{"id":431,"date":"2018-02-13T08:36:13","date_gmt":"2018-02-13T16:36:13","guid":{"rendered":"http:\/\/healingdragon.net\/wp\/?p=431"},"modified":"2021-02-25T05:52:06","modified_gmt":"2021-02-25T05:52:06","slug":"epstein-barr","status":"publish","type":"post","link":"https:\/\/healingdragon.net\/wordpress\/index.php\/2018\/02\/13\/epstein-barr\/","title":{"rendered":"Epstein-Barr"},"content":{"rendered":"<p><strong>Epstein-Barr<\/strong><\/p>\n<p>Epstein-Barr virus (EBV) is part of the Herpes family of viruses.\u00a0 There are eight separate viruses within this family: Herpes simplex 1 and 2 (HV 1, HV 2), Varicella (HV 3), EBV (HV 4), Cytomegalovirus (HV 5), Herpes virus 6 (HV 6), Herpes virus 7 (HV 7), and Kaposi sarcoma-associated virus (HV 8) (1).\u00a0 HV1 and 2 are most commonly associated with oral and genital herpes.\u00a0 Varicella causes chickenpox and shingles and CMV causes CMV mononucleosis, which is similar to EBV mononucleosis but is often less severe. HV6 and HV7 are most commonly associated with roseola infantum.\u00a0 HV8 is not a known cause of acute illness but may cause Kaposi sarcoma and AIDS-related non-Hodgkin lymphomas. (1)<\/p>\n<p><strong>Infection and Transmission<\/strong><\/p>\n<p>All herpes viruses can remain latent within the body and EBV infects the B cells of the immune system.\u00a0 \u00a0EBV spreads primarily through body fluids, most commonly through saliva (3); it can also be transmitted through sexual contact, blood transfusions, and organ transplants (3). \u00a0EBV does not survive on surfaces but it \u201ccan be spread by using objects, such as a toothbrush or drinking glass that an infected person recently used. The virus probably survives on an object at least as long as the object remains moist.\u201d (3)<\/p>\n<p>An infected person can shed the virus for weeks before symptoms appear and \u201cif the virus reactivates, (a person) can potentially spread EBV to others no matter how much time has passed since the initial infection.\u201d (3) People with reactivated infections may also be able to transmit EBV to other people even if they themselves do not have active symptoms. (1)<\/p>\n<p><strong>Symptoms of Acute Infection<\/strong><\/p>\n<p>Half of children are infected with EBV before the age of 5 (2) and \u201cEBV infections in children usually do not cause symptoms, or the symptoms are not distinguishable from other mild, brief childhood illnesses.\u201d (3)<\/p>\n<p>Symptoms of infectious mononucleosis develop most often in older children and adults and include fever, sore throat (pharyngitis), and lymph node swelling (adenopathy). (2)\u00a0 The lymph node swelling is usually symmetrical, can include any group of lymph nodes, and may be the only symptom (2) Patients may also experience enlargement of the spleen and\/or liver, swelling around the eyes, and rash.<\/p>\n<p>The typical symptoms of acute infectious mononucleosis can be similar to those of other infections, and patients with this presentation should also be evaluated for primary HIV infection, cytomegalovirus infection, \u201ctoxoplasmosis, hepatitis B, rubella, or atypical lymphocytes associated with adverse drug reactions.\u201d (2)<\/p>\n<p><strong>Complications of Acute Infection<\/strong><\/p>\n<p>Patients typically recover completely from EBV mononucleosis but fatigue can last for months after other symptoms resolve. (2, 3) Acute complications of the infection are rare but may be significant and can include:<\/p>\n<ul>\n<li><strong>Neurologic complications:<\/strong>encephalitis, seizures, Guillain-Barr\u00e9 syndrome, peripheral neuropathy, viral meningitis, myelitis, cranial nerve palsies, and psychosis<\/li>\n<li><strong>Hematologic complications<\/strong>: granulocytopenia, thrombocytopenia, hemolytic anemia<\/li>\n<li><strong>Splenic rupture<\/strong><\/li>\n<li><strong>Respiratory complications: <\/strong>upper airway obstruction due to adenopathy<\/li>\n<li><strong>Hepatic complications: <\/strong>elevated aminotransferase levels, jaundice (2)<\/li>\n<\/ul>\n<p><strong>Chronic Infection Concerns<\/strong><\/p>\n<p>In addition to causing infectious mononucleosis, EBV is known as a potential cause of hepatitis, encephalitis, nasopharyngeal carcinoma, Hodgkin lymphoma, and Burkitt lymphoma (1, 2).