Real-time Epstein-Barr virus PCR for the diagnosis of primary EBV infections and EBV reactivation

A Case of Epstein-Barr Virus Encephalitis and Orbital-Face Inflammation

Epstein-Barr virus (EBV) can cause follicular conjunctivitis, keratitis, oculoglandular syndrome, meningitis, and encephalitis. We report a 54-year-old Hispanic male who presented with right pupil-involved complete ophthalmoplegia, orbital and masticatory muscle inflammation, trigeminal enhancement, and new corneal infiltrate highly suggestive of EBV. Labwork was negative except for positive EBV polymerase chain reaction (PCR) in serum. Magnetic resonance imaging (MRI) of his brain and orbits with contrast showed enhancement of the right ganglion of the trigeminal nerve, oculomotor nerve, all extraocular muscles in the right orbit, and right masticatory and temporalis muscles and a right subacute lacunar infarct. The patient was diagnosed with encephalitis and orbital-face inflammation secondary to EBV infection. The patient improved with systemic steroids.

Epstein-Barr virus reactivation-related meningoencephalitis with transverse myelitis in pregnancy

Key Clinical Message

Consider the differential of Epstein-Barr virus (EBV) reactivation in pregnant women who develop progressive meningoencephalitis and transverse myelitis. EBV nucleic acid amplification should be considered in immunosuppressed patients.

Abstract

A 32-year-old G10P6M3K22 pregnant female presented to a regional hospital with progressive severe neurological and behavioral deficits. Magnetic resonance revealed cervical transverse myelitis. Lumbar puncture confirmed Epstein-Barr virus (EBV) DNA on a background of IgG-positive EBV serology. A diagnosis of EBV reactivation-related meningoencephalitis with transverse myelitis in pregnancy was concluded.

Is There an Association between Concurrent Epstein-Barr Virus Infection and Sudden Hearing Loss?-A Case-Control Study in an East Asian Population

Viral infection serves as the crucial etiology for the development of sudden sensorineural hearing loss (SSNHL). We aimed to investigate whether there is an association between concurrent Epstein-Barr virus (EBV) infection and SSNHL in an East Asian population. Patients who were older than 18 years of age and met the criteria of sudden hearing loss without an identifiable etiology were enrolled from July 2021 until June 2022, followed by the serological testing of IgA antibody responses against EBV-specific early antigen (EA) and viral capsid antigen (VCA) with an indirect hemagglutination assay (IHA) and real-time quantitative polymerase chain reaction (qPCR) of EBV DNA in serum before the treatment was initiated. After the treatment for SSNHL, post-treatment audiometry was performed to record the treatment response and degree of recovery. Among the 29 patients included during enrollment, 3 (10.3%) had a positive qPCR result for EBV. In addition, a trend of poor recovery of hearing thresholds was noted for those patients with a higher viral PCR titer. This is the first study to use real-time PCR to detect possible concurrent EBV infection in SSNHL. Our study demonstrated that approximately one-tenth of the enrolled SSNHL patients had evidence of concurrent EBV infection, as reflected by the positive qPCR test results, and a negative trend between hearing gain and the viral DNA PCR level was found within the affected cohort after steroid therapy. These findings indicate a possible role for EBV infection in East Asian patients with SSNHL. Further larger-scale research is needed to better understand the potential role and underlying mechanism of viral infection in the etiology of SSNHL.

Treatment for Epstein-Barr Virus-associated uveitis confirmed by polymerase chain reaction: Efficacy of Anti-Viral Agents and a literature review

BACKGROUND

There are still many research challenges and unanswered questions in relation to Epstein-Barr virus-associated uveitis. These include the presence of Epstein-Barr virus (EBV) DNA in asymptomatic patients, its pathogenicity in the uveitis eye, and the role of antiviral therapy for EBV-associated intraocular inflammation.

METHODS

This was a retrospective review of prospectively collected data from the Ophthalmology Department, Rajavithi Hospital between 2015 and 2020. A qualitative assay using multiplex real-time PCR was performed to detect pathogen genes from specimens obtained from a total of 344 patients. The main outcome measure was treatment success defined by clinical improvement and absence of viral DNA confirmed by PCR.

