Evaluation of 12 commercial tests for detection of Epstein-Barr virus-specific and heterophile antibodies

American Medical Society of Sports Medicine Position Statement: Mononucleosis and Athletic Participation

ABSTRACT

Infectious mononucleosis (IM) is a common illness in children and young adults caused primarily by the Epstein-Barr Virus (EBV). Transmission occurs primarily through sharing oral secretions, thus IM is known as the "kissing disease." Common clinical manifestations include fever, pharyngitis, posterior cervical lymphadenopathy, and splenomegaly. Atypical lymphocytosis and transaminase elevations are common, and the diagnosis of IM is confirmed with laboratory findings of a positive heterophile antibody ("Monospot"), polymerase chain reaction, or antibodies specific to EBV. Individuals with acute IM may be quite symptomatic and not feel well enough to participate in sports. Splenic enlargement is common, with rupture a relatively rare occurrence, typically occurring within a month of symptom onset, but this risk complicates sports participation, and is often the reason for restricting activity. The management of IM is primarily supportive, with no role for antivirals or corticosteroids. The variability of clinical presentation and the risk of splenic rupture in patients with IM present clinicians with challenging return to play/return to sport (RTS) decisions. This position statement updates the Evidence-Based Subject Review on Mononucleosis by the American Medical Society for Sports Medicine published in 2008 and reviews the epidemiology, clinical manifestations, laboratory assessment, and management including RTS for the athlete with IM. This statement also addresses complications, imaging, special considerations, diversity and equity considerations, and areas for future clinical research. Understanding the evidence regarding IM and sport is essential when communicating with athletes and their families and incorporating shared decision-making in the RTS decision.

Fever with atypical lymphocytosis: pearls and pitfalls in Epstein-Barr virus serology

The heterophile antibody (also known as the Monospot) test is a useful screening tool for infectious mononucleosis (IM) resulting from primary Epstein-Barr virus (EBV) infection. However, up to 10% of patients with IM are heterophile negative. Heterophile-negative patients who have lymphocytosis or atypical lymphocytes on peripheral blood smear should be further tested for EBV serologies, which include testing for specific IgM and IgG antibodies against viral capsid antigens, early antigens and EBV nuclear antigen proteins. A diagnostic dilemma arises when the patient has clinical and laboratory features of IM, but is both heterophile negative and seronegative for IM, as illustrated in this case presentation. To avoid missed diagnoses of IM, misdiagnosis of mononucleosis-like illnesses and unnecessary testing, knowledge of test characteristics and the evolving course of EBV serologies is important to assure and inform both the physician and the patient.

Identification of ADA as a Biomarker for Atypical Epstein Barr Virus Infection in Children

OBJECTIVE

This study aims to explore the ability of adenosine deaminase (ADA) to discriminate atypical Epstein Barr virus (EBV) infection in children from acute febrile illness.

METHODS

All children admitted to the Children's Hospital of Soochow University between 2018 and 2019, who were acute febrile patients and subjected to the plasma EBV-DNA polymerase chain reaction (PCR) and indirect immunofluorescence (IIF) assay for EBV-specific antibodies assays. The diagnostic value of each detection index was compared by the area under the ROC curve.

RESULTS

In children with atypical Epstein Barr virus infection, the sensitivity, specificity, positive predictive value, negative predictive value and Youden index were 62.87%, 100.00%,100.00%, 61.73% and 0.63 for EBV-DNA PCR assay, 80.84%, 100.00%, 100.00%, 75.76% and 0.81 for VCA-IgG avidity and 89.22%, 87.00%, 91.98%, 82.86% and 0.76 for ADA. VCA-IgG avidity (AUC=0.904, P<0.01) and ADA (AUC=0.881, P<0.01) assays had the great diagnostic efficiency. In addition, the sensitivity, specificity and AUC were 92.75%,91.43% and 0.921(95%CI: 0.856-0.985) for ADA in the course≤3 days group, respectively.

CONCLUSIONS

ADA has a good diagnostic value in the early stage of atypical EBV infection, and is not affected by primary EBV infection and reactivation. SCHLüSSELWöRTER: Adenosine deaminase, Epstein -Barr virus, Biomarker, children.

Use of Monospot Testing in the Diagnosis of Infectious Mononucleosis in the Collegiate Student-Athlete Population

OBJECTIVE

To determine the utility of monospot testing in the diagnosis of mononucleosis in the collegiate student-athlete clinical setting.

DESIGN

Retrospective cohort study.

SETTING

National Collegiate Athletic Association Division I sports medicine clinic.

PATIENTS

All varsity student athletes who had a monospot test and Epstein-Barr virus (EBV) titers obtained from January 1, 2016, through March 31, 2020, (n = 199) were included.

INDEPENDENT VARIABLES

Monospot, EBV antibody titers, and liver transaminase results.

MAIN OUTCOME MEASURES

Using EBV titers indicating acute or recent infection as the gold standard for diagnosing infectious mononucleosis (IM), the reliability of a positive monospot test and elevated liver transaminases for the diagnosis of IM were examined.

RESULTS

The monospot test had a sensitivity and specificity of 80.0% and 90.6%, respectively, with a positive predictive value of 36.4% and a negative predictive value of 98.5% in this cohort. All athletes diagnosed with IM also had elevated liver transaminases.

CONCLUSIONS

The specificity of the monospot test is lower than previously reported in the literature, and a positive test is not sufficient to diagnose mononucleosis in this clinical setting. Positive monospot results should be confirmed with EBV antibody testing. Elevated transaminase levels are highly correlated with acute IM and could play a supporting role in the diagnosis.