\u00a0 While EBV may remain latent for many people, significant research is being done into links between EBV and many autoimmune diseases.\u00a0 A search of the NIH website for research done in just the last 5 years showed studies linking EBV as a potential cause of the development and exacerbation of multiple sclerosis (4, 5, 6), lupus (5), rheumatoid arthritis (7, 8), oral lichen planus (8), Sj\u00f6gren&#8217;s syndrome (7, 9), Hashimoto\u2019s and Grave\u2019s diseases (autoimmune thyroid diseases) as well as possibly primary thyroid lymphoma (10).\u00a0 \u201cAutoimmune\u00a0liver diseases (AiLDs), including\u00a0autoimmune\u00a0hepatitis (AIH), primary biliary cirrhosis (PBC), and primary sclerosing cholangitis (PSC), have a potential causative link with EBV\u201d (11) as do \u201cinterstitial pneumonia, malignant lymphoma, and coronary aneurysm.\u201d (12)<\/p>\n<p>The findings of a 2015 study indicated that EBV infections can become life-threatening in rare cases, but in contrast, \u201ca range of other EBV-positive malignancies of lymphoid or epithelial origin arise in individuals with seemingly intact immune systems through mechanisms that remain to be understood.\u201d (13) This indicates that EBV may cause <u>significant<\/u> immune disruption, including cancers, in otherwise immune <u>healthy<\/u> patients, through routes and interactions with other factors that we have not yet identified.\u00a0 Given that the vast majority of the population has been infected with EBV but not everyone develops these conditions, we know that EBV infection alone is not the cause.\u00a0 However, we also do not know what the characteristics are that would cause any individual person to go on to develop one of these conditions with EBV as one of the causative factors.<\/p>\n<p><strong>Diagnosis<\/strong><\/p>\n<p>Diagnosis of acute infectious mononucleosis is based on symptoms and signs and a positive heterophile antibody (monospot) test. Patients should know that \u201cheterophile antibodies are present in only 50% of patients\u00a0less than 5 years old and in about 80 to 90% of adolescents and adults with infectious mononucleosis.\u201d (2) This test may also give a false-positive result in patients with acute HIV infection. (2) If there is high suspicion of mono but a negative monospot, it is worth repeating the test after 7 to 10 days, as the antibody levels rise in the 2<sup>nd<\/sup> and 3<sup>rd<\/sup> weeks of illness. (2) A complete blood count may also show atypical lymphocytes; it is important to know that \u201catypical lymphocytes may also be present in HIV or CMV infection, hepatitis B, influenza B, rubella, or other viral illnesses\u2026 however, very high atypical lymphocyte counts are typically seen only in primary EBV and CMV infection.\u201d (2)<\/p>\n<p>Laboratory testing may also include antibodies to EBV.\u00a0 There are four different types of EBV antibodies: IgG antibodies for Early Antigen (EA-IgG), IgM antibodies to the viral capsid (VCA-IgM), IgG antibodies to the viral capsid (VCA-IgG), and IgG antibodies to the nuclear antigen (EBNA-IgG). These represent different phases of the immune system\u2019s response to different parts of the virus itself.\u00a0 Most labs provide a table to interpret the pattern of a patient\u2019s results.