Epstein-Barr Virus - EBV

Epstein-Barr virus (EBV) is the cause of a variety of disorders, including infectious mononucleosis (IM). Laboratory testing can help determine whether someone is susceptible to EBV infection or has a recent or past infection.

  • Diagnosis
  • Monitoring
  • Background
  • Lab Tests
  • References
  • Related Topics

Indications for Testing

  • Acute persistent pharyngitis and lymphadenopathy with negative strep testing

Laboratory Testing

  • Epstein-Barr Virus (EBV) diagnosis and testing information (CDC, 2016)
  • CBC with differential – elevated white blood cells with atypical lymphocytes in acute infectious mononucleosis (IM)
  • Rapid strep test and/or culture – negative
  • Positive heterophile antibody (IgM antibodies not specific for EBV) – point-of-care testing (eg, Monospot)
    • Preferred initial serologic test to detect acute EBV IM
    • Heterophile test is often negative in children <5 years; misses 50-70% of cases
    • Antibodies develop after about day 5 of illness; do not test before 4-5 days
  • Serology
    • Diagnosis of acute disease due to EBV depends mostly on testing for an immune response to the virus
    • Immune response during acute infection may be significantly delayed, especially in children and immunocompromised hosts
    • Extensive workup appropriate in markedly febrile patient with enlarged nodes and for whom prior testing was negative
    • Initial antibody testing should include EBV anti-viral capsid antigen (VCA) IgM and IgG
    • Interpretation of Serologic Results

      Infection

      VCA IgM

      VCA IgG

      EAa

      EBNAa

      No previous

      -

      -

      -

      -

      Acute

      +

      +

      ±

      -

      Recent

      ±

      +

      ±

      ±

      Past

      -

      +

      -

      +

      Reactivationb

      ±

      +

      +

      +

      aEA = D early antigen; EBNA = Epstein Barr nuclear antigen

      bAntibody to the early antigen in the presence of a positive EBNA does not automatically indicate that a patient's current medical condition is caused by EBV reactivation. Healthy individuals with no symptoms can have antibodies to early antigen for years after initial EBV infection. Reactivation can occur subclinically.

      Morrison BJ, Labo N, Miley WJ, Whitby D. Serodiagnosis for tumor viruses Semin Oncol. 2015; 42(2): 191-206. PubMed

    • If testing is negative for EBV, consider serologies for cytomegalovirus (CMV) IgM, human herpesvirus 6 (HHV6) IgM, and HIV testing
  • PCR, ELISA, probe testing – usually reserved for immunocompromised patients or those with EBV-related tumors
    • EBV viral load (quantitative PCR) is used in routine monitoring for transplant patients for posttransplant lymphoproliferative disorder
    • Standard of care for diagnosing EBV infection in cerebrospinal fluid (CSF) – PCR

Histology

  • Evaluation of formalin-fixed, paraffin-embedded (FFPE) tissue may be used for virus identification of EBV
  • Immunohistochemistry – stains for EBV latent membrane protein

Differential Diagnosis

  • Epstein-Barr virus (EBV) quantitative viral load testing may be indicated in transplant patients who develop primary mononucleosis or in new transplant patients
    • Inability to clear viral load after primary mononucleosis may be surrogate for posttransplant lymphoproliferative disorder (PTLD)
    • Increasing titers may signal reason to decrease immunosuppressive therapy to abort PTLD

Epidemiology

  • Age – usually <21 years for IM
    • 50% seropositive <5 years
  • Transmission – salivary contact

Organism

  • Gamma herpesvirus that belongs to the Herpesviridae family
  • Like other herpes viruses, may remain dormant for years as a latent infection
    • Infects B lymphocytes, which can then be reactivated

