Clinical characteristics and laboratory findings in Danish children hospitalized with primary Epstein-Barr virus infection

Investigating the correlation between prominent viruses and hematological malignancies: a literature review

Extensive research has been conducted on the correlation between viral infections and hematological cancers ever since the identification of the Rous Sarcoma Virus as a cancer-causing agent. Numerous viruses, such as the Epstein-Barr virus, hepatitis B virus, hepatitis C virus, human immunodeficiency virus, human T-lymphotropic virus 1, and severe acute respiratory syndrome-related coronavirus 2, have been identified as potential contributors to the development and progression of cancer by disrupting normal cellular processes. Different viruses are associated with distinct forms of blood cancers, each exhibiting unique infection mechanisms, pathogenesis, and clinical symptoms. Understanding these connections is crucial for the development of effective prevention and treatment strategies. Healthcare professionals who possess a solid understanding of these associations can offer precise treatments and closely monitor potential complications in individuals with blood cancers and viral infections. By leveraging this information, healthcare providers can optimize patient care and improve outcomes for those affected by both viral infections and hematological cancers.

Could Herpesviridae be the cause of severe acute hepatitis of unknown origin in children?

INTRODUCTION

Severe acute hepatitis (SAH) is defined by a severe inflammation of hepatocytes in the liver parenchyma which can lead to an acute liver failure, a clinical condition with high mortality rate that can be triggered by several factors but is usually associated to hepatotropic viruses' infection. In 2022, cases of children with severe acute hepatitis of unknown origin hospitalized in Glasgow, Scotland, were reported. Possible causes of this condition include, but are not limited to, undiagnosed viral (and non-viral) infections, autoimmune hepatitis, drug and/or chemical toxicity, mitochondrial chain respiratory and metabolic disorders.

AREAS COVERED

Herpesviruses can cause severe acute hepatitis, but little is known about the role and the mechanisms of herpesviruses as a causative agent of this type of hepatitis. We review the role of herpesviruses as causative agent of SAH in children and other possible mechanisms involved in this disease.

EXPERT OPINION

Differential diagnosis for herpesvirus in SAH should be implemented in all settings. Alternative fluids, such as saliva and dried blood, could be used in the diagnosis to overwhelm the availability of biological specimens at sufficient volume. In the future, genetic studies could also be added to increase the knowledge about severe acute hepatitis in children.

Comparison of immune responses in children with infectious mononucleosis caused by Epstein-Barr virus at different infection stages

INTRODUCTION

Infectious mononucleosis (IM) is a common infectious disease in children mainly caused by Epstein-Barr virus (EBV) infection, followed by abnormal immune response, and resulting in serious complications. However, there are few clinical analyses of immune responses in children with IM at different stages.

METHODS

This study combined EBV serological test and EBV DNA test to diagnose the infection status of children with IM, and the infection status was divided into primary acute IM infection (AIM), primary late IM infection (LIM) and reactivation IM infection (RIM).

RESULTS

The results revealed that the absolute numbers of leukocytes and CD8+ T lymphocytes in primary IM infection were significantly higher than those in reactivation infection, while the frequencies of CD4+ T lymphocytes and B cells were significantly lower than those in reactivation infection. In addition, the activities of ALT, AST, α-HBDH and LDH in liver function indicators in primary infection were significantly increased compared with reactivation infection. Similarly, the EBV DNA levels of the primary infection were significantly higher than that of the reactivation infection.

CONCLUSION

There are differences in immune response at different stages of infection, which can provide guidance for effective treatment in children with IM infection.

Grade III Splenic Laceration After a Ground-Level Fall in a Pediatric Patient: The Need for Return-to-Play/Activities Protocols for Individuals With Splenic Injury or Splenomegaly

Splenic injury is a potentially fatal injury if left undetected or untreated. Although most splenic injuries result from a traumatic event, it is important to consider if one's history (past or present) increases their risk for splenic injury (i.e., splenomegaly). We present a case regarding a school-age child who presented to the Emergency Department (ED) with abdominal pain following a ground-level fall onto a carpeted stair step. Prior to this injury, the patient had cold-like symptoms for 3 months that were treated solely with supportive care by their pediatrician(s). A transferring hospital's abdominal CT imaging revealed a grade III splenic laceration. The patient was monitored in the pediatric intensive care unit (PICU) by way of serial abdominal examinations, vitals, and labs. When the patient was cleared for discharge, it was recommended to refrain from strenuous activity for 1-2 months due to the risk of repeat splenic injury. Post-discharge, the patient's Epstein-Barr virus (EBV) serology returned and was consistent with a past infection which was an inconclusive finding. Although trauma is most commonly the culprit of splenic injuries, it is important to keep differentials broad when considering causes of splenomegaly as this may allow healthcare providers to potentially prevent injury/provide appropriate management post-injury and guide return-to-play recommendations.