\u00a0 The following is from Labcorp:<\/p>\n<table width=\"0\">\n<thead>\n<tr>\n<td colspan=\"5\" width=\"618\"><strong>EBV Interpretation Table (14)<\/strong><\/td>\n<\/tr>\n<tr>\n<td width=\"195\">Interpretation<\/td>\n<td width=\"111\">EBV-IgM<\/td>\n<td width=\"96\">EA(D)-IgG<\/td>\n<td width=\"102\">VCA-IgG<\/td>\n<td width=\"114\">EBNA-IgG<\/td>\n<\/tr>\n<\/thead>\n<tbody>\n<tr>\n<td colspan=\"5\" width=\"618\"><strong>Key \u2014<\/strong>\u00a0Antibody present: + Antibody absent: \u2212<\/td>\n<\/tr>\n<tr>\n<td width=\"195\">EBV seronegative<\/td>\n<td width=\"111\">\u2212<\/td>\n<td width=\"96\">\u2212<\/td>\n<td width=\"102\">\u2212<\/td>\n<td width=\"114\">\u2212<\/td>\n<\/tr>\n<tr>\n<td width=\"195\">Early phase<\/td>\n<td width=\"111\">+<\/td>\n<td width=\"96\">\u2212<\/td>\n<td width=\"102\">\u2212<\/td>\n<td width=\"114\">\u2212<\/td>\n<\/tr>\n<tr>\n<td width=\"195\">Acute primary infection<\/td>\n<td width=\"111\">+<\/td>\n<td width=\"96\">\u00b1<\/td>\n<td width=\"102\">+<\/td>\n<td width=\"114\">\u2212<\/td>\n<\/tr>\n<tr>\n<td width=\"195\">Convalescence\/past infection<\/td>\n<td width=\"111\">\u2212<\/td>\n<td width=\"96\">\u00b1<\/td>\n<td width=\"102\">+<\/td>\n<td width=\"114\">+<\/td>\n<\/tr>\n<tr>\n<td width=\"195\">Reactivated infection<\/td>\n<td width=\"111\">\u00b1<\/td>\n<td width=\"96\">+<\/td>\n<td width=\"102\">+<\/td>\n<td width=\"114\">+<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>If all these antibody tests are negative, then it means the patient has never been exposed to EBV.\u00a0 A positive titer for VCA-IgM indicates a primary EBV infection because the IgM antibodies are the first to appear and the first to disappear, typically within 3 months after infection. (2) \u00a0VCA-IgM antibodies can also reappear in a reactivated infection, but are not always present.\u00a0 The EA-IgG and VCA-IgG antibodies develop after the IgM antibodies and there can be a time of overlap between the presences of these two types of antibodies.\u00a0 The EBNA-IgG antibodies are the last to appear and VCA-IgG and EBNA-IgG persist for life.<\/p>\n<p>According to the Merck Manual, \u201cover 90% of adults are seropositive for EBV.\u201d (2) This means that 90% of adults in the general population have been exposed to EBV and will show positives for past infection.\u00a0 This is a very different pattern than that of patients with active infection.\u00a0 Additionally, while the lab table indicates that the EA-IgG is positive for a reactivated infection, Dr. Oethinger , the director of microbiology at Providence Laboratory, indicated in personal communication that \u201cthe EA doesn\u2019t need to be positive again during reactivation.\u201d (15)\u00a0 This means that the pattern between past and reactivated infections can be difficult to differentiate and individual patients must be evaluated based on symptoms as well as potential risks for future issues.<\/p>\n<p><strong>Treatment<\/strong><\/p>\n<p>Treatment of EBV needs to be assessed based on a patient\u2019s current symptoms, test results, and concerns for possible development of future conditions linked to EBV.\u00a0 Because I see many patients with autoimmune conditions, I am very concerned about the developing body of research linking EBV as a potential causative factor for many common autoimmune diseases.<\/p>\n<p>Autoimmune diseases occur due to a combination of many different genetic and environmental factors.\u00a0 Some factors, such as our genes, we cannot change.\u00a0 There may be other factors medicine hasn\u2019t identified yet.\u00a0 Since these are areas we cannot treat, I look to those known environmental factors that are significant risk factors. \u00a0\u00a0By reducing their impact, we can hopefully prevent future disease or reduce disease activity for those patients already diagnosed with autoimmune conditions.