Clinical Presentation

  • Disorders associated with EBV (Taylor, 2015)
    • Infectious mononucleosis
    • Chronic active EBV infection
      • Children
      • Predominantly Asia, native people of Central and South America
      • Often progresses to life-threatening hemophagocytic syndrome
    • Endemic Burkitt lymphoma
      • Primarily in Africa; less common in developed countries
      • High grade B-cell lymphoma
      • >80% of nonendemic Burkitt lymphomas are EBV-negative
    • Nasopharyngeal carcinoma (endemic in China)
      • Malignant nasopharyngeal tumor of the squamous epithelium
    • Other cancers
      • EBV-associated Hodgkin lymphoma (mixed cellularity subtypes)
      • Tonsillar carcinoma
      • T/NK-cell lymphomas (especially sinonasal NK-cell lymphomas)
      • B-cell lymphoma of the elderly (diffuse large B cell)
      • Gastric carcinoma
    • X-linked lymphoproliferative syndrome (Duncan disease)
      • Often results in fatal, polyclonal B-cell proliferation
    • Progressive lymphoproliferative diseases
      • Children with primary immunodeficiencies
      • Posttransplant B-cell lymphoproliferative disorders (PTLD)
      • Immunosuppressed or AIDS patients (eg, Burkitt, diffuse large B cell)
      • Smooth muscle sarcoma
    • No good evidence to implicate EBV in chronic fatigue syndrome
    • Evidence to suggest temporal relationship with multiple sclerosis
  • Primary infection most often manifests as IM
    • IM usually self-limiting and characterized by the following
      • Fever
      • Sore throat
      • Myalgias
      • Lymphadenopathy
        • Cervical site most common
      • Hepatosplenomegaly
    • Other serious symptoms may occur in extremes of age and among immunocompromised patients
Tests generally appear in the order most useful for common clinical situations. Click on number for test-specific information in the ARUP Laboratory Test Directory.

Heterophile Antibody (Infectious Mononucleosis) by Latex Agglutination, Qualitative 0050385
Method: Qualitative Latex Agglutination

Epstein-Barr Virus Antibody Panel I 0050600
Method: Semi-Quantitative Chemiluminescent Immunoassay

Epstein-Barr Virus Antibody to Viral Capsid Antigen, IgM 0050240
Method: Semi-Quantitative Chemiluminescent Immunoassay

Limitations 

EBV IgM values obtained with different manufacturers' assay methods may not be used interchangeably

The magnitude of the reported EBV IgM level cannot be correlated to an endpoint titer

Follow-up 

Repeat testing in 10-14 days may be helpful if results are equivocal

Epstein-Barr Virus Antibody to Viral Capsid Antigen, IgG 0050235
Method: Semi-Quantitative Chemiluminescent Immunoassay

Limitations 

EBV IgG values obtained with different manufacturers' assay methods may not be used interchangeably

The magnitude of the reported EBV IgG level cannot be correlated to an endpoint titer

Follow-up 

Repeat testing in 10-14 days may be helpful if results are equivocal

Epstein-Barr Virus Antibody to Nuclear Antigen, IgG 0050245
Method: Semi-Quantitative Chemiluminescent Immunoassay

Limitations 

EBNA values obtained with different manufacturers' assay methods may not be used interchangeably

The magnitude of the reported EBNA level cannot be correlated to an endpoint titer

Follow-up 

Repeat testing in 10-14 days may be helpful if results are equivocal

Epstein-Barr Virus Antibody to Early D Antigen (EA-D), IgG 0050225
Method: Semi-Quantitative Chemiluminescent Immunoassay

Limitations 

EBV EA-D values obtained with different manufacturers' assay methods may not be used interchangeably

The magnitude of the reported EBV EA-D level cannot be correlated to an endpoint titer

Follow-up 

Repeat testing in 10-14 days may be helpful if results are equivocal

Epstein-Barr Virus by PCR 0050246
Method: Qualitative Polymerase Chain Reaction

Epstein-Barr Virus by Quantitative PCR 0051352
Method: Quantitative Polymerase Chain Reaction

Limitations 

The limit of quantification for this DNA assay is 2.6 log copies/mL (390 copies/mL); if the assay DID NOT DETECT the virus, the test result will be reported as “<2.6 log copies/mL (<390 copies/mL)”

