Infectious Disease Compendium

Epstein Barr virus

(NEJM Review)


A herpes virus, human herpesvirus 4. There are two kinds of EBV: type 1 and 2.

Epidemiologic Risks

Kissing. And life. Live and you will get EBV, although at 10% will have no symptoms (PubMed). Type 2 is often transmitted sexually in young adults (PubMed). Occasional cases with transplant organs and transfusions.


1) Mononucleosis (exudative pharyngitis, lymphadenopathy, atypical lymphs, splenomegaly, hepatitis, cytopenias). More often from type 1 (PubMed).

EBV can affect any organ with encephalitis, hemolytic anemia and jaundice the most common. Monospot negative mononucleosis can be EBV (10% are monospot negative), cytomegalovirus, HHV 6, primary HIV, and toxoplasmosis.

Is Splenic Infarction, as the title suggests, An Under-recognized Complication of Infectious Mononucleosis? (PubMed). Who knows, but I suspect the authors underappreciate the (clustering illusion): "the tendency to erroneously consider the inevitable "streaks" or "clusters" arising in small samples from random distributions to be non-random."

2) Post transplant lymphoproliferative disorders (NEJM 2018 Review) (esp with HLA B51 (PubMed)) .

3) Lymphomas, especially Burkitt’s lymphoma and nasopharyngeal carcinoma

4) Maybe a role in interstitial cystitis (PubMed).


Anti virals do nothing (unless you have stock in the makers of acyclovir).

Consider steroids for impending airway obstruction from ginormous tonsils, severe thrombocytopenia, or hemolytic anemia. Maybe for central nervous system involvement, myocarditis, or pericarditis. But for uncomplicated mono steroids do nothing (PubMed).

For ill hospitalized patients metronidazole results in shortening of hospitalization by a day (PubMed). Given the issues of Fusobacterium and pharyngitis, perhaps there is an anaerobic superinfection component to the disease.


Has nothing to do with Chronic Fatigue Syndrome. 10% of mono will be monospot negative and it can take two weeks for the monospot to be positive.

And don't page me to interpret the EBV serology; no one can. Your ordered the serology, you figure out what it means (CDC Help).

Almost everyone placed on amoxicillin for mono will have a rash and it is probably more sensitive than a monospot. Unfortunately not true and based on information from the 1960's. A study from 2013 found "Fifty-seven (32.9%) of the subjects treated with antibiotics had a rash during their illness compared with 15 (23.1%) in untreated patients (P = .156; not significant). Amoxicillin was associated with the highest incidence of antibiotic-induced rash occurrence (29.5%, 95% confidence interval: 18.52–42.57), but significantly lower than the 90% rate reported for ampicillin in past studies (PubMed)."

Splenic rupture occurs most often three weeks after diagnosis, but has been seen up to 7 months.

"Given the rarity of splenic rupture after 3 weeks, a recent review has suggested that patients may consider a return to contact sports a minimum of 3 weeks after the onset of symptoms or once they are afebrile, after clinical symptoms and findings have resolved, or when they feel well enough to play. (NEJM)"

Curious Cases

Relevant links to my Medscape blog

EB Jeebies

Summer time is encephalopathy time

You figure it out


Last Update: 04/24/18.