- EBV antibody testing
- Epstein-Barr virus antibody testing
- anti-VCA IgM
- anti-VCA IgG
- EBNA-IgG
- anti-EA (D) IgG
- anti-EA (R)
- Paul-Bunnell-Davidsohn antibodies (IgM)
The specimens collected are:
- Blood sample
- Red or tiger top tube (for serology)
- Lavender top tube (for PCR)
- 5-7 mL of venous blood
- Cerebrospinal fluid (CSF)
- Spinal fluid collection tube
- 0.5-1 mL of CSF
- Throat swab (for culture)
- Tissue biopsy samples of lymph node, spleen, liver, etc
Additional information
- Handle blood samples gently to prevent hemolysis
- Throat swab collection: Depress tongue and rub swab vigorously over each tonsillar area and posterior pharynx. If there is exudate, the swab should touch this. Take care to avoid the tongue and uvula. Place swab in transport container provided by the lab
- Send samples to lab immediately
- If delayed, separate serum and store at 4°C for 1—2 days or -20°C for 1 year
- Epstein-Barr virus (EBV) testing involves a group of tests to detect the presence or absence of Epstein-Barr virus or its antibodies from the samples collected
- EBV belongs to the herpesviridae family. It is designated as human herpes virus–4 (HHV-4) and occurs worldwide. The virus primarily causes infectious mononucleosis (IM)
- The group of tests for EBV include:
- Heterophil antibodies (Monospot)
- Serological tests
- Antibodies to viral capsid antigen - IgM and IgG
- Antibody to early antigen, diffuse or restricted pattern [anti-EA (D) or anti-EA(R)]
- Antibody to Epstein-Barr nuclear antigen (EBNA)
- Virus culture
- EBV DNA detection
- Histopathological examination (HPE)
- Epstein-Barr virus testing is indicated in the following conditions:
- In persons presenting with symptoms of mononucleosis-like syndrome
- As an aid in confirming infectious mononucleosis in heterophil (monospot) negative cases
- In pregnant women presenting with flu-like symptoms
- For evaluation of primary acute, convalescent, chronic, or reactivation of EBV infection, and to monitor disease progression
- For evaluation of susceptibility to EBV infection in immunosuppressed patients with lymphoproliferative processes
- For evaluation of persons with serious illness, acute neurological disease of unknown etiology, suspected leukemia, or other lymphoproliferative disorders
- To distinguish EBV infection from other causes of mononucleosis-like syndrome or glandular fever such as:
- Brucellosis
- Cat scratch disease
- Collagen-vascular diseases (especially lupus)
- Cytomegalovirus infections
- Drug reactions (phenytoin, sulfasalazine, dapsone)
- Hepatitis viruses
- HIV-1 seroconversion
- Listeriosis
- Lyme disease
- Rickettsial infections
- Subacute bacterial endocarditis
- Syphilis
- Toxoplasmosis
- Tularemia
- Primary infection by EBV in young children is often asymptomatic or mild. However, in adolescents and young adults it manifests as infectious mononucleosis, a self-limited clinical syndrome
- EBV is transmitted primarily by saliva through close mucocutaneous contact (hence also known as kissing disease) and has a very long incubation period (4–8 weeks)
- About 50% of people are seropositive by 5 years of age, and ~95-99% by 40 years of age
- EBV infection may remain dormant for years as latent infection, reactivating intermittently, especially in immunocompromised conditions
- EBV is associated with a variety of disorders which include:
- Infectious mononucleosis (IM)
- Endemic Burkitt lymphoma, a type of non-Hodgkin's lymphoma, most common in childhood, and primarily found in Africa
- Nasopharyngeal carcinoma (malignanat nasopharyngeal tumor of the squamous epithelium, endemic in China)
- Other EBV-associated cancers
- Hodgkin's lymphoma (mixed cellularity subtypes)
- Leiomyomas and leiomyosarcomas in children
- Oral hairy leukoplakia in HIV patients
- Tonsillar carcinoma
- T-cell lymphomas
- Thymoma
- EBV infection in immunocompromised persons
- X-linked lymphoproliferative syndrome (Duncan's disease)
- Lymphoproliferative diseases in children with primary immunodeficiencies such as ataxia-telangiectasia, Chédiak-Higashi syndrome, Wiskott-Aldrich syndrome