Infectious mononucleosis in children and differences in biomarker levels and other features between disease caused by Epstein-Barr virus and other pathogens: a single-center retrospective study in China

Background

Infectious mononucleosis (IM) is a common viral infection that typically presents with fever, pharyngitis and cervical lymphadenopathy. Our aim was to identify the different pathogens causing IM in children admitted to our hospital and to analyze the differences in features of infection with different organisms.

Methods

We retrospectively analyzed the data of children aged 0-17 years admitted to Wuhan Children's Hospital during 2013-2022 with IM. We compared symptoms, physical findings, blood counts, and serum biomarkers between patients with IM due to Epstein-Barr virus (EBV) and IM due to other pathogens.

Results

Among 1480 enrolled children, 1253 (84.66%) had EBV infection, 806 (54.46%) had M. pneumoniae infection, 796 (53.78%) had cytomegalovirus infection, 159 (10.74%) had parvovirus infection, 38 (2.57%) had influenza virus infection, and 25 (1.69%) had adenovirus infection. Receiver operating characteristic curves were used to determine the area under the curve for alanine transaminase (ALT), aspartate transaminase (AST), Alkaline phosphatase (ALP), total bilirubin (TBil), indirect bilirubin (IBil) levels to assess liver damage, and for creatine kinase (CK), CK-MB, and lactate dehydrogenase (LDH) levels to assess myocardial damage. The optimal cutoff values of these biomarkers were then determined. In multivariate analysis, elevated ALT, AST, ALP, TBil, and IBil were independently associated with liver damage, and age <3 years, CK, CK-MB, and LDH with myocardial damage.

Conclusion

Evaluation of biomarkers and pathogen detection may help physicians to take preventive actions to avoid serious complications in children with infectious mononucleosis.

The utility of liver function tests and abdominal ultrasound in infectious mononucleosis - A systematic review

INTRODUCTION

A large proportion of patients with infectious mononucleosis (IM) have abnormal liver function tests (LFT) at presentation. There is no guideline regarding the management and follow-up of these patients. Some patients also have abdominal ultrasound due to deranged LFT, the need for this practice is unclear. The aim of this systematic review was to evaluate the evidence base on LFT assessment in IM, time to resolution of derangement, and the role of abdominal ultrasound (US).

METHODS

A systematic search of PubMed, EMBASE and the Cochrane library was done. Two authors independently screened records for eligibility using pre-defined criteria. We included both adult and paediatric populations. Quality assessment of included studies was done.

RESULTS

A total of 3924 patients were included from 32 studies, of which LFT values were reported on 2779 patients. A combination of typical clinical features, heterophile antibodies and EBV-specific antibodies were used to ascertain diagnosis. The following proportion of patients had abnormal LFTs: AST (57%); ALT (62%); ALP (65%); Bilirubin (16%); GGT (41%). Reported median (i.q.r.) time to resolution of LFT was 8 (6-12) weeks (n = 438). Maximum time to resolution was >6 months. Clinical hepatomegaly and splenomegaly were found in 35% and 44% of patients respectively. Enlarged liver and spleen on US were seen in 16/29 and 38/38 of patients respectively. There were no reports of decompensated liver disease.

CONCLUSION

Current evidence questions the need for routine assessment of LFTs in immunocompetent patients presenting with IM; serial LFT assessments following initial abnormalities are not required in immunocompetent patients with subclinical derangement of LFTs; routine US abdomen in IM to evaluate for derangement of LFTs is not required.

A combined antibody and DNA assay for EBV infection in children

OBJECTIVE

This paper studied the Epstein-Barr virus (EBV) infection status and influencing factors among children using a combined detection of specific antibodies and DNA.

METHODS

We retrospectively analyzed children who visited the Affiliated Hospital of Hangzhou Normal University from January 2019 to December 2020, and correlations between the social environment and clinical data were analyzed.

RESULTS

The cumulative positive rates of specific antibody, DNA, and combined detection of EBV were 52.4%, 39.5%, and 54.0% (P = 0.001), respectively. The current infection rate was 15.7%, and the peak of infection occurred in the preschool group (P = 0.021). After adjusting for confounding factors, the number of siblings (OR = 1.550) and family members who smoke (OR = 1.524) were independent risk factors for EBV infection, whereas parents with a higher education level (OR = 0.493, OR = 0.316), longer breastfeeding time (OR = 0.578) and dedicated tableware (OR = 0.573) were independent protective factors.