<\/p>\n<p>Western medicine has no options for treatment of EBV infections except supportive care and corticosteroids possibly for severe disease. (2)\u00a0 The anti-virals that are effective for other herpes family viruses (especially acyclovir) do not appear effective against EBV.\u00a0 Studies have shown that acyclovir reduces shedding of EBV in saliva, but it does not change any single symptom or course of disease and viral titers returned to pre-treatment levels one to three weeks after cessation of therapy. (16, 17, 18) These are older studies, but as of February 2016, the Merck Manual still states \u201cthere is no convincing evidence to warrant (acyclovir\u2019s) clinical use\u201d for EBV infection. (2)\u00a0 The Merck Manual does list two other medications as showing possible activity against EBV: cidofovir and foscarnet.\u00a0 However, both of these medications are only given IV and are limited by significant kidney toxicity. (2)\u00a0 Therefore, they would be reserved for the most severe cases.<\/p>\n<p>Naturopathic medicine has many options for treating EBV both in terms of general anti-virals and options specifically designed for EBV.\u00a0 Levels of immune-essential nutrients, such as vitamin A, vitamin D and zinc, can be optimized. Monolaurin is a byproduct of coconut oil and is commonly used as a general anti-viral.\u00a0 Lysine, which is often used to treat herpes simplex outbreaks, can also be used for EBV, as can colostrum for patients who do not have issues with dairy.\u00a0 There are numerous herbs, including olive leaf, garlic, goldenseal, Echinacea, and grape seed, and mushrooms, including cordyceps, turkey tail, shiitake, and lion\u2019s mane, that can be used individually or in combination formulas.\u00a0 Gemmotherapy preparations of several herbs are designed specifically to treat intra-cellular viruses, and essential oils can be added to herbal combinations.\u00a0\u00a0 Treatments can also include supporting the T-regulatory cells of the immune system, including probiotics, fish oil, vitamin D, and glutathione.<\/p>\n<p>When using any of these therapies, it is important to start with low doses and increase slowly to patient\u2019s tolerance.\u00a0 Many people discuss \u201cdie-off\u201d reactions with Lyme disease or candida overgrowth, and the same may be said for EBV infections.\u00a0 As such, a complete plan would also include supports for detoxification and elimination, and would balance and rotate any anti-viral therapies.<\/p>\n<p>Because these anti-virals are generally safe and well-tolerated, and the impacts of autoimmune disease can be devastating, this is one situation where I personally err on the side of treatment, especially in cases where patients have very high antibody levels.\u00a0 My hope is that we can provide safe and relatively inexpensive treatment that could prevent a future autoimmune condition by treating a potential cause before symptoms arise.<\/p>\n<p><strong>Sources<\/strong><\/p>\n<p>(1) https:\/\/www.merckmanuals.com\/professional\/infectious-diseases\/herpesviruses\/overview-of-herpesvirus-infections<\/p>\n<p>(2) https:\/\/www.merckmanuals.com\/professional\/infectious-diseases\/herpesviruses\/infectious-mononucleosis<\/p>\n<p>(3) https:\/\/www.cdc.gov\/epstein-barr\/about-ebv.html<\/p>\n<p>(4) Epstein-Barr\u00a0virus-specific adoptive immunotherapy for progressive multiple sclerosis (https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/24493474)<\/p>\n<p>(5) Epstein-Barr\u00a0virus in multiple sclerosis. (https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/25162741)<\/p>\n<p>(6) Multiple sclerosis and environmental factors: the role of vitamin D, parasites, and\u00a0Epstein-Barr virus infection. (https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/26046559)<\/p>\n<p>(7) Epstein-Barr\u00a0virus