- Post-transplant lymphoproliferative disorders (PTLD)
- Secondary immunodeficiencies such as after chemotherapy
- In AIDS patients with hairy leukoplakia, leiomyosarcoma, CNS lymphoma, and lymphoid interstitial pneumonitis in children
- Other diseases
- Common variable immunodeficiency (CVID)
- Hepatitis
- Herpangioma
- Micropsia or Alice in Wonderland syndrome (AIWS)
- Multiple sclerosis
- Stevens-Johnson syndrome
- EBV infection is unrelated to chronic fatigue syndrome (CFS); but can create a period of prolonged low energy and fatigue that is not CFS
- Infectious mononucleosis may be clinically characterized as:
- Fever (97% cases, persists for 7-10 days)
- Sore throat or exudative pharyngitis (>97%, disappears within 14 days after onset)
- Lymphadenopathy (>97% cases, most common affected is posterior cervical, axillary, and inguinal)
- Chills
- Malaise
- Fatigue
- Myalgias
- Splenomegaly (75%, regresses by 21–28 days)
- Palatal petechiae (50%)
- Periorbital edema (33%)
- Hepatomegaly (20%, regresses by 21–28 days)
- Maculopapular rash (10%)
- Serologic testing for EBV infection includes:
- Antibodies to viral capsid antigen-IgM (anti-VCA IgM):
- It is detectable at the onset of symptoms, peaks at 2-3 weeks, then declines and becomes undetectable by 3-4 months
- Indicates recent, primary acute infection with EBV
- Also tested to confirm or clarify EBV infection in children and teenage patients who may have equivocal or negative monospot test
- Antibodies to viral capsid antigen – IgG (anti-VCA IgG):
- It rises shortly after the onset of symptoms, peaks at 2-3 months, then declines slightly, but persists for life
- It indicates acute illness and rising titers (fourfold increase), and is diagnostic of active disease
- Antibody to early antigen, diffuse pattern IgG [anti-EA (D) IgG]:
- These are proteins produced when latently infected cells are stimulated to produce virus and show diffuse pattern on immunofluorescent staining
- It appears slightly later than anti-VCA IgG, peaks at 3-4 weeks, persists for months or years at low titers
- It is helpful to confirmchronic active mononucleosis, post-transplant lymphoproliferative disease, and nasopharyngeal carcinoma
- Antibody to early antigen, restricted pattern [anti-EA (R)]:
- These are proteins produced when latently infected cells are stimulated to produce virus and show restricted pattern on immunofluorescent staining
- It is useful for diagnosing the African form of Burkitt lymphoma, which is rare in the US
- It is not recommended for mononucleosis assessment since the antibodies are not commonly present
- Antibody to Epstein-Barr nuclear antigen-IgG (EBNA-IgG):
- It appears during convalescence or resolution of acute illness i.e., by 4-8 weeks and persists for life
- Presence of antibody indicates previous infection with EBV
- It is indicated in patients who may have negative Monospot test results, who clinically present with a mononucleosis like syndrome, especially in children and teenagers
Additional information
- Lab diagnosis of EBV infection include:
- Heterophil antibodies (Monospot)
- Please see the detailed explanation and interpretation of this test (Monospot)
- Serological tests
- The serological interpretation of EBV associated diseases are as follows:
Condition Heterophile
Antibodies
(Monospot)Anti-VCA
IgMAnti-VCA
IgGAnti-EA
(D)Anti-EA
(R)Anti-EBNA No present or past infection - - - - - - Acute Infectious Mononucleosis* + + ++ + - - Convalescence +/- - + - +/- + Past Infection - - + - - + Chronic Active Infections - - +++ + ++ +/- Reactivation Immunodeficiency - - ++ + + +/- Burkitt Lymphoma - - +++ +/- ++ + Nasopharyngeal Carcinoma - - +++ ++ +/- + Post-Transplant Lymphoproliferative Disease - - ++ + + +/- *In early acute infectious mononucleosis, Anti-VCA IgG and Anti-EA (D) can be negative Antibody titers described above are absent (-), variably present (+/-), low (+), moderate (++), or high (+++) - Repeat testing in 10-14 days may be helpful if results are equivocal with serological tests
