Consultation outcome

V 26: closed consultation draft

Updated 25 January 2019

This is a draft document: version dd, consulted on between 25 May 2018 to 8 June 2018.

1. General information

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2. Scientific information

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3. Scope of document

This algorithm considers the interpretation of common Epstein-Barr virus (EBV) serology profiles arising from investigation of acute EBV infection and not those arising from investigation of malaise or persistent lymphadenopathy. Although EBV-specific serology is preferable, properly conducted heterophile antibody tests (eg Paul-Bunnell, Monospot) remain acceptable in appropriate clinical circumstances as described below. EBV IgG avidity testing may be helpful in distinguishing acute and past infections^{[footnote 1] [footnote 2]}.

Refer to Q 7 - Good practice when undertaking serology assays for infectious diseases for information regarding good laboratory practice in serological testing.

This UK SMI should be used in conjunction with other UK SMIs.

4. Safety considerations

This guidance should be supplemented with local COSHH and risk assessments. Refer to current guidance on the safe handling of all organisms documented in this UK SMI.

5. Specimen processing and procedure

5.1 Specimen type

Serum, plasma or refer to manufacturer’s guidelines.

5.2 Specimen transport and storage conditions

Specimens should be collected in appropriate CE marked leak proof containers and transport in sealed plastic bag.

Specimens should be transported and processed according to manufacturer’s instructions or locally validation data^{[footnote 3]}.

Samples should be retained in accordance with The Royal College of Pathologists guidelines ‘The retention and storage of pathological records and specimens’^{[footnote 4]}.

6. Investigation: laboratory diagnosis of acute EBV infection^{[footnote 1] [footnote 5] [footnote 6] [footnote 7] [footnote 8]}

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Footnotes

a) Some laboratories choose not to routinely test patients above a specific age as the positive predictive value of any test set will be low for diagnosis of acute infection.

b) Although EBV-specific serology is preferable, properly conducted heterophile antibody tests (for example, Paul-Bunnell, Monospot) remain acceptable in appropriate clinical circumstances^{[footnote 9]}. Heterophile antibody tests are not appropriate for testing children and immunocompromised individuals due to a high false negative rate. False positives are uncommon but have been described in rheumatoid disease, SLE, leukaemia, lymphoma, infections including malaria, HIV, CMV, rubella, viral hepatitis and tularaemia, and after administration of anti-thymocyte globulin^{[footnote 9]}.

c) Two different approaches to initial screening for EBV are in common use; either initial anti-EBNA-1 or initial VCA (IgG and IgM) testing are equally valid if appropriate algorithms are followed and due care is given to interpretation of results. Anti-EBNA-1 usually appears after 3-4 weeks from onset of illness and appears in 95% or more of individuals; but may not be present in the immunocompromised individuals or in chronic EBV infections^{[footnote 10]}. Some laboratories use antibody to early antigen (diffuse) as an additional test in diagnosis of acute infection^{[footnote 10]}.

d) EBV DNA PCR must be used to investigate primary or reactivated EBV infection in patients who are immunocompromised and at risk of severe disease as serological tests may be unreliable in the immunocompromised patients^{[footnote 11]}.

e) EBV DNA PCR on whole blood (EDTA) or plasma may be useful as a confirmatory assay where antibody test results are inconclusive.

f) EBV IgG avidity testing may be helpful in distinguishing acute and past infections^{[footnote 1] [footnote 2]}.

g) Interpret with caution as in a small number of cases EBNA IgG may be detectable early - by immunofluorescent antibody testing as early as ten days after the onset of illness in <5%^{[footnote 12]}.

h) If haematological parameters consistent with acute EBV infection regard as confirmed. If haematological parameters are not consistent with acute EBV infection or are not available regard as unconfirmed and consider doing confirmatory specific EBV serology^{[footnote 13]}.

7. Interpreting and reporting laboratory results

There are other combinations of results which have not been tabled but which do occur and require individual comments based upon profile and clinical setting, along with a further sample.

Note: ‘recent infection’ covers infection in the last 2 to 4 weeks.