RESULTS

Of the 35 cases, 24 with complete data were enrolled in the study, including 22 with post-treatment PCR results. Sixty-seven percent were HIV-infected, and other plausible causes or coinfection with other pathogens were found in 75% of patients. Cytomegalovirus (38%) was the most common co-infecting pathogen. The most commonly employed regimen was a combination of systemic acyclovir and intravitreal ganciclovir injection (58%). Of the 22 cases who had post-treatment PCR results, absence of detection of the virus by PCR in the intraocular fluid after treatment was demonstrated in 73% of patients.

CONCLUSION

Patients with EBV infection can be simultaneously co-infected with other pathogens. Systemic acyclovir and ganciclovir achieved clinical improvement in most cases, and EBV infection was cured in the majority of patients.

Clinical laboratory investigation of a patient with an extremely high D-dimer level: A case report

BACKGROUND

D-dimer, a soluble degradation product of cross-linked fibrin, is commonly used as an important marker for the diagnosis of disseminated intravascular coagulation and differential diagnosis of thrombosis. Herein, we present a geriatric case with an unusually elevated D-dimer level.

CASE SUMMARY

An 82-year-old woman, admitted to the ward with a diagnosis of chronic heart failure, was noted to have a remarkably elevated D-dimer level, beyond the qualified range (> 100 mg/L), utilizing the Innovating D-dimer for Sysmex CS-5100 System™. However, no evidence, including clinical symptoms, radiographic evidence of thromboembolic disease, and parallel fibrinogen degradation product values, suggested that this patient was at high risk of thrombopenia. To confirm the discrepancy, a series of approaches including sample dilution, re-analysis via alternative methods, and sample treatment with blockage of specific heterophilic antibodies were performed. A remarkable disappearance of the elevated D-dimer values was observed in the samples after they were subjected to these approaches (4.49, 9.42, 9.06, and 12.58 mg/L, respectively). This confirmed the presence of heterophilic antibodies in this case. In addition, a reduction in cardiac output due to the presence of cardiac failure could also be responsible for the existence of a hypercoagulable state in this case.

CONCLUSION

In conclusion, the presence of heterophilic antibodies should be considered when an elevated D-dimer value is not in conformity with the clinical evidence, and a viral infection should be considered when interference by a heterophilic antibody exists.

Epidemiologic features of children with Epstein-Barr virus associated diseases in Hangzhou, China

Epstein-Barr virus (EBV) infection is the causative agent of multiple diseases. EBV DNA in blood is a useful diagnostic marker of primary EBV infection and reactivation. This study aimed to provide epidemiological information on children with EBV-associated diseases identified by positive EBV DNA in Hangzhou, a city in East China. All children admitted to the Children's Hospital of Zhejiang University School of Medicine from 2010 to 2015 with suspected EBV-related diseases and serum EBV DNA tested by quantitative real-time polymerase chain reaction were included. Of the 10 470 children, 1205 were determined to have positive EBV DNA, and the positive rate was 11.5%. 15.8% (973 of 6162) of the illnesses of patients aged 1 to 7 years were caused by EBV as compared to that of 6.6% (179 of 2708) of children older than 7 years (P < .01) and 3.3% (53 of 1600) of of that of infants <1 year of age (P < .01). Among positive EBV DNA patients, 80.7% of EBV infections occurred in children at the age stage of 1 to 7 years. IM was the most common EBV-related disease, accounting for 75.7% of 581 hospitalized patients. Children aged 1 to 3 years were the age group most commonly hospitalized with EBV-IM (32.7% of the cohort) and EBV-hemophagocytic lymphohistiocytosis (HLH) (52.6%), while EBV-lymphoma was more common in children over 9-year old (58.3% of the cohort). The serum EBV-DNA load was much higher in patients with EBV-HLH than in patients with IM (P < .05). This is a large sample study, which revealed the epidemiological characteristics of children with EBV-associated diseases, including age, monthly and disease distribution.