Diagnostic value of serological and molecular biological tests for infectious mononucleosis by EBV in different age stages and course of the disease

Epstein-Barr virus (EBV)-based serologic antibody and viral nucleic acid assays have been found to be feasible means to diagnose infectious mononucleosis (IM) caused by EBV in children. In this study, we will further explore their diagnostic value for IM by EBV in different age stages and over the course of the disease. A collection of 616 children from clinically suspected IM cases was studied. Indirect immunofluorescence (IIF) for EBV-specific antibody (Euroimmun) combined with plasma EB viral nucleic acid assay (real-time fluorescence quantitative polymerase chain reaction reverse-transcription polymerase chain reaction) were used as reference methods. The diagnostic efficiency of the peripheral blood routine test, serologic antibody test, and plasma EB viral nucleic acid assay for the diagnosis of IM was evaluated, respectively. The sensitivity, specificity, Youden' index and the area under curve (AUC) were 93.08%, 87.77%, 0.81 and 0.904 (95% confidence interval [CI]: 0.878-0.931) for the peripheral lymphocyte test (lymphocytosis > 5 × 109 /L), 98.27%, 91.13%, 0.89 and 0.947 (95% CI: 0.927-0.967) for the plasma EBV-DNA test, and 84.08%, 96.33%, 0.80 and 0.902 (95% CI: 0.874-0.930) for the EBV viral capsid antigen (VCA)-IgG avidity test. The plasma EBV-DNA test has a higher diagnostic value than the VCA-IgG avidity test in children aged <6 years, especially aged <3 years; the peripheral lymphocyte test and plasma EBV-DNA test are suitable for the early stage of the disease, while the VCA-IgG avidity test for after 7 days of the disease. EBV antibody detection (IIF) should be combined with EBV nucleic acid detection in children age <6 years and the early stage of the disease.

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.

Characteristics of primary Epstein-Barr virus infection disease spectrum and its reactivation in children, in Suzhou, China

Epstein-Barr virus (EBV) is a globally prevalent herpesvirus associated with multiple diseases. This study aimed to determine the characteristics of primary EBV infection disease spectrum and reactivation in children, in Suzhou, China. All children admitted to the Children's Hospital of Soochow University between May 2018 and September 2020 with suspected EBV-associated disease and subjected to the indirect immunofluorescence assay for EBV-specific antibodies and plasma EBV-DNA assays were included. Of the 3567 children, 2782 (78.0%) tested positive for EBV. The positive rates of viral capsid antigen (VCA)-IgM, VCA-IgG, early antigen (EA)-IgG, nuclear antigen (EBNA)-IgG, and plasma EBV-DNA were 12.1%, 74.6%, 37.9%, 35.6%, and 31.1%, respectively. The lowest VCA-IgG and EBNA-IgG seropositivity rates occurred at ages between 8 and 36 months, then increased gradually in the older age groups. The EBV-IgM seropositivity rate was the highest in those aged 36 to <72 months. Primary EBV infection was more common in children aged 36 to <72 months. In past infections, reactivation mainly occurred in 8 to <36 months. The most common disease caused by primary EBV infection was infectious mononucleosis (56.1%), followed by a respiratory infection (17.0%). Respiratory infection (30.0%), EBV infection (29.2%), and hemophagocytic lymphohistiocytosis (HLH) (15.8%) were the commonest diseases caused by EBV reactivation. EBV reactivation was a risk factor for HLH (adjusted odds ratio, 16.4; 95% confidence interval, 7.9-34.0). Among reactivated patients, the viral load of HLH was higher than that of EBV infection and respiratory infection (p < .01). This is a retrospective large sample study that explored the characteristics of primary EBV infection disease spectrum and reactivation in children.

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.

Development of Systemic Lupus Erythematosus After Infectious Mononucleosis in a 64-Year-Old Woman

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by heterogeneous symptoms that can manifest in any organ, and often presents at a young age. Infectious mononucleosis (IM) is the acute clinical manifestation of Epstein–Barr virus (EBV). It is characterized by low-grade fever, malaise, lymphadenopathy, splenomegaly, and occasionally symmetrical arthralgias. It has been proposed that EBV is a trigger for new-onset SLE, and patients with autoimmune disorders such as SLE are more likely to have recurrent IM infections. The patient, a 64-year old Caucasian female who’s only past medical history was hypertension, developed several months–long period of vague symptoms, including fatigue, malaise, nausea, and nonbilious vomiting with oral intake. She presented with symmetrical polyarthritis involving the hands and elbows, with no history of arthritis before this episode. At the 5-month follow-up, she presented with worsening arthritis bilaterally in her elbows and in her right knee. For several decades, there has been a theoretical association between EBV and SLE, with EBV thought to be one of the many possible triggers for development of SLE. Based on the disease course, we theorize that the patient’s IM and EBV infection led to development of SLE. A small fraction of SLE cases have been reported in literature to be associated with EBV. This case adds to that literature with EBV triggering development of SLE in a seemingly previously asymptomatic patient.

[Importance of machine blood count in the diagnosis of infectious mononucleosis by EBV]

INTRODUCTION

EBV serology is recommended for serological diagnosis of mononucleosis. As results of an automated differential blood count is available more quickly, possible differences between an EBV primary infection and a bacterial tonsillitis were investigated.

METHODS

A retrospective evaluation of absolute and relative lymphocyte and monocyte counts of n = 140 patients > 16 years from 01/2008 to 01/2019 (mean age 21.4 years, 51 % ♀, 49 % ♂) with suspected EBV infection was performed. The groups of a serologically confirmed or excluded EBV infection were compared.