CONCLUSION

A combination of antibody and DNA tests may be beneficial for the diagnosis of EBV infection. The EBV infection rate in children at our hospital was lower than the national average. Furthermore, the infection rate is closely related to the number of siblings, regardless of whether family members smoke, the status of parents' education, breastfeeding duration, and meal patterns. Overall, prevention measures should focus on the preschoolers.

Clinical characteristics and effectiveness of antiviral agents in hospitalized children with infectious mononucleosis in China: A multicenter retrospective study

IMPORTANCE

The clinical characteristics of infectious mononucleosis (IM) in Chinese children have not been evaluated in multicenter studies, and the effectiveness of antiviral treatment are controversial.

OBJECTIVE

To investigate the clinical characteristics of Chinese children with IM and current status of antiviral therapy for affected patients.

METHODS

Hospitalized patients with IM were enrolled between 2018 and 2020 in five children's hospitals in China. The clinical characteristics were compared among four age groups: <3 years, 3-<6 years, 6-<10 years, and ≥10 years. The clinical characteristics of IM and effectiveness of antiviral therapy were compared among patients receiving acyclovir (ACV), ganciclovir (GCV), and no antiviral therapy (i.e., non-antiviral group).

RESULTS

In total, 499 patients were analyzed; most patients were 3-<6 years of age. The most common symptoms and signs included fever (100%), lymphadenopathy (98.6%), pharyngitis (86.4%), eyelid edema (76.8%), and snoring (72.9%). There were significant differences in rash, hepatomegaly, and liver dysfunction among the four age groups. Patients aged < 3 years had a lower incidence of liver dysfunction and a higher incidence of rash. Among the 499 patients, 50.1% were treated with GCV, 26.3% were treated with ACV, and 23.6% received no antiviral therapy. Compared with the non-antiviral group, patients in the ACV and GCV groups had longer durations of fever (P < 0.001). There were no significant differences in the incidences of complications among the three treatment groups.

INTERPRETATION

The incidence of IM in Chinese children peaked at 3-<6 years of age. Clinical features of IM varied according to age. Patients receiving antiviral therapy exhibited more serious clinical manifestations than did patients without antiviral therapy. The effectiveness of antiviral therapy for IM requires further analysis.

Mindray BC-6800 haematological analyser: 3D-DIFF scattergram usefulness in infectious mononucleosis diagnosis

INTRODUCTION

3D-DIFF scattergram of the Mindray BC-6800 haematological analyser shows morphological abnormalities and lymphocyte cluster splitting related to the presence of reactive lymphocytes. This study aims to assess whether these cytographic changes are useful in detecting both activated and apoptotic lymphocytes, leading to an improvement in the laboratory diagnostic process of infectious mononucleosis.

METHODS

Two hundred three samples with modified shape and doubled lymphocyte cluster of DIFF scattergram (study group) were divided into two different subgroups: with and, respectively, without serological evidence of ongoing IM. Activated and apoptotic cells in peripheral blood were counted by light microscopy or gating in the instrumental dot plots. Values of apoptotic cells counted by microscopy were compared with those resulting from gating.

RESULTS

Samples with both shape change and doubled lymphocyte cluster had serological profiles according to the diagnosis of ongoing infectious mononucleosis. Blood smears review was positive for reactive lymphocytes in all 112 samples (100%). An underestimation of apoptotic cell count by light microscopy compared with the gating in the instrumental scatterplot was also observed (96 out of 112, 85.7%).

CONCLUSION

The additional lymphocyte cluster was significantly associated with activated and apoptotic lymphocytes in samples with serology suggesting ongoing infectious mononucleosis. Considering the significance of clue for infectious mononucleosis assigned to the apoptotic lymphocytes, a specific flag such as "apoptotic cells?" could be associate with the related cluster. Such a flag could be used for dedicated rules for smears review, thus increasing infectious mononucleosis detection in laboratories that do not usually practise instrumental cytograms observation.

Usefulness of lactate dehydrogenase in differentiating abnormal cervical lymphadenopathy

BACKGROUND

Cervical lymphadenopathy is commonly seen in general practice, and its etiology is diverse. Establishing the diagnostic strategy for lymphadenopathy would be desirable to avoid overlooking neoplasms or other critical conditions. This study aims to identify the useful laboratory parameters for cervical lymphadenopathy that require clinical observation or intervention.

METHODS

The participants were outpatients presenting cervical swelling or cervical lymph node (LN) pain who consulted the General Internal Medicine department from 2010 to 2016. We evaluated the characteristics, physical findings, and laboratory parameters with final diagnoses by multivariate logistic regression analysis. We categorized the final diagnoses as "Clinical Intervention Required Group (CIRG)" including necrotizing lymphadenitis, hematologic neoplasms, metastatic lymphadenopathy, tuberculous lymphadenitis, bacterial infectious diseases, infectious mononucleosis, autoimmune diseases, and other abnormal conditions or "No-CIRG" not requiring further clinical observation or intervention.