Facial nerve palsy secondary to Epstein-Barr virus infection of the middle ear in pediatric population may be more common than we think

BACKGROUND

Facial nerve palsy is a rare complication of acute otitis media (AOM). The general understanding is that this complication has a bacterial cause although bacteria can be isolated from the middle ear only in approximately two-thirds of cases of AOM. Detection of viral agents from specimens obtained during myringotomy in patients with AOM suggests a possible role of viruses in the etiology of this disease.

CASE PRESENTATIONS

We studied 5 otherwise healthy 17- to 27-month-old children who were referred to the Department of Otorhinolaryngology and Cervicofacial Surgery from December 2012 to January 2016 because of AOM and ipsilateral facial nerve palsy. In all cases, serological tests were indicative of a primary Epstein-Barr virus (EBV) infection and no other causative pathogens were identified during hospitalization. In one patient, the technique of in situ hybridization (ISH) detected EBV-specific ribonucleic acid (RNA) sequences within tissue sections obtained during mastoidectomy.

CONCLUSIONS

The aim of this article is to alert clinicians that AOM induced facial nerve palsy secondary to an acute EBV infection in the pediatric population is very likely more common than originally thought. To our knowledge until the present case series, only 2 cases of AOM induced facial nerve palsy secondary to an acute EBV infection have been reported and no cases of EBV infection proven by the ISH technique showing the presence of EBV-specific RNA sequences in patient's tissue biopsies have been reported until now.

The incidence of epstein-barr virus primary infection among suspected patients referred to namazi hospital of shiraz, iran

Background:

Many children become infected with Epstein-Barr virus (EBV) during their childhood. Since the clinical profile of EBV primary infection is challenging, it is important to use the best diagnostic clinical means. Detection of IgM against viral capsid antigen (VCA) by ELISA has been shown to be a reliable method.

Objectives:

This study was conducted to demonstrate the incidence of EBV primary infection, among suspected patients referred to Namazi hospital, Shiraz, Iran.

Patients and Methods:

The sample included 346 patients with an age range of 0 to 20 years (6.31 ± 4.66: 10.97 years). A volume of 5 mL of blood was collected from each case. The patients were divided to four age groups. The sera were tested for the presence of VCA-IgM by commercially available Anti-EBV-VCA ELISA kit.

Results:

The results indicated that 104 (30.0%) of the patients were EBV VCA IgM positive, with no significant difference in the incidence of EBV primary infection between males and females. However, the incidence of infection was significantly different between age group I (0 - 5 years) and III (11 - 15 years), and also between age group I (0 - 5 years) and IV (16 - 20 years) (P < 0.05).

Conclusions:

Considering the results, accurate and on time diagnosis of EBV primary infection in both children and adolescents will help prevent unnecessary hospitalization, medication and incorrect medical decisions. In addition, this will decrease further treatment costs and related medical procedures.

Epstein-Barr virus: dermatologic associations and implications: part I. Mucocutaneous manifestations of Epstein-Barr virus and nonmalignant disorders

Epstein-Barr virus (EBV) is a ubiquitous virus that has been implicated in a wide range of human diseases, many of which have mucocutaneous manifestations. As a member of the herpesviridae family, EBV causes lifelong infection by establishing latency in B lymphocytes. An intact immune response is critical in preventing progression of EBV disease, and the clinical manifestations of infection are dependent on the intricate relationship between virus and host immune system. This review provides a comprehensive overview of the epidemiology, pathophysiology, and diagnostic testing in EBV infection. In part I of this continuing medical education article, the mucocutaneous manifestations of EBV infection are reviewed with an emphasis on pathophysiology and management.

Duplex realtime PCR method for Epstein-Barr virus and human DNA quantification: its application for post-transplant lymphoproliferative disorders detection

INTRODUCTION

The quantification of circulating Epstein-Barr virus (EBV) DNA is used to monitor transplant patients as an early marker of Post-Transplant Lymphoproliferative Disorders (PTLD). So far no standardized methodology exists for such determination.

OBJECTIVE

Our purpose was to develop and validate a real-time PCR assay to quantify EBV DNA in clinical samples from transplant recipients.