RESULTS

An automated differential blood count was available in n = 42 patients with primary EBV infection. Average lymphocyte count was 5.5 ± 2.6 giga/l. Patients with acute bacterial tonsillitis (n = 36) had significantly lower values with 1.6 ± 1.3 giga/l, p < 0.05. Equal results were found in relative lymphocyte counts (47.4 ± 17.9 vs. 12.8 ± 9.1 %, p < 0.05). For monocyte counts, neither absolute (1.2 ± 0.8 vs. 1.2 ± 0.6 giga/l, p = 0.617) nor relative (8.8 ± 3.6 vs. 9.8 ± 5.2 %, p = 0.746) monocyte counts showed significant differences.

CONCLUSION

Increased lymphocyte counts in an automated differential blood count can be a first indication of primary EBV infection. Perhaps up to 30 % morphologically altered lymphocytes are increasingly counted correctly with modern hematology analyzers and no longer counted as monocytes. These results could be used to make decisions about further diagnosis (abdominal ultrasonography, ECG) and antibiotic therapy before results of EBV serology are available.

Limited Utility of Serology and Heterophile Test in the Early Diagnosis of Epstein–Barr Virus Mononucleosis in a Child after Renal Transplantation

Background: Epstein–Barr virus (EBV) infection is associated with significant morbidity and mortality in renal transplant (RT) recipients. The spectrum of illness ranges from infectious mononucleosis (IM) to post-transplant lymphoproliferative disorder (PTLD). In association with clinical signs and symptoms, virus-specific serology and heterophile antibody tests are widely used in confirming the diagnosis of IM in the general population. However, these tests may have a limited role in immunosuppressed RT recipients from seropositive donor, especially in children who were EBV-seronegative prior to the transplant. The aim of this study is to evaluate the utility of these tests in the early diagnosis of IM in this subset of patients. Methods: This is a case study with a review of literature. Results: Here, we present a 14-year-old male with hemophilia B who presented with fever, fatigue, sore throat, palatal petechial rash, exudative tonsillitis and cervical lymphadenopathy 3 months post-RT. He was EBV seronegative prior to RT and received a deceased donor kidney transplant from a seropositive donor. Induction was done with Thymoglobulin and maintenance immunosuppression consisted of tacrolimus and mycophenolate. Initial heterophile antibody test (monospot) was negative, but became positive at 5 months and remained positive at 9 months follow-up post-RT. EBV viral capsid antigens (VCA) IgM and IgG, early antigen (EA) and nuclear antigen (EBNA) were all negative at the time of presentation. VCA IgM and IgG both became positive at 5 months and peaked at 9 months follow-up, however the EA and EBNA remained negative. EBV viral load as measured by polymerase chain reaction (PCR) was negative for the first 3 months post-RT but became positive at presentation, peaked at 6 months and started declining thereafter. Peripheral blood smear examination showed no absolute and atypical lymphocytosis. Cytomegalovirus PCR in the blood and throat culture for streptococcus were negative. There was no splenomegaly. He was managed conservatively with intravenous fluids, bed rest, antipyretics and reduction of immunosuppression. Conclusions: EBV serological markers have a limited role in the early diagnosis of EBV-IM following RT in prior seronegative children. Initial heterophile antibody test may also be negative, and hence a repeat test may be necessary. Once becoming positive, the VCA IgM may remain persistently elevated for prolonged duration. In addition to the suppressed cellular immunity secondary to immunosuppression, humoral response to viral infections is also delayed in transplant recipients, especially in the early transplant period. Hence, routine monitoring with PCR is superior to serology in diagnosing IM early and monitoring the EBV infection post-RT for timely evaluation and management.

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.

Epstein Barr Virus-induced Antiphospholipid Antibodies Resulting in Splenic Infarct: A Case Report

Splenic infarction is a rare cause of abdominal pain. We herein reported a unique case of a 30-year-old male patient who developed a splenic infarct during the acute phase of Epstein-Barr virus (EBV)-associated infectious mononucleosis (IM) and was subsequently found to have the presence of antiphospholipid antibodies (APA).

Clinical differentiation of infectious mononucleosis that is caused by Epstein-Barr virus or cytomegalovirus: A single-center case-control study in Japan

Introduction

Infectious mononucleosis (IM) is a common viral infection that typically causes fever, pharyngitis, and lymphadenopathy in young patients. The Epstein-Barr virus (EBV) is the most common cause of IM, followed by cytomegalovirus (CMV). Given that serological testing is associated with limitations regarding its accuracy, availability, and time to receive results, clinical differentiation based on symptoms, signs, and basic tests would be useful. We evaluated whether clinical findings could be used to differentiate EBV-IM from CMV-IM.

Methods

In this single-center retrospective case-control study, we evaluated >14-year-old patients with serologically confirmed EBV-IM or CMV-IM during 2006–2017. We compared the patients’ symptoms, physical findings, blood counts, and serum biomarkers to create three regression models: model 1 (symptoms and signs), model 2 (model 1 plus sonographic hepatosplenomegaly and blood counts), and model 3 (model 2 plus hepatobiliary biomarkers).

Results

Among the 122 patients (72.6%) with EBV-IM and 46 patients (27.4%) with CMV-IM, the median age was 25 years and 82 patients (48.8%) were male. The median age was 10 years older in the CMV-IM group (p < 0.001) and the median interval from onset to visit was 5 days longer in the CMV-IM group (p < 0.001). Logistic regression revealed that EBV-IM was predicted by younger age, short onset-to-visit interval, lymphadenopathy, tonsillar white coat, hepatosplenomegaly, atypical lymphocytosis, and elevations of lactate dehydrogenase and gamma-glutamyl transferase. All regression models had areas under the curve of >0.9.

Conclusion

History and physical findings, especially when used with atypical lymphocytosis and sonographic hepatosplenomegaly, can help physicians differentiate EBV-IM from CMV-IM.

