Serological diagnosis of Epstein-Barr virus infection: Problems and solutions

Table 1 Types of latency in Epstein-Barr virus-associated diseases

Type 0 latency (EBERs, BARTs)	AIDS-related plasmablastic lymphoma
Type I latency (EBNA1, LMP2, EBERs, BARTs) (BamHI A rightward fragments)	Burkitt’s lymphoma
Type II latency (EBNA1, LMP1, LMP2, EBERs, BARTs)	Hodgkin’s lymphoma, AIDS-related Burkitt’s lymphoma or primary effusion lymphoma
	Peripheral T cell lymphoma
	NK/T cell lymphoma, nasal type
	Nasopharyngeal carcinoma (plus BARF1)
	Gastric adenocarcinoma (plus BARF1)
Type III latency (EBNA1, -2, -3A, -3B, -3C; LMP1, LMP2, EBERs, BARTs)	Post-transplant lymphoproliferative disorder
	AIDS-related immunoblastic or brain lymphoma
	Infectious mononucleosis
	Chronic active EBV infection
	Lymphoblastoid cell lines in vitro
	X-linked lymphoproliferative disease

Table 2 Interpretation of Epstein-Barr virus serological profiles in immunocompetent patients

Anti-EBV antibodies			Interpretation
VCA IgM	VCA IgG	EBNA-1 IgG
Negative	Negative	Negative	No immunity
Positive	Negative	Negative	Acute infection or non-specificity1
Positive	Positive	Negative	Acute infection
Negative	Positive	Positive	Past infection
Negative	Positive	Negative	Acute or past infection1
Positive	Positive	Positive	Late primary infection or reactivation1
Negative	Negative	Positive	Past infection or non-specificity1

¹Further testing required.

Table 3 Serological profiles in Epstein-Barr virus reactivation and some Epstein-Barr virus-associated diseases

Diseases	VCA IgM	VCA IgG	VCA IgA	EA (D) IgG	EA (R) IgG	EA IgA	EBNA1 IgG
Choronic active infection	+/-	++	+/-	+	++	-	+/-
Burkitt’s lymphoma	-	++	-	+/-	++	-	+
Nasopharingeal carcinoma	-	++	+	++	+/-	+	+
Hodgkin’s lymphoma	-	++	-	+	-	-	+
Reactivation	+/-	++	+/-	+	+/-	+/-	+/-

Table 4 Interpretation of IgG avidity test with immunoblotting

IgG	IgG avidity	Interpretation
Negative	Not observed	No infection
Positive BZLF1, p138, p54	Low-high avidity for BZLF1 and/or p138 and/or p54	Acute infection
Positive p23, BZLF1, p138, p54	Low avidity for p23	Acute infection
Positive p23, BZLF1, p138, p54	High avidity for p23	Recent infection
Positive p18, p23, BZLF1, p138, p54	Low-intermediate avidity for p18 and p23	Recent infection
Positive EBNA-1, p18, p23, BZLF1, p138, p54	Low-high avidity for EBNA-1 and/or p18, and possible high avidity for p23	Past infection

Table 5 Additional tests in the case of an isolated viral capsid antigen IgG pattern

Tests	Advantages	Disadvantages
EBV IgG immunoblotting	Useful in distinguishing acute from past infection	Individual antibody production; expensive
IgG avidity	Useful in distinguishing acute from past infection	Individual maturation. Not useful in newborns
Molecular biology	Useful in distinguishing acute from past infection	Uncorrected conservation of blood sample, presence of nucleasis; expensive; organisational problems
Heterophile antibodies	Useful in distinguishing acute from past infection if positive; inexpensive and simple	Not very sensitive (especially in children)
Anti-EA(D) IgG	Of some use in distinguishing acute from past infection; costs the same as a screening test	Not useful in at least 10% of cases

EBV: Epstein-Barr virus.

Table 6 Additional tests in the case of a simultaneous Epstein-Barr virus nuclear antigen 1 IgG, viral capsid antigen IgG and IgM positive pattern

Tests	Advantages	Disadvantages
EBV IgM immunoblotting	Useful only in verifying the specificity of EBV IgM	Not useful in distinguishing late primary infection (transient) from reactivation; expensive
HCMV IgM Parvovirus IgM	Useful in verifying the specificity of EBV IgM	Not useful in distinguishing late primary infection (transient) from reactivation
EBV IgG immunoblotting	Only useful in verifying the specificity of EBNA-1 IgG	Not useful in distinguishing late primary infection (transient) from reactivation; expensive
IgG avidity	Useful in distinguishing primary infection (transient) from reactivation	Individual maturation
Molecular biology	Useful for EBV reactivation follow-up	Difficult to distinguish late primary infection (transient) from reactivation in a single sample; expensive; organisational problems
Heterophile antibodies	Useful in distinguishing late primary infection (transient) reactivation when positive; inexpensive and simple	Not very sensitive (especially in children)
Anti-EA(D) IgG	Useful for EBV reactivation follow-up	Not useful in distinguishing late primary infection (transient) from reactivation in a single sample
CLIA for EBV antibodies with differential cut-off values	Useful in distinguishing primary infection (transient) from past infection; can be used for screening	Requires further study

EBV: Epstein-Barr virus; EBNA: EBV nuclear antigen; CLIA: Chemiluminescence immunoassay.