pyrexia and cervical Iymphadenopathy and confirmed by laboratory tests, ‘The white blood count is moderately raised and a blood film contains ‘atypical lymphocytes’ that ‘can make up to 10-20% of the blood mononuclear cells, These are the cytotoxic CD8+ Tcels. ‘¢ Tests for ‘heterophil antibodies’ such as the Paul- © EBV-specific IgM anti-VCA can be detected by ‘© Differential diagnosis includes: streptococcal 5. How is the disease managed and prevented? ‘© Usually no treatment is given other than good ‘© Adequate hydration is required; throat lozenges ‘¢ Nonsteroidal anti-inflammatory drugs are given ‘© Patients are recommended to rest and return to ‘* Corticosteroids may be considered in patients ‘© Vaccines targeting the membrane gp350 have Bunnell test or Monospot tests are positive. indirect immunofluorescence or ELISA. pharyngitis, several viruses inducing pharyngitis, acute CMV infection and toxoplasmosis, acute HIV infection. supportive care. or sprays, or gargling with a 2% lidocaine (Kylocaine®) solution to relieve pharyngeal discomfort. for fever and myalgias. usual activities based on their energy levels. with significant pharyngeal edema that might cause or threaten respiratory compromise. already been trialed (phase I and phase I) and shown to be safe and induce an antibody response including neutralizing antibodies. Vaccines against EBNA-3A are also being developed. Humphreys H, Irving WL. Problem-orientated Clinical Microbiology and Infection, 2nd edition. Onford University Press, Oxford, 2004 Knipe DM, Howley PM, Griffin DE, eta. Fields Virology, Sth edivon, Lippincos Willams and Wilkins, Philadelphia, 2007 ‘Mandell GL, Bennete JE, Dolin R, Mandells Pinepls and Practice of infections Diseases, th edition. Elsevier Health Sciences, Philaelphi, USA, 2005 Mims G, Dockrell HM, Goering RV, Roitt I, Wakelin D, Zuckerman M. Medical Microbiology, 3rd edition. Mosby, Edinburgh, 2004 Murphy K, Travers, and Walport M. Janeway’s Immunobiology, 7th edition, Garland Seience, New York, 2008, Richman DD, Whitley RJ, Hayden FG. Clinical Virology, 2nd edition, ASM Press, Washington, DC, 2002, ‘Zuckerman AJ, Banatvala JE, Pattison JR, Griffiths PD, Shaub BD. Principles and Practice of Clinical Virology, Sth edition, Wiley, 2004.CASES + EPSTEINBARRVIRUS 127 Cohen JL Medial progress: Epstein-Bar virus. N Engl) Med, 2000, 345 481-492, Lislop AD, ‘Taylor GS, Sauce D, Rickinson AB. Cellular responses to vial infection in humans: lessons from Epstein- Barr viru. Ann Rev Immunol, 2007, 25: 587-617, ‘Moutschen M, Leonard P, Sokai FM, etal. Phase V1 sues to ‘evaluate safety and immunogenicity of a recombinant gp350 [Epstein-Barr virus vaccine in healthy adults. Vaccine, 2007, 25 4697-4708, ‘Thorley-Lawson DA, Gross A. Persistence of the Epstein-Barr virus and the origins of associated Iymphomas. N Engl J Med, 2004, 350: 1328-1337. Williams 1, Crawford DIL. Epstein-Barr virus: the impact of si- entific advances on clinical practice. Blood, 2006, 107: 862-869, American Academy of Family Physicians, ‘American Family Physician’, October 1, 2004. Written by MIT Fhell, Athens, Georgia: herpi//worwaatp.org/afp/20041001/ 1279,hem ‘Australian Academy of Science, ‘Nova Science in the News,’ published November 1997: hupi//wwwscience.org.au/nova/ 026,026key.ium ‘Centers for Disease Control and Prevention (CDC), National Center of Infectious Diseases, 2008, United States Peblic Health Agency: hisp//www.ede gov/ncidod/diseases/ebv htm World Health Organization, Initiative for Vaccine Research, Copyright WHO 2008: http:/Avww.who inu/vaccine_research/ disezses/viral_cancersfen/indext html eTrex sued ‘The questions should be answered either by selecting True (T) or False (F) for each answer statement, or by scleeting the answer statements which best answer the ‘question. Answers can be found in the back of the book. 1. Which of the following are true of Epstei A. Tris an RNA virus, B, Ithas a helical capsid. . Te mainly infects T cell D. It isa zoonosis Barr E, It always causes infectious mononucleosis, 2. Which of the following diseases are associated with EBV? A. X-linked Iymphoproliferative disease. B, Graves’ disease, ©. Burkite’s lymphoma, D. Cervical cancer. E, Nasopharyngeal cancer. Which of the following laboratory tests would be helpful in the diagnosis of infectious mononucleosis? A. Pasl-Bunnell test. B, Monospot test. , Electron mieroscopy of pharyngeal cell seraping, D. Culture of the virus on fibroblasts E, Presence of serum IgM VCA antibodies. 4. What are the typical symptoms of a patient presenting with infectious mononucleosis? A. Pharyngitis, pyrexia, and cervical ymphadenopathy with tonsillar enlargement. 1B, Pharyngeal inflammation and transient palatal petechia. ©. Encephalitis, D, Osteomyelitis, E, Hepatitis and jaundice in young patienss, 5. How would you treat a patient with infectious mononucleosis? A. Just for symproms, B, With acyclovir, ©. Aspirin, D. Steroids E, Ampicilin.