RESULTS

We evaluated 409 participants, with 130 (31.8%) diagnosed as belonging to the CIRG. There was an association between CIRG and various parameters: age ≥60 years old (adjusted odds ratio [AOR], 2.70; 95% confidence interval [CI], 1.48-4.90), having a referral (AOR, 1.83; 95% CI, 1.12-3.00), diameter of LN ≥ 2 cm (AOR, 1.91; 95% CI, 1.05-3.48), fixed LNs (AOR, 2.74; 95% CI, 1.02-7.37), and lactate dehydrogenase (LD) ≥400 U/L (AOR, 3.78; 95% CI, 1.46-9.77). Eighty-two percent of LD ≥ 400 cases in the CIRG were infectious mononucleosis or necrotizing lymphadenitis.

CONCLUSIONS

Besides the clinical indicators reported previously, we may apply an elevated LD level as a useful indicator of cervical lymphadenopathy that requires further clinical observation or intervention.

Dynamic Distribution and Clinical Value of Peripheral Lymphocyte Subsets in Children with Infectious Mononucleosis

OBJECTIVE

To study the dynamic change of peripheral lymphocyte subsets and its clinical value in children with infectious mononucleosis (IM).

METHODS

Thirty-six pediatric patients with IM, 19 children with IM-like symptoms but lacking the serological pattern compatible with EB virus infection, and 33 healthy children were enrolled. The changes of peripheral lymphocyte subsets were detected by flow cytometry on admission and on the fifth day of antiviral treatment, respectively. Indicators of liver function and routine blood count were also detected. Besides, the receiver operating characteristic (ROC) curve and the correlation of related indicators was analyzed.

RESULTS

When IM patients were admitted, the frequency and absolute number of T, CD4^-CD8⁺T, and CD4⁺CD8⁺T (DPT) cells were significantly increased while B cells were decreased; the frequency of CD4⁺CD8^-T cells were decreased, but its absolute number did not change significantly; the frequency of NK cells decreased, but its absolute number increased. The absolute number of CD4^-CD8⁺T most significantly positively correlated with serum lactate dehydrogenase (LDH) concentration which could reflect the severity of IM patients. After short-term treatment with acyclovir, elevated lymphocytes decreased, but only DPT-cell frequency and NK-cell absolute number were recovering towards normal. The ROC curve suggested that the frequency of B cells has better diagnostic value for IM in pediatric patients compared to other lymphocyte subsets.

CONCLUSIONS

Peripheral lymphocyte subsets are closely related to the condition of children with IM, and each subset plays a relatively different role in the diagnosis and evaluation of IM.

Evaluation of the Serological Point-of-Care Testing of Infectious Mononucleosis by Data of External Quality Control Samples

Timely and reliable laboratory diagnostics is a necessity for patient safety and good patient management. Success in external quality assessment (EQA) reflects on the everyday work in a clinical laboratory. This study evaluated the reliability of serological point-of-care (POC) testing for the Epstein-Barr virus (EBV) that causes infectious mononucleosis (IM). Data from the results of 95 external quality control (EQC) samples, altogether 18 885 results during an eight-year period (2010-2017) were collected from 273 Finnish testing sites. Diagnosing acute infectious mononucleosis (EBV IM) is based on clinical, haematological and serological findings. Heterophile antibody tests are used for this purpose because they can be carried out at POC and are cheap and robust to perform. In this study, the data showed that the testing sites used 3 test methods and 17 different test kits; of the kits, 4 were used during the whole study period. The most commonly used test methods were immunochromatographic assays (12 test kits, 17 959 EQC results). Latex agglutination (4 test kits, 504 results) and immunofiltration test methods (one kit, 422 results) were also used. The overall success rate was 99.3% (for positive samples 99.6%, for negative samples 99.1%). The success rates of the different test methods varied from 94.3% for the immunofiltration method to 99.6% for the latex agglutination method. The lowest success rates were found for negative samples: 82.0% (QuickVue, Quidel [immunochromatographic method]), 91.3% (RDT EBV IgM Assay, Bio-Rad [immunofiltration method]). The results of the negative samples that represented old EBV immunity were the most difficult to interpret with a success rate of 98.9% compared to success rates of clearly positive (99.6%) and negative (99.5%) samples (P < .001). Especially the immunofiltration method (RDT EBV IgM Assay) produced 13.7% false positive results for samples of old immunity. The data showed that 42 of the studied 95 EBV IM EQA rounds were reported as expected (true positive or true negative) by all testing sites.