Analytical validation of an ultra low-cost mobile phone microplate reader for infectious disease testing

Most mobile health (mHealth) diagnostic devices for laboratory tests only analyze one sample at a time, which is not suitable for large volume serology testing, especially in low-resource settings with shortage of health professionals. In this study, we developed an ultra-low-cost clinically-accurate mobile phone microplate reader (mReader), and clinically validated this optical device for 12 infectious disease tests. The mReader optically reads 96 samples on a microplate at one time. 771 de-identified patient samples were tested for 12 serology assays for bacterial/viral infections. The mReader and the clinical instrument blindly read and analyzed all tests in parallel. The analytical accuracy and the diagnostic performance of the mReader were evaluated across the clinical reportable categories by comparison with clinical laboratorial testing results. The mReader exhibited 97.59-99.90% analytical accuracy and <5% coefficient of variation (CV). The positive percent agreement (PPA) in all 12 tests achieved 100%, negative percent agreement (NPA) was higher than 83% except for one test (42.86%), and overall percent agreement (OPA) ranged 89.33-100%. We envision the mReader can benefit underserved areas/populations and low-resource settings in rural clinics/hospitals at a low cost (~$50 USD) with clinical-level analytical quality. It has the potential to improve health access, speed up healthcare delivery, and reduce health disparities and education disparities by providing access to a low-cost spectrophotometer.

Infectious diseases

The measurement of biochemical parameters such as blood glucose, blood gases, electrolytes and cardiac markers have particularly benefited from recent advances in POCT. More and more, this form of analysis is now positively impacting the field of infectious diseases. Many microbiological POCT systems tend to be designed as rapid tests. In general, such tests can be carried out in a few simple steps by medical assistants or physicians without laboratory equipment or laboratory experience. It is even possible for the patients themselves to perform a series of such tests.

Drug rash with eosinophilia and systemic symptoms (DRESS) caused by phenytoin

Drug rash with eosinophilia and systemic symptoms (DRESS) is a rare but potentially life-threatening condition with high mortality. Diagnosis is challenging due to variable clinical presentation and a protracted latency period following initiation of the offending drug. DRESS is a complex interplay that starts by introduction of the offending drug, reactivation of viruses and activation of the immune system. Herpes virus reactivation is considered a diagnostic marker and indicator of illness severity. Prompt recognition and the removal of offending agent remain the key to successful treatment. In cases of severe organ involvement, corticosteroids, immunoglobulins, antiviral and specialist consultation may be helpful. Here we present a case of a 36-year-old African-American male who presented with symptoms mimicking sepsis with an associated skin eruption that was diagnosed as DRESS.

Molecular diversity of IgG responses to Epstein-Barr virus proteins in asymptomatic Epstein-Barr virus carriers

The Epstein-Barr virus (EBV) is a ubiquitous pathogen that infects over 90 % of adults. EBV is the primary etiological agent of infectious mononucleosis and is closely associated with nasopharyngeal carcinoma, gastric carcinoma, Hodgkin lymphoma and Burkitt lymphoma. Clinical serological assays for EBV diagnosis only survey a small portion of the viral proteome, which does not represent the total antigenic breadth presented to the immune system during viral infection. In this study, we have generated an expression library containing the majority of EBV ORFs, and have systematically evaluated IgG responses to those EBV proteins in sera from EBV carriers. In addition to confirming previously recognized dominant EBV antigens, this study has identified additional immunodominant antigens, and has revealed a more expansive antigenic profile of the humoral responses to EBV in asymptomatic carriers. This EBV expression library will be deposited in a public repository with the goal of disseminating this new research tool for the application of identifying potential new biomarkers for EBV-associated diseases.

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.

Fluorescence in situ hybridization is superior for monitoring Epstein Barr viral load in infectious mononucleosis patients

BACKGROUND

Epstein Barr virus (EBV) plays a causal role in some diseases, including infectious mononucleosis, lymphoproliferative diseases and nasopharyngeal carcinoma. Detection of EBV infection has been shown to be a useful tool for diagnosing EBV-related diseases. In the present study, we compared the performance of molecular tests, including fluorescence in situ hybridization (FISH) and EBV real-time PCR, to those of serological assays for the detection of EBV infection.

METHODS

Thirty-eight patients with infectious mononucleosis (IM) were enrolled, of whom 31 were diagnosed with a mild type, and seven were diagnosed with IM with haemophagocytic lymphohistiocytosis and chronic active EBV infection. Twenty healthy controls were involved in the study. The atypical lymphocytes in peripheral blood were detected under a microscope and the percentage of positive cells was calculated. EBV DNA load in peripheral blood was detected using real-time PCR. The FISH assay was developed to detect the EBV genome from peripheral blood mononuclear cells (PBMC). Other diagnosis methods including the heterophil agglutination (HA) test and EBV-VCA-IgM test, to detect EBV were also compared. SPSS17.0 was used for statistical analysis.

RESULTS

In all, 5-41% atypical lymphocytes were found among the PBMC in mild IM patients, whereas 8-51% atypical lymphocytes were found in IM patients with haemophagocytic lymphohistiocytosis and chronic active EBV infection patients. There was no significant difference in the ratios of atypical lymphoma between patients of the different types. We observed that 71.2% of mild IM patients and 85.7% of IM patients with haemophagocytic lymphohistiocytosis and chronic active EBV infection patients were positive for EBV-VCA-IgM. EBV-VCA-IgM was negative in all healthy control subjects. In addition, 67.1% of mild IM patients tested heterophile antibody positive, whereas 71.4% of IM patients with haemophagocytic lymphohistiocytosis and chronic active EBV infection tested positive. EBV DNA detected using real-time PCR was observed in 89.5% of these IM patients. The EBV genome was detected by the FISH assay in 97.4% of the IM patients. The EB viral loads detected by FISH and real-time PCR increased with the severity of IM. The EBV genome was detected in almost all the PBMC of IM with haemophagocytic lymphohistiocytosis and chronic active EBV infection patients.