	VCA IgM	VCA IgG	EBNA IgG	Interpretative Comment	Notes
1	Not detected	Not detected	Not detected	No serological evidence of EBV infection at any time.	Re-test if recent onset of illness. Consider testing for HIV[footnote 14].
2	Not detected	Detected	Detected	Consistent with past EBV infection. Consider testing for HIV if at risk[footnote 14].
3	Detected	Detected	Not detected	Consistent with recent acute EBV infection	Consider possibility of false negative anti-EBNA-1 when reporting.
4	Detected	Not detected	Not detected	Consistent with but not diagnostic of early acute EBV infection. Repeat to confirm in 4-6 weeks.	IgM result may be false, repeat to clarify. EBV DNA PCR may be useful in this situation.
5	Not detected	Detected	Not detected	The EBV serological profile may reflect distant past infection, however recent infection cannot be excluded. Repeat in 4-6 weeks if recent EBV infection is suspected.	Consider EBV PCR and heterophile antibody testing[footnote 7] [footnote 10].
6	Detected	Detected	Detected	Evidence of EBV infection at some time, but this profile is difficult to interpret. Although the IgM reactivity might be false, late primary infection or recent EBV reactivation cannot be excluded.	Some laboratories may be able to establish a cut off for IgM below which most results are false, and can be reported as such, if EBV VCA IgG and anti-EBNA-1 IgG are positive. Unrelated acute infection can result in the non-specific polyclonal activation of memory cells and the release of VCA IgM. Consider testing for CMV IgM, Parvovirus IgM, HAV IgM and HIV[footnote 7] [footnote 10]. EBV PCR and heterophile antibody testing may be helpful. Review in light of clinical details, and the numerical values of the test results and consider repeat to clarify.

This is a draft document: version dd, consulted on between 25 May 2018 to 8 June 2018.

8. References

1. Nystad TW, Myrmel H. Prevalence of primary versus reactivated Epstein-Barr virus infection in patients with VCA IgG-, VCA IgM- and EBNA-1-antibodies and suspected infectious mononucleosis. JClinVirol 2007;38:292-7. ↩ ↩² ↩³

2. Robertson P, Beynon S, Whybin R, Brennan C, Vollmer-Conna U, Hickie I et al. Measurement of EBV-IgG anti-VCA avidity aids the early and reliable diagnosis of primary EBV infection. JMed Virol 2003;70:617-23. ↩ ↩²

3. Baron EJ, Miller JM, Weinstein MP, Richter SS, Gilligan PH, Thomson RB, Jr. et al. A Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2013 Recommendations by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM). ClinInfectDis 2013;57:e22-e121. ↩

4. The Royal College of Pathologists. The retention and storage of pathological records and specimens (5th edition). 1-59. 2015. ↩

5. Berger C, Day P, Meier G, Zingg W, Bossart W, Nadal D. Dynamics of Epstein Barr virus DNA levels in serum during EBV associated disease. J Med Virol 2001;64:505-12. ↩

6. Leung E, Shenton BK, Jackson G, Gould FK, Yap C, Talbot D. Use of real time PCR to measure Epstein Barr virus genomes in whole blood. J Immunol Methods 2002;270:259-67. ↩

7. De Paschale M, Agrappi C, Manco MT, Mirri P, Vigano EF, Clerici P. Seroepidemiology of EBV and interpretation of the “isolated VCA IgG” pattern. JMed Virol 2009;81:325-31. ↩ ↩² ↩³

8. Odumade OA, Hogquist KA, Balfour HH, Jr. Progress and problems in understanding and managing primary Epstein-Barr virus infections. ClinMicrobiolRev 2011;24:193-209. ↩

9. Marshall-Andon T, Heinz P. How to use … the Monospot and other heterophile antibody tests. Arch Dis Child Educ Pract Ed 2017;102:188-93. ↩ ↩²

10. De Paschale M, Clerici P. Serological diagnosis of Epstein-Barr virus infection: Problems and solutions. World JVirol 2012;1:31-43. ↩ ↩² ↩³ ↩⁴

11. Luderer R, Kok M, Niesters HG, Schuurman R, de Weerdt O, Thijsen SF. Real-time Epstein-Barr virus PCR for the diagnosis of primary EBV infections and EBV reactivation. Mol Diagn 2005;9:195-200. ↩

12. Henie G, Henle W, Horwitz CA. Antibodies to Epstein-Barr virus-associated nuclear antigen in infectious mononucleosis. The Journal of infectious diseases 1974;130:231-9. ↩

13. Okano M. Haematological associations of Epstein-Barr virus infection. Baillieres Best Pract Res Clin Haematol 2000;13:199-214. ↩

14. British HIV Association, British Association for Sexual Health and HIV, British Infection Association. UK National Guidelines on HIV Testing 2008. Available at http://www.bhiva.org/documents/Guidelines/Testing/GlinesHIVTest08.pdf. 2008. ↩ ↩²