Clinical manifestations and laboratory results of 61 children with infectious mononucleosis

Objective

To investigate the clinical manifestations of infectious mononucleosis in children of different ages.

Methods

Clinical data from pediatric patients with infectious mononucleosis admitted from May 2015 to April 2019 were retrospectively analyzed. Patients were stratified into three groups (age 1–3 years, 4–6 years, and 7–14 years) for analysis of clinical and laboratory results.

Results

Data from 61 patients (male:female ratio 1.18:1) aged 5.15 ± 2.93 years (mean ± standard deviation; range: 1–14 years) were analyzed. Infectious mononucleosis occurred throughout the year and the main clinical manifestations were fever (98.3%), tonsillitis (100%), tonsillar white exudate (83.6%), cervical lymphadenopathy (98.3%), hepatomegaly (37.7%), splenomegaly (42.6%), eyelid edema (41.0%), and nasal obstruction (49.2%). Disease onset was most common during early childhood (37.7%) and at preschool age (37.7%). Younger children had more obvious symptoms of nasal obstruction and older children had more significant elevations of alanine aminotransferase and higher percentages of atypical lymphocytes.

Conclusion

The clinical manifestations of infectious mononucleosis in children differed by age. These associations required attention for clinical decision making.

Clinical features and outcomes of lymphadenopathy in a tertiary children's hospital

AIM

The aim of the present study is to describe the clinical features and outcomes of childhood lymphadenopathy and to define factors able to predict neoplastic aetiology or may improve its prognosis.

METHODS

All children evaluated for lymphadenopathy in our tertiary children's hospital and who underwent their first examination between 1 January, 2015 and 31 December, 2017 were enrolled in this retrospective observational study. Data were analysed using SPSS.Statistics, 24.0.

RESULTS

A total of 322 children, aged between 0 and 18 years (median 4.5; interquartile range 2.5-9), were enrolled. A specific diagnosis was achieved in almost half of the cases (n = 159, 49.4%) by using one or more methods, including serological, microbiological, biomolecular or histological investigations on surgical samples. Epstein Barr virus and non-tuberculous mycobacteria were the most common etiological agents among acute/sub-acute and chronic lymphadenopathy, respectively. At the end of the study period, two-thirds (210, 65.2%) of enrolled patients were successfully treated. Malignancies and non-tuberculous mycobacteria infections had the longest time to resolution.

CONCLUSIONS

Our data suggest that lymphadenopathy is a benign condition in most cases. Of note in our study, 2.5% of lymphadenopathy cases were found to be due to oncologic conditions. The most frequent infective causes were Epstein Barr virus, bacteria and non-tuberculous mycobacteria infections. No haematic or ultrasonographic features were independently able to provide sufficient evidence for a conclusive diagnosis. However, utilising these findings alongside evaluation for clinical criteria can guide decision-making for physicians. Lymphadenectomy is the most appropriate process to follow in the event of chronic lymphadenopathy with undefined diagnosis.

Are unexplained adverse health events following HPV vaccination associated with infectious mononucleosis? - A Danish nationwide matched case-control study

BACKGROUND

In Denmark, the acceptance of the HPV vaccination program has been threatened by reports of suspected adverse events. Epstein Barr Virus (EBV) infection is associated with symptoms of long-lasting tiredness and may be misinterpreted as HPV vaccine adverse events. The main aim of this study was to examine if EBV infection around time of HPV vaccination was a risk factor for later suspected vaccine adverse events.

METHODS

The study was a nationwide register-based matched case-control study. Cases were females vaccinated against HPV in the period 2011 throughout 2017 with suspected adverse events. For each case, five HPV vaccinated females without suspected adverse events were selected. Information about EBV infection was obtained from the Danish Microbiology Database and assessed for three time periods: (1) before first HPV vaccination, (2) around time of HPV vaccination, and (3) any time during the study period 2010-2017. Multiple logistic regression was used to estimate the association between EBV and suspected adverse events.

RESULTS

We identified 1217 cases, matched to 6085 controls. A higher proportion of cases (38; 3.1%) than controls (31; 0.5%) were tested for EBV around time of HPV vaccination and cases had elevated odds for testing both EBV positive (OR 4.52, 95% CI 2.68-7.63) and EBV negative (OR 20.99, 95% CI 5.81-75.79). Only five females were classified with acute/recent EVB infection in this period.