CONCLUSION

Molecular tests, including FISH and EBV real-time PCR, are more sensitive than serological assays for the detection of EBV infection. The FISH assay detecting EBV copies in unfractionated whole blood is preferable and superior to plasma real-time PCR in its reflection of the absolute viral burden circulating in the patients.

Exercise and the Athlete With Infectious Mononucleosis

OBJECTIVE

To determine appropriate management of the active individual with infectious mononucleosis (IM), including issues of diagnosis, the determination of splenomegaly, and other measures of disease status, the relationship of the disease to chronic fatigue syndrome (CFS), and the risks of exercise at various points in the disease process.

DATA SOURCES

An Ovid/MEDLINE search (January 1996-June 2015) was widely supplemented by "similar articles" found in Ovid/MEDLINE and PubMed, reference lists, and personal files.

MAIN RESULTS

Clinical diagnoses of IM are unreliable. Traditional laboratory indicators (lymphocytosis, abnormal lymphocytes, and a heterophile-positive slide test) can be supplemented by more sensitive and more specific but also more costly Epstein-Barr antigen determinations. Clinical estimates of splenomegaly are fallible. Laboratory determinations, commonly by 2D ultrasonography, must take account of methodology, the formulae used in calculations and the individual's body size. The SD of normal values matches the typical increase of size in IM, but repeat measurements can help to monitor regression of the disease. The main risks to the athlete are spontaneous splenic rupture (seen in 0.1%-0.5% of patients and signaled by acute abdominal pain) and progression to chronic fatigue, best avoided by 3 to 4 weeks of restricted activity followed by graded reconditioning. A full recovery of athletic performance is usual with 2 to 3 months of conservative management.

CONCLUSIONS

Infectious mononucleosis is a common issue for young athletes. But given accurate diagnosis and the avoidance of splenic rupture and progression to CFS through a few weeks of restricted activity, long-term risks to the health of athletes are few.

Viral exanthems: An update on laboratory testing of the adult patient

Although classic viral exanthems of childhood are well described, they are rarely differentiated in adults. Laboratory techniques for viral identification have advanced without substantial literature to suggest how a dermatologist ought to conduct a cost-effective and diagnostic viral panel. Certain clinical features such as petechiae, vesicles, and dusky macular or morbilliform exanthems point strongly toward a viral exanthem. Differentiation of drug and viral causes of morbilliform eruptions has proven difficult. It is possible that with further diagnostic refinement that unnecessary and fruitless workups of an exanthem and unneeded discontinuation of drugs can be avoided. We review viral exanthems based on clinical features and discuss the available and optimal laboratory techniques to assist the dermatologist in a targeted workup.

Serodiagnosis for tumor viruses

The known human tumor viruses include the DNA viruses Epstein-Barr virus (EBV), Kaposi sarcoma herpesvirus (KSHV), Merkel cell polyomavirus (MCPyV), human papillomavirus (HPV), and hepatitis B virus (BV). RNA tumor viruses include human T-cell lymphotrophic virus type 1 (HTLV-1) and hepatitis C virus (HCV). The serological identification of antigens/antibodies in serum is a rapidly progressing field with utility for both scientists and clinicians. Serology is useful for conducting seroepidemiology studies and to inform on the pathogenesis and host immune response to a particular viral agent. Clinically, serology is useful for diagnosing current or past infection and for aiding in clinical management decisions. Serology is useful for screening blood donations for infectious agents and for monitoring the outcome of vaccination against these viruses. Serodiagnosis of human tumor viruses has improved in recent years with increased specificity and sensitivity of the assays, as well as reductions in cost and the ability to assess multiple antibody/antigens in single assays. Serodiagnosis of tumor viruses plays an important role in our understanding of the prevalence and transmission of these viruses and ultimately in the ability to develop treatments/preventions for these globally important diseases.

Splenic infarction caused by a rare coinfection of Epstein-Barr virus, cytomegalovirus, and Mycoplasma pneumoniae

Epstein-Barr virus (EBV), cytomegalovirus (CMV), and Mycoplasma pneumoniae are common pathogens of respiratory infection among children and young adults. Although single infection of 1 of these pathogens is common enough, their coinfection has been rarely reported. A 19-year-old woman presented with severe upper abdominal pain for 5 hours as well as flu-like symptoms and jaundice for 2 to 3 weeks. Initial tests found pancytopenia, abnormal liver functions, and presence of atypical lymphocytes in blood smear; the computed tomography of the abdomen revealed para-aortic lymphadenopathy, splenomegaly, and a wedge-shaped focal hypodensity lesion at the periphery of the spleen that was later diagnosed as splenic infarction. Her presentation raised suspicion of infectious mononucleosis. Nevertheless, monospot test, human immunodeficiency virus screening, and hepatitis viral serology were all negative, except that her M pneumoniae immunoglobulin M was found positive. Azithromycin was promptly given, but her fever and abdominal pain persisted. A strong suspicion of mononucleosis led to serological tests for EBV and CMV, which confirmed coinfection of EBV and CMV. By hospital day 7, her fever and abdominal pain had subsided and her liver function became normal. This case exemplifies the challenges in the diagnosis of coinfection of multiple respiratory pathogens and its associated complications. Greater awareness among clinicians would ensure an earlier and more accurate diagnosis of coinfection of EBV/CMV with other respiratory pathogen(s).

