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Epstein Barr (HHV-4): transmission, symptoms, and diagnosis

Last updated: Oct 31, 2019
4 min read


If you have any medical questions or concerns, please talk to your healthcare provider. The articles on Health Guide are underpinned by peer-reviewed research and information drawn from medical societies and governmental agencies. However, they are not a substitute for professional medical advice, diagnosis, or treatment.

The Epstein-Barr virus (EBV or HHV-4) is a member of the herpesvirus family. It shares common traits with the viruses that cause chickenpox, shingles, cold sores, and genital herpes. EBV is tremendously prevalent—approximately 90–95% of all adults in the United States have previously been infected with EBV (Dunmire, 2018). EBV is well known as the cause of infectious mononucleosis (“mono” or IM) but has also been linked to long-term risks of cancer. Like the other herpesviruses, it has the ability to go into latency in the body and remains in the cells in your immune system for life after you develop an infection.


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What are the signs and symptoms of EBV?

Most people get Epstein-Barr virus infections as a child and are completely asymptomatic. If you do get EBV as an adult, however, it can cause a group of symptoms called infectious mononucleosis, also commonly known as “mono” or the “kissing disease.” EBV has also been associated with the development of certain cancers, including B cell lymphoma, T cell lymphoma, Burkitt lymphoma, Hodgkin’s lymphoma, and nasopharyngeal carcinoma. EBV may also increase your risk of multiple sclerosis (Guan, 2019). The good news is that infants infected with EBV during pregnancy almost never develop any symptoms (Orphanet, n.d.).

What is mono?

Infectious mononucleosis is a group of symptoms that occur around 1-2 months after an initial or primary infection with EBV (Dunmire, 2015). Sometimes it is referred to as the “kissing disease.” Young adults in college or the military have particularly high rates of mono (Grotto, 2003). The main symptoms are a high fever, sore throat, swollen lymph nodes, and extreme fatigue. People with mono might also get:

  • Muscle aches or weakness
  • Skin rash
  • Headache
  • Loss of appetite
  • Enlargement of the spleen, an organ on the left side of the abdomen

If you have infectious mononucleosis, it’s very important to avoid contact sports for 3 to 4 weeks to avoid rupturing the spleen. Sam Darnold, the quarterback for the New York Jets, had to miss four games in 2019 with mononucleosis because of the risk to his spleen.

Typically, mono symptoms take 2 to 4 weeks to get better. However, in some people, fatigue can last for six months or more—it’s suspected that EBV is the cause of some cases of chronic fatigue syndrome (Williams-Harmon, 2016). In most cases, people with mono get better on their own. In rare cases, your lymph nodes can get so swollen that it becomes difficult to breathe. If this happens, you’ll need to be treated at a hospital. Other rare complications include liver damage, anemia (low red blood cell levels), low white blood cell levels, and inflammation of the brain and nervous system.

How is EBV transmitted?

EBV is usually passed from person to person through infected saliva. This is commonly through kissing or sharing utensils, beverages, toothbrushes, or food. It may also be possible to transmit EBV through other bodily fluids. Most of the time, EBV is spread from people that are asymptomatic. Only 5% of people get EBV from someone that has active mono (Kaye, 2019). EBV can survive outside of the body for up to 2 weeks under laboratory conditions, but it’s not known how long it remains infectious in the real world (Allen, 2018).

How do you diagnose EBV?

To diagnose you with an EBV infection, your healthcare provider will first obtain your history and physical exam. Then, they’ll most likely send a few blood tests to confirm the diagnosis that will look for elevated numbers of lymphocytes, a type of white blood cell, and the presence of a type of antibody called the heterophile antibody (Monospot test). If these tests are inconclusive, your healthcare provider may test you for antibodies that your body makes against different parts of the virus. These include two types of antibodies, IgG and IgM, targeting:

  • The viral capsid antigen (VCA)
  • EBV nuclear antigen (EBNA)
  • Early antigen (EA)

How is EBV treated? How can you prevent EBV?

EBV infections are often asymptomatic. Even when people get mono, they usually get better on their own. Getting enough rest, drinking enough fluids, and getting adequate nutrition are all important to get through mono. Acetaminophen (brand name Tylenol) and other anti-inflammatory medications can be helpful in bringing down high fevers. Antiviral medications have not been shown to be helpful in treating EBV infections.

There is currently no vaccine for EBV, which makes preventing it very difficult. The best way to avoid EBV is not to kiss or share utensils, drinking containers, toothbrushes, and other personal items with people infected with EBV. 


  1. Allen, C., Rooney, C. M., & Gottschalk, S. (2018). Chapter 54 – Infectious Mononucleosis and Other Epstein-Barr Virus–Associated Diseases. In Hematology (7th ed., pp. 747–759). doi: 10.1016/B978-0-323-35762-3.00054-8. 
  2. Dunmire, S. K., Verghese, P. S., & Balfour, H. H. (2018). Primary Epstein-Barr virus infection. Journal of Clinical Virology, 102, 84–92. doi: 10.1016/j.jcv.2018.03.001. Retrieved from
  3. Dunmire, S. K., Grimm, J. M., Schmeling, D. O., Balfour, H. H., & Hogquist, K. A. (2015). The Incubation Period of Primary Epstein-Barr Virus Infection: Viral Dynamics and Immunologic Events. PLOS Pathogens, 11(12), e1005286. doi: 10.1371/journal.ppat.1005286. Retrieved from
  4. Grotto, I., Mimouni, D., Huerta, M., Mimouni, M., Cohen, D., Robin, G., et al. (2003). Clinical and laboratory presentation of EBV positive infectious mononucleosis in young adults. Epidemiology and Infection, 131, 683–689. doi: 10.1017/s0950268803008550. Retrieved from
  5. Guan, Y., Zivadinov, D., Ramanathan, M., Weinstock-Guttman, B., & Zivadinov, R. (2019). The role of Epstein-Barr virus in multiple sclerosis: from molecular pathophysiology to in vivo imaging. Neural Regeneration Research, 14(3), 373–386. doi: 10.4103/1673-5374.245462. Retrieved from
  6. Kaye, K. M. (2019, October). Infectious Mononucleosis (Mono). Retrieved from 
  7. Orphanet. (n.d.). Congenital Epstein Barr virus infection. Retrieved from 
  8. Williams-Harmon, Y. J., Jason, L. A., & Katz, B. Z. (2016). Incidence of Infectious Mononucleosis in Universities and U.S. Military Settings. Journal of Diagnostic Techniques and Biomedical Analysis, 5(1). doi: 10.4172/2469-5653.1000113. Retrieved from

Dr. Mike is a licensed physician and the Director, Medical Content & Education at Ro.