CONCLUSION

Misinterpretation of EBV infection late symptoms is not a leading explanation for Danish females experiencing suspected adverse events after HPV vaccination. Although EBV cannot be excluded as an explanatory factor for a very small proportion of suspected adverse events, the findings are more likely explained by protopathic bias, i.e. the fact that a larger proportion of females suspecting adverse events are tested for EBV.

Treatment outcomes and prognostic factors for non- malignancy associated secondary hemophagocytic lymphohistiocytosis in children

BACKGROUND

Secondary hemophagocytic lymphohistiocytosis (HLH) is a rare hyperinflammatory syndrome that requires prompt diagnosis and appropriate treatment. A risk-stratification model that could be used to identify high-risk pediatric patients with HLH who should be considered for second-line therapies, including salvage regimens and allogeneic hematopoietic cell transplantation (HCT), was developed.

METHODS

The medical records of 88 pediatric patients (median age 1.4 years, range 0.2-15 years) with non-malignancy associated secondary HLH were retrospectively reviewed. Treatment strategies included dexamethasone, etoposide, and cyclosporine.

RESULTS

Survival analysis showed HLH patients with infections other than Epstein-Barr virus (EBV) and unknown causes experienced better 5-year overall survival (OS) than patients with HLH due to autoimmune disease, EBV or immunodeficiency (76% vs. 65, 33.3, 11%, p < 0.001). On multivariate analysis, among all patients, non-response at 8 weeks was the most powerful predictor of poor OS. When treatment response was excluded, hemoglobin < 60 g/L and albumin < 25 g/L at diagnosis were associated with poor OS. In patients with EBV-HLH, hemoglobin < 60 g/L at diagnosis was associated with poor OS. A prognostic risk score was established and weighted based on hazard ratios calculated for three parameters measured at diagnosis: hemoglobin < 60 g/L (2 points), platelets < 30 × 10⁹/L (1 point), albumin < 25 g/L (2 points). Five-year OS of low-risk (score 0-1), intermediate-risk (score 2), and poor-risk (score ≥ 3) patients were 88, 38, and 22%, respectively (p < 0.001).

CONCLUSIONS

These findings indicate that clinicians should be aware of predictive factors at diagnosis and consider 8-week treatment response to identify patients with high-risk of disease progression and the need for second-line therapy and allogeneic HCT.

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.

Primary Epstein-Barr virus infection with and without infectious mononucleosis

Background

Infectious mononucleosis (IM) is a common adverse presentation of primary infection with Epstein-Barr virus (EBV) in adolescence and later, but is rarely recognized in early childhood where primary EBV infection commonly occurs. It is not known what triggers IM, and also not why IM risk upon primary EBV infection (IM attack rate) seemingly varies between children and adolescents. IM symptoms may be severe and persist for a long time. IM also markedly elevates the risk of Hodgkin lymphoma and multiple sclerosis for unknown reasons. The way IM occurrence depends on age and sex is incompletely described and hard to interpret etiologically, because it depends on three quantities that are not readily observable: the prevalence of EBV-naϊve persons, the hazard rate of seroconverting and the attack rate, i.e. the fraction of primary EBV infections that is accompanied by IM. We therefore aimed to provide these quantities indirectly, to obtain epidemiologically interpretable measures of the dynamics of IM occurrence to provide etiological clues.

Methods and findings

We used joint modeling of EBV prevalence and IM occurrence data to provide detailed sex- and age-specific EBV infection rates and IM attack rates and derivatives thereof for a target population of all Danes age 0–29 years in 2006–2011. We demonstrate for the first time that IM attack rates increase dramatically rather precisely in conjunction to typical ages of puberty onset. The shape of the seroconversion hazard rate for children and teenagers confirmed a priori expectations and underlined the importance of what happens at age 0–2 years. The cumulative risk of IM before age 30 years was 13.3% for males and 22.4% for females. IM is likely to become more common through delaying EBV infection in years to come.

Conclusions

The change in attack rate at typical ages of puberty onset suggests that the immunologic response to EBV drastically changes over a relatively short age-span. We speculate that these changes are an integrated part of normal sexual maturation. Our findings may inform further etiologic research into EBV-related diseases and vaccine design. Our methodology is applicable to the epidemiological study of any infectious agent that establishes a persistent infection in the host and the sequelae thereof.

