Understanding Epstein-Barr Virus (EBV), Glandular Fever, and Mononucleosis

What is Epstein-Barr Virus (EBV)?

According to Professor Eftyxia Vardas, a clinical virologist at Lancet laboratories, “These viruses are all enveloped DNA viruses that have the characteristic of latency, which means once they cause the first infection, they can hide out in the person’s body after they recover from the first infection and may reactivate at a later stage to cause a secondary infection or reactivation.”  EBV belongs to a family in the Herpes virus group called the Gammaherpesvirinae that has the characteristic of being able to directly infect cells of the immune system, lymphocytes, or white blood cells, specifically B cells that are responsible for making protective antibodies in response to an infecting pathogen. 

Glandular fever and infectious mononucleosis are descriptive terms used to describe the clinical syndrome that includes fever, swollen glands in the neck (cervical lymph nodes), and exudative pharyngitis (sore throat). This syndrome occurs when a person gets a primary EBV infection, but it is not exclusively caused by EBV. The syndrome can also occur after infection with other viruses (like CMV) and some bacteria.

How is Epstein-Barr virus transmitted?

EBV is transmitted person to person through contact with saliva. That’s why it is called the ‘kissing disease’ because it occurs in adolescents and young adults that are kissing each other and exchanging saliva in the process. “Besides kissing, sharing drinks or eating utensils can also facilitate transmission. The virus infects epithelial cells in the oropharynx (the part of the throat at the back of the mouth) and subsequently infects B cells,” says Vardas.

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Clinical Presentation of Glandular Fever/Mononucleosis

Infectious mononucleosis, commonly caused by EBV, is characterised by a triad of symptoms:

1. Fever: Patients often experience a high fever, which can persist for several weeks.
2. Pharyngitis: This refers to a severe sore throat, often resembling strep throat.
3. Lymphadenopathy: swelling of the lymph nodes, particularly in the neck, is common.

Other symptoms can include fatigue, malaise, headache, muscle aches, and a rash. The incubation period for IM is typically 4-6 weeks, and the infection usually resolves within 2-4 weeks, although fatigue can linger for several months.

Who is Most at Risk?

Primary infection with EBV is worse as a person gets older. Young children may get primary EBV infection as they frequently exchange saliva on toys and on their hands with other toddlers of the same age, but the infection is usually mild and unnoticed. “Adolescents and young adults are most at risk and will get severe disease as they start kissing/exchanging saliva by sharing drinks, toothbrushes, and vapes,” says Vardas.

What are the potential complications?

While most cases of EBV infection are self-limiting and resolve without significant intervention, there are potential dangers and complications associated with the virus:

1. Splenic Rupture: Usually, the spleen of a person is also involved because there is a high concentration of B cells in it, and it becomes swollen and may be injured with minor trauma. This condition requires immediate medical attention and can be life-threatening.
2. Neurological Complications: EBV can occasionally lead to neurological complications such as meningitis, encephalitis, and Guillain-Barré syndrome.
3. Haematological Complications: In some cases, EBV can cause haematological issues such as haemolytic anaemia, thrombocytopenia (low platelet count), and neutropenia (low white blood cell count).
4. Chronic Active EBV Infection: A small number of individuals may develop chronic active EBV infection characterised by persistent symptoms and elevated EBV DNA levels. This condition can lead to severe organ damage and requires ongoing medical management.
5. Cancers: EBV has this characteristic of latency (like all viruses in the herpes virus group), but it also has a characteristic of transforming the cells that it infects into malignant cells. EBV is associated with several types of cancer, including Burkitt’s lymphoma, Hodgkin’s lymphoma, and nasopharyngeal carcinoma.

EBV and Pregnancy

Pregnant women infected with EBV face unique considerations. While primary EBV infection during pregnancy is relatively uncommon, it can pose risks to both the mother and the foetus. Potential complications during pregnancy include:

• Maternal Health: Pregnant women with EBV infection can experience severe symptoms of IM, which can lead to complications such as dehydration, severe throat pain, and secondary bacterial infections.
• Foetal Health: There is limited evidence to suggest that primary EBV infection during pregnancy can lead to adverse foetal outcomes such as low birth weight, prematurity, or congenital abnormalities. However, the overall risk appears to be low.
• Vertical Transmission: EBV is not typically transmitted from mother to foetus, and congenital infection is rare. However, newborns can acquire the virus through exposure to infected blood or secretions during delivery.

Diagnosis and Testing

The diagnosis of glandular fever/mononucleosis primarily involves clinical assessment and laboratory tests. “The most common laboratory abnormality with infectious mononucleosis is a high white cell count (leucocytosis) on a full blood count. What is also frequently identified under the microscope is abnormal white cells that are transiently present (so-called atypical lymphocytes),” says Vardas.

There is a blood test that looks for special antibodies that occur with EBV infection called heterophile antibodies. These tests are called Monospot or Paul Bunell tests, but they are nonspecific, and heterophile antibodies can be found in other infections, so not only EBV.

The best blood test is for specific EBV antibodies; serology for EBV VCA IgM is diagnostic for EBV infection in the absence of another EBV-specific antibody, the NA (nuclear antigen).

Treatment and management for mononucleosis

Currently, there is no specific treatment for infectious mononucleosis. Management primarily involves supportive care.

1. Rest: Adequate rest is crucial for recovery, especially during the acute phase of the illness.
2. Hydration: Maintaining proper hydration helps alleviate symptoms such as fever and sore throat.
3. Pain Relief: Over-the-counter medications like acetaminophen or ibuprofen can help manage fever and pain.
4. Avoiding Physical Activity: Due to the risk of splenic rupture, individuals with splenomegaly should avoid contact sports and heavy lifting.

Prevention

Preventing EBV infection can be challenging due to its widespread nature and modes of transmission. However, certain measures can reduce the risk:

1. Avoiding Close Contact: Minimising close contact with individuals who have active symptoms of IM can reduce the risk of transmission.
2. Good hygiene practices: regular handwashing and avoiding sharing personal items like utensils and toothbrushes can help prevent the spread of the virus.

“There is no preventative vaccine and no specific treatment for EBV infection. Regarding kissing people, it is not possible to tell when someone is shedding EBV in their saliva,’ says Vardas.

In conclusion, Epstein-Barr virus is a prevalent and often benign virus that causes infectious mononucleosis. While most individuals recover fully with supportive care, EBV can lead to significant complications in certain cases, including splenic rupture, neurological issues, and an association with certain cancers. Pregnant women need to be particularly cautious, although the overall risk to the foetus is low. Understanding EBV, its transmission, symptoms, and management is crucial for mitigating its impact and ensuring a healthy recovery.

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