Epstein-Barr virus and risk of non-Hodgkin lymphoma in the cancer prevention study-II and a meta-analysis of serologic studies

Epstein-Barr virus (EBV) causes rare, malignant lymphomas. The role of EBV in other non-Hodgkin lymphomas (NHLs) remains unclear, but mildly reduced immune function could lead to reactivation of EBV and subsequent NHL. We examined the association between prospectively-collected plasma EBV antibodies and NHL risk in the Cancer Prevention Study-II (CPS-II) Nutrition Cohort and conducted a meta-analysis of our and published results. The CPS-II study included 225 NHL cases and 2:1 matched controls. No associations were observed between EBV serostatus or antibody levels and risk of NHL overall. However, when including only the three most common types of NHL (diffuse large B-cell lymphoma, follicular lymphoma, chronic lymphocytic leukemia/small lymphocytic lymphoma), high compared to low early antigen (EA-D) diffuse and BZLF1-encoded replication activator antibodies were associated with approximately 60% higher risk of NHL. Odds ratios (ORs) for EBV nuclear antigen-1 and viral capsid antigen (VCA)-p18 were elevated but not statistically significant. In the meta-analysis, both EA (summary OR = 1.52, 95% confidence interval (CI): 1.16-2.00) and VCA (summary OR = 1.20, 95% CI: 1.00-1.44) were positively associated with NHL risk. These results suggest EBV may be associated with a wider spectrum of NHL subtypes, but further study is needed to confirm and fully understand these associations.

Return to play after infectious mononucleosis

Context:

Infectious mononucleosis is a disease primarily of adolescence and early adulthood. The risk of splenic injury and chronic fatigue make return-to-play decisions a challenge for the clinician caring for athletes with infectious mononucleosis.

Evidence Acquisition:

Data were obtained from the PubMed and MEDLINE databases through December 2012 by searching for epidemiology, diagnosis, clinical manifestations, management, and the role of the spleen in infectious mononucleosis.

Study Design:

Clinical review.

Level of Evidence:

Level 4.

Results:

Infectious mononucleosis is commonly encountered in young athletes. Its disease pattern is variable and can affect multiple organ systems. Supportive care is the cornerstone, with little role for medications such as corticosteroids. Physical examination is unreliable for the spleen, and ultrasound imaging has limitations in its ability to guide return-to-play decisions. Exercise does not appear to place the young athlete at risk for chronic fatigue, but determining who is at risk for persistent symptoms is a challenge.

Conclusion:

Return-to-play decisions for the athlete with infectious mononucleosis need to be individualized because of the variable disease course and lack of evidence-based guidelines.

Laboratory diagnosis of viral infection

Since the last Handbook of Clinical Neurology volume on this topic, viral diagnosis has made tremendous strides, moving from the margin to the mainstream of clinical care. For many years, conventional virus isolation was the mainstay of viral diagnosis since it was sensitive and “open-minded.” However, growth in conventional cell culture entails an inherent delay that limits its clinical impact. Although rapid culture and viral antigen methods detect fewer pathogens and are less sensitive than conventional culture, both require less expertise and have greatly reduced time to result. Polymerase chain reaction has ushered in a new era in virology, especially in the diagnosis of neurologic diseases. Molecular amplification methods are rapid, highly sensitive, can be automated, quantitative, and detect viruses not amenable to routine culture. User-friendly, walk-away tests with results in an hour, as well as multiplex tests that can detect 20 viruses in a single reaction, are now a reality. As the variety of test methods and commercial products proliferate, the challenges for clinicians and laboratories are selecting which tests to utilize in which clinical scenarios, and understanding how to interpret the results. The advantages and limitations of each method are discussed in this chapter, with special attention to neurologic disease.

Reliability of the Siemens Enzygnost and Novagnost Epstein-Barr virus assays for routine laboratory diagnosis: agreement with clinical diagnosis and comparison with the Merifluor Epstein-Barr virus immunofluorescence assay

Background

Diagnosis of Epstein–Barr virus (EBV) infection is routinely conducted by clinical laboratories, especially to diagnose infectious mononucleosis. At an estimated general population incidence of 1:200, this represents a potentially significant testing burden. We evaluated the reliability of the Siemens Novagnost® and Enzygnost® EBV microtiter assays measuring VCA IgM and IgG, and EBNA-1 IgG for clinical diagnosis of EBV-related infectious mononucleosis.

Methods

Remnant sera from 537 patients tested for EBV infection were used to compare the Siemens assays to each other and to the Merifluor assay. The Siemens assays are qualitative/semiquantitative, automatable enzyme immunoassays. The Merifluor assays are manual, qualitative indirect immunofluorescent assays. Testing was conducted on the Siemens and Merifluor assays in parallel. All assays were conducted and interpreted according to each manufacturer’s specifications. Agreement of serostatus between each of the three assays was assessed. Discrepant results were resolved using a third method (Mikrogen recomLine).

Results

Final EBV serostatus indicated 2.9% of the population had an acute infection, 89.6% had a past infection, and 7.5% were EBV naive. All three assays demonstrated 100% agreement with acute infection. Agreement with past-infection serostatus was 99.1% for Enzygnost, between 86% and 98.8% for Novagnost, and 98.1% for Merifluor. Seronegative agreement was 100% for Enzygnost, 89.7% for Novagnost, and 92.3% for Merifluor.

Conclusions

The Siemens Enzygnost and Novagnost EBV microtiter assays are suitable for clinical rule-in of acute EBV infection and for identifying EBV-naive individuals. Both assays also adequately identify remote EBV infections. Because these assays can be automated, they can improve speed and efficiency of EBV testing, especially in high-volume laboratories.