Increasing Epstein-Barr virus infection in Chinese children: A single institutional based retrospective study

The Epstein-Barr virus (EBV) is a common virus in humans and the most common causative agent of Infectious Mononucleosis. EBV primary infection has recently risen in some countries and children below 2 years of age are highly susceptible. The clinical manifestations in children with EB virus infection involve multiple systems, causing severe illness, meaning attention should be paid during diagnosis and treatment. Objective:  This single institution based retrospective study was carried out with the aim of estimating the overall prevalence of EBV infection and identifying high-risk age group among children.  Methods: This study include total 253 patients under 15 years of age found to be  positive for EBV DNA by serum PCR who were admitted to the Pediatrics Department of Renmin Hospital,(Shiyan, China) during a 4-year period from 2014 to 2017. Patients were divided into three groups; 0-<4years, 4-<6years and 6-<15years. We then calculated the percentage and prevalence of EBV DNA-positive cases. Results: The yearly EBV prevalence rate was 4.99 per 1000 admissions in 2014, 6.97 per 1000 admissions in 2015, 10.42 per 1000 admissions in 2016, and 12.16 per 1000 admissions in 2017. Out of 253 EBV-positive cases, those under 4 years had the highest rate of EBV infection (74.7%). The rate drops to 11.06% in the 4-6 years group, and was 14.22% in the 6-15 years group. Those between 6 months and 1 year are those at the highest risk.  Conclusion: The rate of hospital admission of children due to EBV infection is increasing day by day. Children under 4 years of age are highly susceptible to infection and children of age between 6 months and 1 year are the high-risk group for EBV infection.

Increasing Epstein-Barr virus infection in Chinese children: A single institutional based retrospective study

The Epstein-Barr virus (EBV) is a common virus in humans and the most common causative agent of Infectious Mononucleosis. EBV primary infection has recently risen in some countries and children below 2 years of age are highly susceptible. The clinical manifestations in children with EB virus infection involve multiple systems, causing severe illness, meaning attention should be paid during diagnosis and treatment. Objective:  This single institution based retrospective study was carried out with the aim of estimating the overall prevalence of EBV infection and identifying high-risk age group among children.  Methods: This study include total 253 patients under 15 years of age found to be  positive for EBV DNA by PCR who were admitted to the Pediatrics Department of Renmin Hospital,(Shiyan, China) during a 4-year period from 2014 to 2017. Patients were divided into three groups; 0-<4years, 4-<6years and 6-<15years. We then calculated the percentage and prevalence of EBV DNA-positive cases. Results: The yearly EBV prevalence rate was 4.99 per 1000 admissions in 2014, 6.97 per 1000 admissions in 2015, 10.42 per 1000 admissions in 2016, and 12.16 per 1000 admissions in 2017. Out of 253 EBV-positive cases, those under 4 years had the highest rate of EBV infection (74.7%). The rate drops to 11.06% in the 4-6 years group, and was 14.22% in the 6-15 years group. Those between 6 months and 1 year are those at the highest risk.  Conclusion: The rate of hospital admission of children due to EBV infection is increasing day by day. Children under 4 years of age are highly susceptible to infection and children of age between 6 months and 1 year are the high-risk group for EBV infection.

Infectious mononucleosis and hepatic function

Abnormal hepatic function is common in infectious mononucleosis (IM). However, it remains unknown why increased transferase levels are more common than bilirubin abnormalities in IM. The current study aimed to investigate these associations in the Chinese population. A total of 95 patients with IM (47 males and 48 females) were enrolled in the current study, as well as 95 healthy controls. Patients were sorted by sex. A receiver operating characteristic (ROC) curve was used to determine cut-off values for IM diagnosis and prediction. Crude and adjusted odds ratios (OR) for IM were analyzed using binary logistic regression. It was determined that alanine aminotransferase (ALT), aspartate aminotransferase (AST) and γ-glutamyl transferase (GGT) levels were significantly higher in patients with IM compared with controls; however, total bilirubin (TB) levels were significantly lower in patients with IM. ROCs demonstrated that, if ALT, AST and GGT concentrations were higher than, or if TB was lower than, cut-off values, they were predictive of IM. Binary logistic regression identified that the risk of IM in patients exhibiting high levels of transferases was significantly increased, particularly in males. Crude ORs in ALT quartile 4 were 21.667 and 10.111 for males and females, respectively and adjusted ORs were 38.054 and 9.882, respectively. A significant IM risk of IM was evident in patients with low bilirubin levels and females appeared to be particularly susceptible. For example, crude ORs in quartile 1 were 8.229 and 8.257 for males and females, respectively and adjusted ORs were 8.883 and 10.048, respectively. Therefore, the current study identified a positive association between transferase levels and IM and a negative association between TB and IM. Therefore, the results of the current study indicate that high transferases are suggestive of IM, particularly in males, whereas low TB is suggestive for IM, particularly in females.

Anti-Epstein-Barr virus antibodies in Beijing during 2013-2017: What we have found in the different patients

Background

Epstein–Barr virus (EBV) is associated with nasopharyngeal carcinoma (NPC) which is prevalent in South China, and its association with systemic lupus erythematosus (SLE) or other autoimmune diseases has not been studied in the mainland of China. The EBV serological tests have been performed on patients with various diseases or manifestations for years at our institution and their values need to be evaluated.

