Epstein-Barr virus (EBV)

Parallel testing

Not immune Acute infection Transient phase** Past infection
VCA IgM - + + -
VCA IgG - +* + +
EBNA-1 IgG - - + +

* Can be negative in very early phase of acute infection
** Indeterminate infection stage. Requires additional testing. Same result constellation can be observed during reactivation of infection.

Adapted from:

  1. Hess R. Routine Epstein-Barr virus diagnostics from the laboratory perspective: still challenging after 35 years. J Clin Microbiol. 2004;42:3381-7.
  2. Middeldrop JA. Epstein-Barr virus-specific humoral immune responses in health and disease. In: C. Münz (ed.), Epstein Barr Virus Volume 2, Current Topics in Microbiology and Immunology 391, pp. 289-322. Springer International Publishing. Switzerland; 2015.
  3. De Paschale M and Clerici P. Serological diagnosis of Epstein-Barr virus infection: Problems and solutions. World J Virol. 2012;1:31-43.
  4. Public Health England (PHE). UK Standards for Microbiology Investigations. Epstein-Barr virus serology. Virology. 2019;26(6):2-8. [Internet; updated 2019 Jan 24; cited 2024 Mar 4]. Available from: https://www.gov.uk/government/publications/smi-v-26-epstein-barr-virus-serology.
  5. Rea TD, Ashley RL, et al. A Systematic Study of Epstein-Barr Virus Serologic Assays Following Acute Infection. Am J Clin Pathol. 2002;117:156-61.
Product Description Tests Product page
Elecsys® EBV IgM a) Qualitative detection of IgM class antibodies to EBV in human serum and plasma 100
Elecsys® EBV IgM b) 300
Elecsys® EBV VCA IgG a) Qualitative detection of IgG class antibodies to EBV, including VCA, in human serum and plasma 100
Elecsys® EBV VCA IgG b) 300
Elecsys® EBV EBNA IgG a) Qualitative detection of IgG class antibodies to EBV EBNA-1 in human serum and plasma 100
Elecsys® EBV EBNA IgG b) 300

a) for use on the cobas® e 411 analyzer and the cobas® e 601 / 602 modules;
b) for use on the cobas® e 402 and cobas® e 801 analytical units

VCA IgM VCA IgG EBNA-1 IgG Interpretation
- - - Seronegative, no immunity
+ - - Presumed early phase of infection#
+ + - Acute infection
+ + + Transient phase of primary infection, or reactivation#
- + + Past infection
- + - Isolated VCA IgG#
- - + Isolated EBNA-1 IgG#
+ - + Implausible result#

Note: EBV serology is not recommended to diagnose immunocompromised individuals.
# Indeterminate EBV serology. Additional testing required.

Adapted from:

  1. De Paschale M and Clerici P. Serological diagnosis of Epstein-Barr virus infection: Problems and solutions. World J Virol. 2012;1:31-43.
  2. De Paschale M, Agrappi C, et al. Seroepidemiology of EBV and Interpretation
    of the ‘‘Isolated VCA IgG’’ Pattern". J Med Virol. 2009;81:325-331.
  3. De Paschale M, Cagnin D, et al. Significance of the “isolated EBNA-1 IgG”
    pattern in past EBV infection. Micro Med. 2009;24:51-52.
  4. Public Health England (PHE). UK Standards for Microbiology Investigations. Epstein-Barr virus serology. Virology. 2019;26(6):2-8. [Internet; updated 2019 Jan 24; cited 2024 Mar 4]. Available from: https://www.gov.uk/government/publications/smi-v-26-epstein-barr-virus-serology.
  5. Henle G, et al. Antibodies to Epstein-Barr virus-associated nuclear antigen in infectious mononucleosis. J Inf Dis. 1974;130:231-9.
  • Step 1
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Step 1

Perform VCA IgM, VCA IgG and EBNA-1 IgG tests in parallel

VCA IgM test
VCA IgG test
EBNA-1 IgG test
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  • Step 2

Summary

Seronegative, no immunity
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  • Step 2

Summary

This constellation usually indicates an early stage of acute infection, but can also occur due to unspecificity of the VCA IgM test due to interferences or cross-reactivity.   