METHODS

A duplex real-time PCR method was developed to amplify DNA from EBV and from a human gene. The EBV load was determined in peripheral blood mononuclear cells (PBMC), plasma and oropharyngeal tissue from 64 non-transplanted patients with lymphoid-hypertrophy (Non-Tx), 47 transplant recipients without PTLD (Tx), 54 recipients with PTLD (Tx-PTLD), and 66 blood donors (BD). WinPEPI, version 11.14 software was used for statistical analysis.

RESULTS

Analytical validation: the intra and inter-assays variation coefficients were less than 4.5% (EBV-reaction) and 3% (glyceraldehyde 3-phosphate dehydrogenase - GAPDH reaction). Linear ranges comprised 10(7)-10 EBV genome equivalents (gEq) (EBV-reaction) and 500,000-32 human gEq (GAPDH-reaction). The detection limit was 2.9 EBV gEq (EBV-reaction). Both reactions showed specificity. Application to clinical samples: higher levels of EBV were found in oropharyngeal tissue from transplanted groups with and without PTLD, compared to Non-Tx (p<0.05). The EBV load in PBMC from the groups of BD, Non-Tx, Tx and Tx-PTLD exhibited increasing levels (p<0.05). In BD, PBMC and plasma, EBV loads were undetectable.

CONCLUSIONS

The performance of the assay was suitable for the required clinical application. The assay may be useful to monitor EBV infection in transplant patients, in particular in laboratories from low-income regions that cannot afford to use commercial assays.

Sudden unexpected death due to hemophagocytic lymphohistiocytosis syndrome

The hemophagocytic lymphohistiocytosis (HLH) syndrome is a hyperimmune disorder characterized by lymphohistiocytic infiltrations, elevated cytokine levels in the blood, macrophage activation, and hemophagocytosis, frequently presenting with a febrile septic picture. This unusual disease is more common in infancy and childhood than adulthood. It is classified as primary or familial when a genetic defect is identified and secondary or acquired when triggered by certain infections, autoimmune disorders, or malignancies. If or when such patients expire, they typically do so within a hospital or under a physician's care and so such cases rarely come to the attention of forensic pathologists. We report on the unexpected deaths of two hospitalized adult cases of HLH brought to autopsy without a premortem diagnosis. Postmortem examination demonstrated marked hepatosplenomegaly and lymphadenopathy in association with hemophagocytosis. Although very uncommon HLH must be considered in infants, children, or adults who die unexpectedly with an undiagnosed septic presentation.

Serological diagnosis of Epstein-Barr virus infection: Problems and solutions

Serological tests for antibodies specific for Epstein-Barr virus (EBV) antigens are frequently used to define infection status and for the differential diagnosis of other pathogens responsible for mononucleosis syndrome. Using only three parameters [viral capsid antigen (VCA) IgG, VCA IgM and EBV nuclear antigen (EBNA)-1 IgG],it is normally possible to distinguish acute from past infection: the presence of VCA IgM and VCA IgG without EBNA-1 IgG indicates acute infection, whereas the presence of VCA IgG and EBNA-1 IgG without VCA IgM is typical of past infection. However, serological findings may sometimes be difficult to interpret as VCA IgG can be present without VCA IgM or EBNA-1 IgG in cases of acute or past infection, or all the three parameters may be detected simultaneously in the case of recent infection or during the course of reactivation. A profile of isolated EBNA-1 IgG may also create some doubts. In order to interpret these patterns correctly, it is necessary to determine IgG avidity, identify anti-EBV IgG and IgM antibodies by immunoblotting, and look for heterophile antibodies, anti-EA (D) antibodies or viral genome using molecular biology methods. These tests make it possible to define the status of the infection and solve any problems that may arise in routine laboratory practice.