in systemic\u00a0autoimmune\u00a0diseases (https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/24062777)<\/p>\n<p>(8) Epstein-Barr\u00a0virus and its association with rheumatoid arthritis and oral lichen planus. (https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/26980953)<\/p>\n<p>(9) Connective tissue diseases:\u00a0Epstein-Barr\u00a0virus in Sj\u00f6gren&#8217;s syndrome salivary glands drives local\u00a0autoimmunity. (https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/24934188)<\/p>\n<p>(10) The role of\u00a0Epstein-Barr\u00a0virus infection in the development of\u00a0autoimmune\u00a0thyroid diseases. (https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/25931043)<\/p>\n<p>(11) Epstein-barr\u00a0virus as a trigger of\u00a0autoimmune\u00a0liver diseases. (https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/22693505)<\/p>\n<p>(12) Possible\u00a0autoimmune\u00a0hepatitis induced after chronic active\u00a0Epstein-Barr\u00a0virus infection. ( https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/26183510)<\/p>\n<p>(13) The immunology of\u00a0Epstein-Barr\u00a0virus-induced disease. (https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/25706097)<\/p>\n<p>(14) https:\/\/www.labcorp.com\/test-menu\/24771\/epstein-barr-virus-ebv-acute-infection-antibodies-profile<\/p>\n<p>(15) personal communication, Dr. Kimberly Hindman and Dr. Oethinger<\/p>\n<p>(16) Acyclovir\u00a0treatment in primary\u00a0Epstein-Barr\u00a0virus infection. A double-blind placebo-controlled study. (https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/3006226)<\/p>\n<p>(17) Acyclovir\u00a0and\u00a0Epstein-Barr\u00a0virus infection. (https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/6313591)<\/p>\n<p>(18) Acyclovir\u00a0treatment in infectious mononucleosis: a clinical and virological study. (https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/3036715)<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Epstein-Barr Epstein-Barr virus (EBV) is part of the Herpes family of viruses.\u00a0 There are eight separate viruses within this family: Herpes simplex 1 and 2&#8230;<\/p>\n<div class=\"more-link-wrapper\"><a class=\"more-link\" href=\"https:\/\/healingdragon.net\/wordpress\/index.php\/2018\/02\/13\/epstein-barr\/\">Continue reading<span class=\"screen-reader-text\">Epstein-Barr<\/span><\/a><\/div>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[11],"tags":[50,51],"class_list":["post-431","post","type-post","status-publish","format-standard","hentry","category-handouts","tag-autoimmune","tag-infection","entry"],"_links":{"self":[{"href":"https:\/\/healingdragon.net\/wordpress\/index.php\/wp-json\/wp\/v2\/posts\/431","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/healingdragon.net\/wordpress\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/healingdragon.net\/wordpress\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/healingdragon.net\/wordpress\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/healingdragon.net\/wordpress\/index.php\/wp-json\/wp\/v2\/comments?post=431"}],"version-history":[{"count":1,"href":"https:\/\/healingdragon.net\/wordpress\/index.php\/wp-json\/wp\/v2\/posts\/431\/revisions"}],"predecessor-version":[{"id":491,"href":"https:\/\/healingdragon.net\/wordpress\/index.php\/wp-json\/wp\/v2\/posts\/431\/revisions\/491"}],"wp:attachment":[{"href":"https:\/\/healingdragon.net\/wordpress\/index.php\/wp-json\/wp\/v2\/media?parent=431"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/healingdragon.net\/wordpress\/index.php\/wp-json\/wp\/v2\/categories?post=431"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/healingdragon.net\/wordpress\/index.php\/wp-json\/wp\/v2\/tags?post=431"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}