This serological profile is considered indeterminate and additional testing is required to confirm acute infection, including:

  • Potential interfering or cross-reacting factors (e.g. Rheumatoid factor, auto antibodies, CMV, Parvovirus B19) in case of an isolated VCA IgM profile

  • Immunoblots for IgM, based on recombinant antigens

  • EBV DNA testing

  • Heterophilic antibodies and anti-EA (D) IgG, both commonly found in acute infection, but not very sensitive or specific.

  • Serial testing (after about 30 days) to observe changes in antibody profiles


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Summary

Acute infection
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Summary

This constellation might appear in patients with primary EBV infection if VCA IgM persists and EBNA-1 IgG have already been produced (recent infection, transient phase or convalescence), or in those with viral reactivation.

This serological profile is considered indeterminate. Additional testing is required to confirm or resolve indeterminate EBV profiles obtained with screening assays (VCA IgM, VCA IgG and EBNA IgG), in particular to distinguish acute and past infections:

  • Immunoblots based on recombinant antigens
  • IgG avidity: low avidity indicates recent infection (<12 weeks after symptom onset)
  • EBV DNA testing: the presence of EBV DNA in plasma/serum is considered a sign of primary infection. Particularly useful in immunocompromised patients, and when antibody test results are inconclusive, but acute infection is suspected (isolated VCA IgM, or reactivity of all three markers).
  • Heterophilic antibodies and anti-EA (D) IgG, both commonly found in acute infection, but not very sensitive or specific.
  • Potential interfering or cross-reacting factors (e.g. Rheumatoid factor, auto-antibodies, CMV, Parvovirus B19) in case of an isolated VCA IgM profile
  • Serial testing (after about 30 days) to observe changes in antibody profiles
  • Step 1
  • Step 2

Summary

Past infection
  • Step 1
  • Step 2

Summary

This constellation may be found in cases of past infection with the loss or disappearance of EBNA-1 IgG, or in cases of acute infection with the delayed or early disappearance of VCA IgM.

This serological profile is considered indeterminate and is observed in approximately 7% of laboratory routine. Additional testing is required to distinguish transient infection and reactivation, including:

  • Immunoblots for IgG, based on recombinant antigens
  • IgG avidity: low avidity indicates recent infection (<12 weeks after symptom onset)
  • EBV DNA testing: the presence of EBV DNA in plasma/serum is considered a sign of primary infection. 
  • Heterophilic antibodies and anti-EA (D) IgG, both commonly found in acute infection, but not very sensitive or specific.
  • Serial testing (after about 30 days) to observe changes in antibody profiles
  • Step 1
  • Step 2

Summary

This constellation is rarely observed in routine EBV serology, and might be due to the lack of VCA IgG production in some individuals, loss over time, or low sensitivity of the assay. 

This serological profile is considered indeterminate. Additional testing is required to confirm a past infection. Immunoblots for IgG based on recombinant antigens can confirm the presence of EBNA-1 IgG in past infection. 

  • Step 1
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Summary

This constellation is considered implausible. Repeat testing or consider pre-analytical errors.

Step
Result
Interpretation
1
VCA IgM test = ...
VCA IgG test = ...
EBNA-1 IgG = ...
waiting for input
1
VCA IgM test = negative
VCA IgG test = negative
EBNA-1 IgG = negative
Seronegative, no immunity
1
VCA IgM test = positive
VCA IgG test = negative
EBNA-1 IgG = negative
Presumed early phase of infection
1
VCA IgM test = positive
VCA IgG test = positive
EBNA-1 IgG = negative
Acute infection
1
VCA IgM test = positive
VCA IgG test = positive
EBNA-1 IgG = positive
Transient phase of primary infection, or reactivation
1
VCA IgM test = negative
VCA IgG test = positive
EBNA-1 IgG = positive
Past infection
1
VCA IgM test = negative
VCA IgG test = positive
EBNA-1 IgG = negative
Isolated VCA IgG
1
VCA IgM test = negative
VCA IgG test = negative
EBNA-1 IgG = positive
Isolated EBNA-1 IgG
1
VCA IgM test = positive
VCA IgG test = negative
EBNA-1 IgG = positive
Implausible result
End of test sequence