Search for Anti-EA(D) Antibodies in Subjects with an "Isolated VCA IgG" Pattern

The presence of an “isolated viral capsid antigen (VCA) IgG” pattern in serum is not easy to interpret without the aid of further tests, such as specific immunoblotting or a virus genome search, that often give rise to organisational and economic problems. However, one alternative is to use an enzyme-linked immunosorbent assay (ELISA) to detect anti-early antigen (EA) antibodies, which can be found in about 85% of subjects with acute Epstein-Barr virus (EBV) infections. The purpose of this work was to search for anti-EA(D) antibodies in 130 samples with an isolated VCA IgG pattern at ELISA screening and classified as being indicative of past (102 cases) or acute (28 cases) infection on the basis of the immunoblotting results. Thirty-seven samples (28.5%) were positive for anti-EA(D), of which 25 (89.3%) had been classified by immunoblotting as indicating acute and 12 (11.8%) past EBV infection. This difference was statistically significant (P < .01). The results of our search for anti-EA(D) antibodies correctly identified nearly 90% of acute (presence) or past EBV infections (absence). When other tests are not available, the search for anti-EA antibodies may therefore be helpful in diagnosing patients with an isolated VCA IgG pattern at screening tests.

Reactivation of lymphocryptovirus (Epstein-Barr virus chimpanzee) and dominance in chimpanzees

Nine male chimpanzees originally reared in solitary cages were set up to form a group. Plasma viral load of the lymphocryptovirus (LCV) of chimpanzee [Epstein-Barr virus chimpanzee (EBVcmp)] was measured by real-time PCR. In the group formation (Form) period, the first-ranking male showed an imminent increase in plasma EBVcmp load compared with 1 week before (pre-Form) and 3 months after (post-Form) group formation. Other upper-ranking males such as the second-, third- and fourth-male also showed the highest level of viral load in the Form period. The kinetics of EBVcmp load in the Form period were statistically different from other periods (against pre-Form, t=-4.878, P<0.001; against post-Form, t=6.434, P<0.001). The effect of the male dominance rank did not differ between the pre-Form and post-Form periods (t=-1.557, P=0.12). Reactivation of LCV (EBV) as an immunological stress marker for humans might also be applied to chimpanzees.

Elevated Epstein-Barr virus loads and lower antibody titers in competitive athletes

Epstein-Barr virus (EBV) is a persisting herpesvirus which is controlled by the adaptive immune response after primary infection and maintained in a latent state. However, reactivation or persistent replication is observed in situations where the immune response is compromised. Since intensive physical training has been reported to diminish immune function, increased EBV load may be a cause of reduced performance and decreased ability to sustain high training loads in competitive athletes. Samples drawn from 209 athletes during their regular follow-up appointments were tested. One hundred sixty-five individuals of similar age not active in competitive sports served as case-controls. EBV load was quantified in peripheral blood leucocytes (PBLs) by real-time PCR, and EBV antibodies were detected in plasma by ELISA and immunoblot analysis. EBV DNA was detectable in 25 of 209 athletes and in 26 of 165 controls. Of note, the EBV load per 10(5) PBLs was 6.44 +/- 1.75 in the case and 1.67 +/- 0.44 copies in the controls, yielding a high significant difference (P < 0.0001). However, EBV-specific IgG titers were significantly lower in athletes (150.4 +/- 10.73 U ml(-1) vs. 241.6 +/- 18.59 U ml(-1)). As monitored by immunoblotting, primary infections were detected with low prevalence, three in the case group and one in the control group. These findings demonstrate that EBV is present at higher levels in athletes, but the antibody response is lower in athletes than in the controls. J. Med. Virol. 82:446-451, 2010. (c) 2010 Wiley-Liss, Inc.

The neuroanatomic localization of Epstein-Barr virus encephalitis may be a predictive factor for its clinical outcome: a case report and review of 100 cases in 28 reports

Encephalitis is one of the manifestations of infection with Epstein-Barr virus with clinical outcome varying from complete recovery to death. A 16-year-old boy with Epstein-Barr virus encephalitis with global cortical and subcortical gray matter involvement and a full clinical recovery is reported. The case inspired a literature review which yielded 100 cases of Epstein-Barr virus encephalitis subjected to radiological investigation and published in 28 reports. Cerebellum and basal ganglia were reported to be equally involved by Epstein-Barr virus infection, next to cerebral hemisphere. Patients with isolated hemispheric gray or white matter involvement were reported to achieve good recovery while almost half of the patients with thalamic involvement developed sequelae. The highest mortality rate was among patients with isolated brain stem involvement. In conclusion, neuroanatomic distribution of the radiological abnormalities in Epstein-Barr virus encephalitis may be useful as a prognostic marker.