Methods

For routine medical purposes, anti-EB viral capsid antigen (VCA) IgG, IgA and IgM antibodies, anti-EBV diffuse early antigen (EA-D) IgA antibodies, and anti-EBV nuclear antigen-1(EBNA-1) IgG antibodies were tested with commercial enzyme-linked immunosorbent assay (ELISA) in patients visiting Peking Union Medical College Hospital between 2013 and 2017. The test results were analyzed in this retrospective study.

Results

There were a total of 11122 serum samples available to be tested in the study. As indicators of past EBV infection, the prevalence of VCA-IgG/EBNA1-IgG were 66.6%/58.5%, 84.3%/78.8%, 92.9%/87.0% and 98.5%/95.4% in patients aged under 5 years, 6–10 years, 11–20 years and 21–30 years old, respectively, and these values maintained at this highest rate as age increased further. The prevalence of VCA-IgM, as a parameter of acute EBV infection, was 14.6%, 10.2%, 10.4%, 6.3% and 3.1% in patients aged under 5 years, 6–10 years,11–20 years, 21–30 years, 31–40 years old, respectively, and decreased to 2%~3% in older patients. Patients with elevated serum liver enzymes were more likely to have a higher prevalence of EA/D IgA antibody (P < 0.01) and young patients (≤30 years) with lymphadenopathy were more likely to have higher prevalence of VCA-IgM antibody (P < 0.01). The prevalence of VCA-IgA and EAD-IgA were 87.0% and 59.2% in NPC patients, respectively, and both were significantly higher (P < 0.001) than that in non-NPC patients. The prevalence of VCA-IgA was 45.4% and 25.6% in SLE patients and patients with other autoimmune diseases, respectively, which were significantly (P < 0.001) and mildly (P = 0.039) higher than their controls. In pediatric SLE patients between 6 and10 years old, the prevalence of VCA-IgG, VCA-IgA and EBNA1-IgG was 100%, 59.5% and 100%, respectively, all being significantly higher than the age (6-10y) related controls (P< 0.01). In the 705 cerebral spinal fluid (CSF) specimens, VCA-IgG, VCA-IgM, VCA-IgA and EAD-IgA were found to be positive in 12.1%, 0.15%, 0.25% and 0.25%, respectively. There were 157 paired specimens (CSF and serum were collected simultaneously) and VCA-IgG was identified as positive in 12.7% of the CSF and 100% of the serum specimens.

Conclusions

Around 98% of Chinese patients were infected with EBV before 30 years of age and the highest rate of acute EBV infection were observed in patients under 5 years old. EBV infection was found to be associated with elevated serum liver enzymes, NPC and SLE. Acute anti-EBV antibody was valued for young patients with lymphadenopathy but limited value for CNS neuropathy.

How to use … the Monospot and other heterophile antibody tests

Epstein-Barr virus (EBV) is a highly prevalent virus, transmitted via saliva, which often causes asymptomatic infection in children but frequently results in infectious mononucleosis in adolescents. Heterophile antibody tests, including the Monospot test, are red cell or latex agglutination assays, which detect antired cell antibodies produced as part of a polyclonal antibody response occurring during EBV infection. Heterophile antibody tests are rapid, cheap and specific tests that can be performed from the onset of symptoms of infectious mononucleosis. In adolescents, heterophile antibody tests have high specificity and sensitivity in the diagnosis of primary acute EBV infection. However, the tests have low sensitivity and low negative predictive value in young children and are not useful under the age of 4. Heterophile tests may be positive in other viral infections, autoimmune disease and haematological malignancies, but do not appear to be positive in primary bacterial infection. Virus-specific serology is required in children under the age of 4 or if an older child is heterophile negative. Virus-specific serology allows diagnosis and the pattern of positivity and negativity enables the clinician to stage the EBV infection. Virus-specific serology appears to have better sensitivity in young children, but there is cross-reaction with other herpesvirus infections, a longer turnaround time and it is more expensive to perform. Further research is needed to establish which children benefit from and hence require testing for heterophile antibodies, the cost-effectiveness of EBV investigations and whether heterophile titres have predictive value for the severity of infection and the likelihood of complications.

Conjunctival tumor caused by Epstein-Barr virus-related infectious mononucleosis: Case report and review of literature

The conjunctival tumor associated with Epstein-Barr virus related infectious mononucleosis is a rare ocular manifestation. Only a few cases have been reported in the literature. We reported this rare condition that presented in a 5-year-old boy.