EBV – Epstein Barr Virus
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Epstein-Barr virus (EBV) is a type of human herpes virus. It is extremely widespread, and is contracted by close person to person contact. It can cause a wide range of clinical consequences, and the most common clinical manifestation is Infectious Mononucleosis.

Many infections (up to 50%) are subclinical and asymptomatic. In (the other) 50% of people, primary infection with the virus will cause clinical symptoms, usually in the form of infectious mononucleosis.
In both subclinical, and clinical primary infections, the host will carry the virus asymptomatically for the rest of their life, after the initial presentation has resolved.

Long-term, it has been associated with an increased risk of B cell lymphoma, T cell lymphoma, Hodgkin’s lymphoma, and nasopharyngeal carcinoma.


  • Up to 95% of individuals carry the virus
  • Approximately 50% of cases are symptomatic on primary infection, most commonly in the form of Infectious Mononucleosis
  • Can present at any age. May be more common in teenagers, and occasionally referred to as ‘kissing disease’

Infectious Mononucleosis

Infectious mononucleosis (IM) also known as Glandular Fever is the most common clinical manifestation of EBV.

Presentation and Diagnosis

Often described as ‘flu-like’ symptoms they can be difficult to differentiate from other viral and URTI causes. Any combination of the following may be present:
  • Headache
  • Fever
  • Tonsillitis / sore throat
  • Cervical lymph node enlargement and tenderness (usually symmetrical)
  • Malaise and severe fatigue
  • May have tonsillar exudate
  • Nausea / vomiting / GI symptoms. Up to 90% of patients also have a mild hepatitis
  • Splenomegaly occurs in 50% of patients
  • Jaundice and hepatomegaly are rare
  • Occasionally patients may present with hepatitis with none of the other features
It can be difficult to differentiate from other cause or URTI / sore throat. As in tonsillitis, there are four parameters that can help differentiate a viral from a bacterial cause. If all four are present, there is a 50% chance the cause is bacterial. Antibitoics should only be recommended if all four features are present (although in reality, they are often given when all features are not present)
  • Fever >38 degrees
  • Tender cervical lympadenopathy
  • Tonsillar Exudate
  • No cough

Often in a bacterial cause, there is asymmetrical cervical lymphadenopathy also.

It is particularly important to differentiate EBV from bacterial causes because giving amoxicillin or ampicillin in EBV infection is contraindicated and can cause a rash (which is unrelated to any penicillin hypersentivity).

Epstein Barr Virus
Epsteine Barr Virus. This electron microscopic image of two Epstein Barr Virus virions (viral particles) shows round capsids—protein-encased genetic material—loosely surrounded by the membrane envelope. This file is taken from wikimedia commons and is licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license.


  • Avoid antibiotics
  • Most cases resolve spontaneously within 1-2 weeks
  • Fatigue can persist for several weeks or months
Most individuals subsequently develop lifelong immunity to further acute infections.

Other Infections

EBV can affect almost any organ, and is associated with a wide range of diseases. It is often screened for in wide ranging presentations where no cause can be found, and is also often part of a liver screen.


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Dr Tom Leach

Dr Tom Leach MBChB DCH EMCert(ACEM) FRACGP currently works as a GP and an Emergency Department CMO in Australia. He is also a Clinical Associate Lecturer at the Australian National University, and is studying for a Masters of Sports Medicine at the University of Queensland. After graduating from his medical degree at the University of Manchester in 2011, Tom completed his Foundation Training at Bolton Royal Hospital, before moving to Australia in 2013. He started almostadoctor whilst a third year medical student in 2009. Read full bio

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