Performance of two commercially available automated immunoassays for the determination of Epstein-Barr virus serological status

This study evaluated the performance of two automated Vidas (V) and Liaison (L) immunoassays for Epstein-Barr virus (EBV) serology. The detection of the viral capsid antigen (VCA) IgM, the VCA/early antigen (VCA/EA) IgG, and the Epstein-Barr nuclear antigen (EBNA) IgG was assessed on 526 sera collected for routine EBV testing in immunocompetent subjects. The determination of expected EBV status (186 EBV primary infections, 183 past EBV infections, and 157 EBV-seronegative individuals) was based on results of routine laboratory enzyme immunoassays (EIAs) together with clinical data. The sensitivity and specificity of each individual marker were determined in comparison to the expected EBV status. The agreement between the V and L profiles and the expected EBV status was established through the interpretation of combinations of the different EBV markers. Statistically significant differences between the two tests were found for the specificity of the VCA IgM marker (96.2% for V versus 93.2% for L), the sensitivity of the VCA/EA IgG marker (89% for V versus 94% for L), and the specificity of the EBNA IgG marker (96.5% for V versus 74.2% for L). The results determined for the two assays with respect to overall agreement with the established expected EBV status were not significantly different (89.7% for V versus 88.2% for L), with discrepancies mainly observed in sera referenced as primary infections. These findings demonstrated the similar performances of the Vidas and the Liaison assays for the establishment of an EBV serological status using the VCA, EA, and EBNA markers.

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.

Validity of a point-of-care based on heterophile antibody detection for the diagnosis of infectious mononucleosis in primary care

OBJECTIVE

To evaluate the validity of a point-of-care test to diagnose infectious mononucleosis (IM) compared with Epstein-Barr virus (EBV) specific serology.

METHODS

Patients over 14 years with sore throat and four Centor criteria--tonsillar exudate, fever, lymph glands tenderness and absence of cough--and negative pharyngeal testing for group A β-haemolytic streptococcal antigen were consecutively recruited. All patients underwent pharyngotonsillar swab for microbiological culture, the rapid OSOM MonoTest for the diagnosis of IM in whole blood, the Paul-Bunnell test and complete blood analysis with serology for EBV and cytomegalovirus the day after the visit and at 15 days. Sensitivity and specificity were determined.

RESULTS

We included 145 patients with a mean age of 24 ± 6.8 years. Of these, serology was determined in 129 subjects, with IM being diagnosed in 14 (10.9%). Both the MonoTest and the Paul-Bunnell test were positive in 13 patients with IM (92.9%) with no patient without disease being positive for either test--sensitivity of 92.9% (95% CI: 64.2-99.6%) and specificity of 100% (95% CI: 96-100%). The culture showed streptococcus A infection in 1 case (0.7%) and streptococcus C in 62 cases (42.8%). A total of 78 patients presented past infection by EBV (60.5%).

CONCLUSIONS

Only one out of 10 patients with sore throat, four Centor criteria and negative rapid test for streptococcal infection presents IM. Despite the MonoTest presenting optimum sensitivity and specificity, it was found to have the same validity as the Paul-Bunnell test, with serological study continuing to be necessary for precise diagnosis of IM.

Etiologies of rash and fever illnesses in Campinas, Brazil

BACKGROUND

Few population-based studies of infectious etiologies of fever-rash illnesses have been conducted. This study reports on enhanced febrile-rash illness surveillance in Campinas, Brazil, a setting of low measles and rubella virus transmission.

METHODS

Cases of febrile-rash illnesses in individuals aged <40 years that occurred during the period 1 May 2003-30 May 2004 were reported. Blood samples were collected for laboratory diagnostic confirmation, which included testing for adenovirus, dengue virus, Epstein-Barr virus (EBV), enterovirus, human herpes virus 6 (HHV6), measles virus, parvovirus-B19, Rickettsia rickettsii, rubella virus, and group A streptococci (GAS) infections. Notification rates were compared with the prestudy period.

RESULTS

A total of 1248 cases were notified, of which 519 (42%) had laboratory diagnosis. Of these, HHV-6 (312 cases), EBV (66 cases), parvovirus (30 cases), rubella virus (30 cases), and GAS (30 cases) were the most frequent causes of infection. Only 10 rubella cases met the rubella clinical case definition currently in use. Notification rates were higher during the study than in the prestudy period (181 vs 52.3 cases per 100,000 population aged <40 years).

CONCLUSIONS

Stimulating a passive surveillance system enhanced its sensitivity and resulted in additional rubella cases detected. In settings with rubella elimination goals, rubella testing may be considered for all cases of febrile-rash illness, regardless of suspected clinical diagnosis.

Epstein-Barr virus serologic abnormalities and risk of rheumatoid arthritis among women

BACKGROUND

Epstein-Barr virus (EBV) infection and the immune response may be involved in the pathogenesis of rheumatoid arthritis (RA). Past studies have suggested an association between EBV and RA.

METHODS

We studied the association between EBV serologies and RA risk in a nested case-control study in the Nurses' Health Study (NHS) cohorts. We confirmed incident RA cases from 1990 to 2002 by questionnaire and medical record review. Each incident case with blood collected prior to RA symptoms was matched with a healthy participant by time of day and date of blood collection, birth year, menopausal status and postmenopausal hormone use. Immunofluorescence assays measured serologic EBV responses: viral capsid antigen, early-antigen-diffuse and early antigen-complex (restricted and diffuse), Epstein Barr nuclear antigen (EBNA)-1, EBNA-2 and cytomegalovirus (CMV), as control. All were reported as titers, except CMV, which was reported as positive or negative. Antinuclear antibody positive samples were excluded. Elevated EBV antibody titers were defined as the upper 20% (or nearest titer) among controls. Conditional logistic regression analyses modeled RA risk associated with elevated EBV titers or the presence/absence of CMV, further adjusted for pack-years smoking and alcohol intake.

