Clinical Pearls: Practical Thoughts on "EBV Reactivation"

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This week's topic: EBV Reactivation

EBV reactivation is a condition (or concept) that is prevalent in the integrative/functional medicine space, but no one agrees on how to best evaluate and treat this...or if it even is a true condition!

I have spent a lot of time researching this and trying out various treatments and testing in clinic, and will share some of my experience (and thoughts) on this in today's email.

Overview of today's email:

1. What is EBV Reactivation?
2. Diagnosis of EBV Reactivation
3. Practical clinical tips

1. What is EBV reactivation?

Most of us are familiar with EBV (Epstein Barr Virus) as human herpes virus-4 (HHV-4) that causes mononucleosis (aka acute EBV infection).

Over 90% of people have been exposed to EBV, and virus never leaves the body after initial infection.

But EBV appears to be able to "reactivate" and is correlated with a number of conditions, including:

• Chronic Fatigue Syndrome (CFS)
• ​Multiple sclerosis (MS)
• Parkinson's Disease (PD)
• ​Autoimmune conditions: Autoimmune thyroid disorders (Hashimoto's, Graves), autoimmune hepatitis, SLE, RA, Celiac, T1DM, Scleroderma, IBD, Sjogren's
• Multiple cancers (nasopharyngeal and some lymphomas in particular)

Symptoms:

• Dyspepsia/GERD
• Significant fatigue
• Swollen lymph nodes
• Headaches

2. Diagnosis of EBV Reactivation

First, diagnosis is not straight-forward.

There is no diagnostic test that is 100% sensitive or specific, and you must ALWAYS clinically correlate symptoms with lab results.

A few things that can complicate diagnosis:

1. HHV (Human Herpes Virus) cross-reactivity (i.e. another virus triggering symptoms or lab findings). Co-infections are common.
2. Do not diagnose EBV reactivation off of one lab result (since, especially in adults, there can be acute on chronic infection)
3. The degree of elevation of EBV EA IgG does not correlate with severity or symptoms

Labs used for screening and diagnosis:

1. The most important screening antibody = EBV EA IgG (early antigen) (not included in a screening EBV lab)
2. If able to, I like to also run an EBV panel via InfectoLab (uses a different technology than commercial labs)
3. Potentially helpful = EBNA IgG, EBV VCA IgG, and EBV VCA IgM panel

Labs not as useful for screening and diagnosis, but may show abnormalities:

• EBV PCR testing (picks up dead and live viruses)
• Isolated EBV antibody testing
• WBC or lymphocyte subset status
• Inflammatory markers such as ferritin or hsCRP
• Liver enzymes (even though some studies suggest reactivated EBV appears to particularly affect the liver)

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3. Practical Clinical Tips

Treatment of EBV reactivation, if suspected, is complex. Here are a few tips:

First tip: If you suspect this is contributing to a patient's set of symptoms, follow the symptom response to treatment (not the lab results - which should only be rechecked every 6 months to avoid feeling discouraged).

Second tip: Patients can get really fixated on this as a diagnosis, and want to get rid of the virus. EBV is opportunistic, and we can never get rid of the virus from our body, so it is important to provide realistic expectations for patients before treatment.

Third tip: EBV reactivation is one of the more difficult conditions to treat via a functional medicine model, primarily because addressing the virus itself is maybe only 10-20% of the actual treatment (and I suspect there is something we have yet to identify that is causing antibodies to be elevated on labs). In my experience, EBV reactivation is never the primary cause of symptoms or conditions. A good treatment plan involves:

• Lowering sources of oxidative stress and inflammation (especially stress itself and trauma)
• Self care and "grace" e.g. limbic system support (many patients can get fixated on this as THE reason for their health challenges)
• Support an optimal immune response (to keep EBV in the latent stage)
• Ruling out biotoxin exposure as a trigger (especially mold toxins)
• Patience!

Because I have a lot of material on this topic, I will make sure to dive into this more in the mentorship!

There is still a lot of research that needs to be done on this topic - especially in how we test for it - but it is something to have on our radar when treating patients with chronic fatigue and other symptoms that aren't resolving with foundational functional (or mainstream) treatment approaches.

Thank you for being a part of this newsletter community!

I hope these serve you in some way :)

Stay well, and enjoy the weekend!

Meg

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