Epstein-Barr Virus Infection in an Elderly Nonimmunocompromised Adult Successfully Treated with Rituximab

Epstein-Barr virus (EBV) is a ubiquitous virus that commonly affects children and adolescents. In addition to causing a viral illness, it is also associated with various malignancies in particular B cell lymphomas and lymphoproliferative disorders. Differentiating between the two processes can be a diagnostic challenge. Here, we present a case of an atypical EBV infection in an elderly patient with severe systemic symptoms, multiorgan involvement, lymphadenopathy, and negative EBV serology. Excisional lymph node biopsy demonstrated features of a lymphoproliferative process involving EBV. Despite supportive care, she experienced continued clinical deterioration and was successfully treated with rituximab. This case illustrates the diagnostic challenges of these cases particularly in the elderly who may have age related immunosenescence, the utility of EBV PCR testing, and the clinical efficacy of rituximab in clearing the infected cells. Epstein-Barr virus (EBV) is a ubiquitous virus that afflicts >90% of adults usually as adolescents and young adults. Primary EBV infections in children are often asymptomatic but infections in adolescents can manifest as infectious mononucleosis with overt symptoms of an acute viral infection. After primary infection, EBV typically persists in memory B cells in an asymptomatic latent state [1]. Natural killer cells and CD4+ and CD8+ T cells control EBV-induced B cell proliferation. Various malignancies have been associated with EBV including solid tumors such as nasopharyngeal carcinoma [2]; however, it is most commonly associated with various types of lymphoma including Burkitt’s, Hodgkin, HIV related non-Hodgkin lymphoma (NHL), posttransplant lymphoproliferative disorder, and T cell NHL. In addition, EBV positive diffuse large B cell NHL is a recognized type of DLBCL that occurs in the elderly. This entity was first described in East-Asian population [3] and appears less common in western population [4]. EBV infections can also produce lymphadenopathy and systemic symptoms that mimic true lymphoma often presenting a difficult diagnostic and therapeutic dilemma for the clinician. Herein, we describe such a case that illustrates the utility of EBV quantitation by PCR for diagnosis and rituximab for therapy in an immunocompetent female. A 65-year-old previously healthy female presented to an outside clinic with a one-week history of fatigue, fever, and neck swelling. Past medical history was negative for known prior Epstein-Barr infection or infectious mononucleosis. On examination she was noted to have cervical