If the assay DETECTED the presence of the virus but was not able to accurately quantify the number of copies, the test result will be reported as “Not Quantified"

Inhibition may also lead to underestimation of viral quantitation

Epstein-Barr Virus (EBV) by in situ Hybridization, Paraffin 2002902
Method: In situ Hybridization

Epstein-Barr Virus (EBV) by In Situ Hybridization, Stain Only 2013592
Method: In Situ Hybridization

Guidelines

Parker A, Bowles K, Bradley A, Emery V, Featherstone C, Gupte G, Marcus R, Parameshwar J, Ramsay A, Newstead C, Haemato-oncology Task Force of the British Committee for Standards in Haematology and British Transplantation Society. Diagnosis of post-transplant lymphoproliferative disorder in solid organ transplant recipients - BCSH and BTS Guidelines. Br J Haematol. 2010; 149(5): 675-92. PubMed

General References

Auerbach A, Aguilera NS. Epstein-Barr virus (EBV)-associated lymphoid lesions of the head and neck. Semin Diagn Pathol. 2015; 32(1): 12-22. PubMed

Brady G, MacArthur GJ, Farrell PJ. Epstein-Barr virus and Burkitt lymphoma. J Clin Pathol. 2007; 60(12): 1397-402. PubMed

Gulley ML, Tang W. Laboratory assays for Epstein-Barr virus-related disease. J Mol Diagn. 2008; 10(4): 279-92. PubMed

Gulley ML, Tang W. Using Epstein-Barr viral load assays to diagnose, monitor, and prevent posttransplant lymphoproliferative disorder. Clin Microbiol Rev. 2010; 23(2): 350-66. PubMed

Lennon P, Crotty M, Fenton JE. Infectious mononucleosis. BMJ. 2015; 350: h1825. PubMed

Luzuriaga K, Sullivan JL. Infectious mononucleosis. N Engl J Med. 2010; 362(21): 1993-2000. PubMed

Morrison BJ, Labo N, Miley WJ, Whitby D. Serodiagnosis for tumor viruses. Semin Oncol. 2015; 42(2): 191-206. PubMed

Taylor GS, Long HM, Brooks JM, Rickinson AB, Hislop AD. The immunology of Epstein-Barr virus-induced disease. Annu Rev Immunol. 2015; 33: 787-821. PubMed

References from the ARUP Institute for Clinical and Experimental Pathology®

Gross TG, Orjuela MA, Perkins SL, Park JR, Lynch JC, Cairo MS, Smith LM, Hayashi RJ. Low-dose chemotherapy and rituximab for posttransplant lymphoproliferative disease (PTLD): a Children's Oncology Group Report. Am J Transplant. 2012; 12(11): 3069-75. PubMed

Hayden RT, Hokanson KM, Pounds SB, Bankowski MJ, Belzer SW, Carr J, Diorio D, Forman MS, Joshi Y, Hillyard D, Hodinka RL, Nikiforova MN, Romain CA, Stevenson J, Valsamakis A, Balfour HH, U.S. EBV Working Group. Multicenter comparison of different real-time PCR assays for quantitative detection of Epstein-Barr virus. J Clin Microbiol. 2008; 46(1): 157-63. PubMed

Martins TB, Litwin CM, Hill HR. Evaluation of a multiplex fluorescent microsphere immunoassay for the determination of epstein-barr virus serologic status. Am J Clin Pathol. 2008; 129(1): 34-41. PubMed

Salama ME, Perkins SL, Mariappan R. Images in HIV/AIDS. Primary bone marrow presentation of Epstein-Barr virus-driven HIV-associated Hodgkin lymphoma. AIDS Read. 2007; 17(12): 604-5. PubMed

She RC, Stevenson J, Phansalkar AR, Hillyard DR, Litwin CM, Petti CA. Limitations of polymerase chain reaction testing for diagnosing acute Epstein-Barr virus infections. Diagn Microbiol Infect Dis. 2007; 58(3): 333-5. PubMed

Medical Reviewers

Last Update: November 2017