Seroepidemiology of EBV and interpretation of the "isolated VCA IgG" pattern

The presence of VCA IgG in the absence of VCA IgM and EBNA-1 IgG antibodies makes classifying EBV infection more difficult as this serological picture can be seen in the case of past infection with EBNA-1 IgG loss or non-appearance, or acute infections with the early disappearance or delayed onset of VCA IgM. The aim of this study was to assess the prevalence of this pattern in 2,422 outpatients with suspected EBV infection examined in 2005-2006, and to interpret its significance by means of immunoblotting. One hundred and seventy-seven (7.3%) of the patients were VCA IgG-positive, VCA IgM-negative and EBNA-1 IgG-negative, 15 of whom (8.5%) presented with heterophile antibodies. Analysis by age class showed that the prevalence of isolated VCA IgG ranged from 4.5% in the subjects aged 1-10 years to 9% in those aged >60 years. Immunoblotting allowed 18.9% of the cases to be classified as acute and 81.1% as past infections, the latter being observed in about 37% of the patients aged less than 10 years and in 100% of those aged >30 years. Therefore, in our case series, the presence of isolated VCA IgG was associated usually with past infection, particularly among adults. In children aged less than 10 years, it was associated mainly with acute infection but as past infection may be present in about one-third of such children, this possibility should not be overlooked.

Mucocutaneous manifestations of Epstein-Barr virus infection

This review focuses on Epstein-Barr virus (EBV) infection, diagnosis, and current treatment, with emphasis on EBV-associated mucocutaneous manifestations in primary infections, acute EBV-associated syndromes, chronic infections, lymphoproliferative disorders, and lymphomas. In primary infection, EBV infects B cells and can cause mucocutaneous manifestations in infectious mononucleosis or acute EBV-associated syndromes such as Gianotti-Crosti syndrome and hemophagocytic syndrome. EBV then persists in the majority of humans generally without causing disease. In some cases, however, latent EBV infection may result in diseases such as hydroa vacciniforme, hypersensitivity to mosquito bites, and lymphoproliferative disorders such as plasmablastic lymphoma, oral hairy leukoplakia, and post-transplant lymphoproliferative disorders, particularly in immunocompromised patients. Latent EBV infection has also been implicated in a variety of malignant conditions such as Burkitt lymphoma, Hodgkin lymphoma, nasopharyngeal carcinoma, and Kikuchi histocytic necrotizing lymphadenitis. Since the immune system is critical in preventing the progression of EBV disease, the immunologic status of the patient plays a crucial role in the subsequent development of pathologies.

Laboratory assays for Epstein-Barr virus-related disease

Epstein-Barr virus (EBV) infects various cell types in a wide spectrum of benign and malignant diseases. Laboratory tests for EBV have improved and are increasingly used in diagnosis, prognosis, prediction, and prevention of diseases ranging from infectious mononucleosis to selected subtypes of lymphoma, sarcoma, and carcinoma. Indeed, the presence of EBV is among the most effective tumor markers supporting clinical management of cancer patients. In biopsies, localization of EBER transcripts by in situ hybridization remains the gold standard for identifying latent infection. Other RNA- and protein-based assays detect lytic viral replication and can distinguish carcinoma-derived from lymphocyte-derived EBV in saliva or nasopharyngeal brushings. Analysis of blood using EBV viral load and serology reflects disease status and risk of progression. This review summarizes prior research in the context of basic virologic principles to provide a rational strategy for applying and interpreting EBV tests in various clinical settings. Such assays have been incorporated into standard clinical practice in selected settings such as diagnosis of primary infection and management of patients with immune dysfunction or nasopharyngeal carcinoma. As novel therapies are developed that target virus-infected cells or overcome the adverse effects of infection, laboratory testing becomes even more critical for determining when intervention is appropriate and the extent to which it has succeeded.