RESULTS

Eighty-seven incident RA cases were identified. Mean time to RA after blood draw was 6.2 (± 3.5) years in NHS and 1.9 (± 0.6) years in NHS II. Antibody titers against EBV were not significantly different between pre-RA cases and controls.

CONCLUSIONS

In this prospective study of women, we observed no association between EBV serologies and RA risk.

Anti-EBNA-1 IgG is not a reliable marker of multiple sclerosis clinical disease activity

BACKGROUND

Sero-epidemiological studies have demonstrated the association between multiple sclerosis (MS) and prior Epstein-Barr virus (EBV) infection. It has been hypothesized that intermittent peripheral EBV reactivation may drive continuing central inflammation. Recent investigation has shown significant differences in median serum levels of anti-EBV nuclear antigen-1 (EBNA-1) IgG between disease subgroups and positive correlation with disease activity reflected by number of Gd-enhancing lesions and T2 lesion volume. These important data have led to hopes that anti-EBNA-1 IgG may be useful as an easily accessible and effective biomarker of disease activity.

METHODS

We examined the applicability of these findings in routine clinical practice, assessing a well-characterized cohort of 100 subjects (25 primary progressive, 25 stable relapsing remitting, 25 active relapsing remitting seen in acute relapse and 25 controls) for serum anti-EBNA-1 IgG using both the Liaison quantitative chemiluminescent assay and Biotest ELISA.

RESULTS

We were unable to show a difference in quantitative analysis of serum anti-EBNA-1 IgG levels between disease subgroups and no correlation with phenotypic characteristics including age at onset (r = -0.17, P = 0.16), disease duration (r = 0.03, P = 0.78), EDSS (r = 0.03, P = 0.78) or MSSS (r = 0.02, P = 0.9). In addition, there was only moderate correlation between the two test methods used (intraclass correlation coefficient 0.67; 0.56-0.78) suggesting potential problems with test interpretation.

CONCLUSIONS

We have been unable to determine a clinical value for serum anti-EBNA-1 IgG levels in MS or to confirm reported association with disease course and clinical disease activity.

Point of care testing: diagnosis outside the virology laboratory

Numerous point-of-care tests (POCTs) are available to diagnose viral infections in both hospital and community settings. The ideal POCT is rapid, sensitive, specific, and simple to perform. This chapter will describe the benefits of POCTs, factors that can influence the accuracy of POCTs and highlight some limitations of POCT strategies. The sensitivity, specificity, and turn-around time of available POCTs are included for common conditions including respiratory viral infections (e.g. influenza, RSV) and blood-borne viral infections (e.g. HIV).

Epstein-Barr virus-associated infectious mononucleosis and risk of systemic lupus erythematosus

OBJECTIVES

Elevated levels of serological markers of EBV infection in patients with SLE and observations that infectious mononucleosis (IM) may precede some cases of SLE suggest a possible role of EBV in the aetiology of SLE. We evaluated the relationship between EBV-associated IM and subsequent risk of SLE in a population-based cohort study.

METHODS

We followed cohorts of Danes tested serologically for IM using the Paul-Bunnell (PB) heterophile antibody test between 1939 and 1989, and patients hospitalized with IM between 1977 and 2007 for subsequent first hospitalizations with SLE in the period 1977-2008. Standardized incidence ratios (SIRs) with 95% CI served as measures of relative risk.

RESULTS

Risk of SLE was not increased either in individuals with a positive PB test (SIR = 1.1; 95% CI 0.8, 1.6; n = 27) or in individuals hospitalized with IM (SIR = 1.3; 95% CI 0.7, 2.2; n = 12). However, SLE risk in PB-negative individuals was significantly increased (SIR = 2.6; 95% CI 2.1, 3.2; n = 82), a risk that was particularly high 1-4 years after the PB test (SIR = 6.6; 95% CI 3.3, 13.2) and remained significantly elevated for >25 years.

CONCLUSIONS

EBV-associated IM does not seem to be a risk factor for SLE. The temporal pattern of increased SLE risk in individuals with a negative PB test suggests that some patients who go on to develop SLE may present with unspecific symptoms, for which they may be tested for IM, long in advance of their SLE diagnosis.

Epstein-Barr virus antibody level and gastric cancer risk in Korea: a nested case-control study

Background:

Few cohort studies have investigated Epstein–Barr virus (EBV) infection before the occurrence of gastric cancer.

Methods:

Among 14 440 cohort participants, 100 incident gastric cancer cases were individually matched to two controls. Epstein–Barr virus antibodies IgG and IgA against viral capsid antigen (VCA), EBV nuclear antigen (EBNA) antibody IgG, and early antigen (EA) antibody IgG were measured using enzyme immunoassays (EIAs).

Results:

The highest titres of VCA IgG (odds ratio (OR): 1.37, 95% confidence interval (CI): 0.62–3.06) or EBNA IgG (OR: 0.87, 95% CI: 0.51–1.46) were not associated with gastric cancer risk.

Conclusion:

Higher levels of VCA IgG or EBNA IgG were not associated with increased risk of gastric adenocarcinoma in Koreans.

Evaluation of Epstein-Barr virus antibodies, anti-VCA avidity by immunofluorescence and immunoblot assays for assessment of Epstein-Barr virus immunologic state

Three hundred twenty two serum samples were evaluated by indirect immunofluorescence assay (IFA) and immunoblotting for the assessment of the immunologic status of Epstein-Barr virus (EBV). Serological profiles of 322 serum samples were classified by the IgM and IgG antibodies by the immunofluorescence assay as seronegative, acute infection, reactivation and past infection. Higher rates of seropositivity were determined in serum samples belonging to old age groups. Routine tests used for EBV diagnosis were efficient.