- During the course of infectious mononucleosis, heterophil antibodies are detected in up to 90% of patients while antibodies to viral capsid antigen, anti-EA, and anti-EBNA are detected in 100% of patients
- Virus culture
- Throat culture for virus may be positive during acute disease, as intermittent or continuous shedding of virus occurs up to three months after exposure to infection
- Leukocyte culture for virus may be positive during acute disease and convalescence
- EBV DNA detection
- Various techniques such as Southern blot analysis, in-situ hybridization, and polymerase chain reaction (PCR) are used to detect EBV in tissues, body fluids (CSF and blood), and tumors
- It is useful especially in EBV-related diseases in immunocompromised persons or in patients with lymphoproliferative tumors
- Histopathological examination (HPE)
- HPE with the help of immunohistochemistry is used to detect EBV infection from tissue biopsy specimens such as lymph node, spleen, and liver
- It is useful especially to determine the involvement of EBV infection in nasopharyngeal carcinoma
- It is also helpful in confirming EBV-related diseases in immunocompromised persons or in patients with lymphoproliferative tumors
- Peak incidence of EBV infection occurs in the teens and early twenties
- The three classic criteria for laboratory confirmation of acute infectious mononucleosis due to EBV include
- Lymphocytosis (>10-20%)
- Presence of at least 10% atypical lymphocytes (T-cells) on peripheral smear
- Positive serologic tests for EBV
- Related laboratory tests include:
- Antinuclear antibodies
- Cold agglutinins
- Complete blood count with peripheral blood smear evaluation
- Cryoglobulins
- Cytomegalovirus testing (CMV)
- Liver function
- Toxoplasmosis testing
Consult your laboratory for their normal ranges as these may vary somewhat from the ones listed below.
Heterophil antibodies (Monospot)
EBV antibody testing can be performed by latex agglutination, indirect immunofluorescence (IFA), or ELISA; with each technique yielding a different format to the result. Refer to your laboratory for their normal ranges. The interpretation of test results is as follows:
| Condition | Heterophile Antibodies (Monospot) | Anti-VCA IgM | Anti-VCA IgG | Anti-EA (D) | Anti-EA (R) | Anti-EBNA |
|---|---|---|---|---|---|---|
| No present or past infection | - | - | - | - | - | - |
| Acute Infectious Mononucleosis* | + | + | ++ | + | - | - |
| Convalescence | +/- | - | + | - | +/- | + |
| Past Infection | - | - | + | - | - | + |
| Chronic Active Infections | - | - | +++ | + | ++ | +/- |
| Reactivation Immunodeficiency | - | - | ++ | + | + | +/- |
| Burkitt Lymphoma | - | - | +++ | +/- | ++ | + |
| Nasopharyngeal Carcinoma | - | - | +++ | ++ | +/- | + |
| Post-Transplant Lymphoproliferative Disease | - | - | ++ | + | + | +/- |
| *In early acute infectious mononucleosis, Anti-VCA IgG and Anti-EA (D) can be negative Antibody titers described above are absent (-), variably present (+/-), low (+), moderate (++), or high (+++) | ||||||
A positive result must be interpreted in conjunction with the clinical scenario.
Positive result interpretation is aided by the following table
Heterophil antibodies (Monospot)
Conditions associated with false positive test results include:
- For anti-VCA IgM:
- Acute hepatitis A infection
- Presence of rheumatoid factor
- High titers of Anti-VCA IgG
- Cytomegalovirus infection
- Toxoplasma gondii infection
- For EBV antibody tests
- Cancer of the pancreas
- Hepatitis
- Leukemia
- Lymphomas
- Narcotic addiction
- Phenytoin therapy
- Serum sickness
A negative result must be interpreted with the clinical scenario as false negative results can occur and additional/repeat testing may be indicated in selected cases.
Heterophil antibodies (Monospot)
Conditions associated with false negative antibody test results include:
- If the test was done less than 6 days after exposure to the virus
- Presence of PCR inhibitors in patient specimen for EBV DNA detection, due to concentrations below assay detection
- In young children less than two years of age
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