By Dr. Shawna Darou, ND
Fatigue is an issue that I have been seeing even more than before in my clinic consults, and I wanted to write about an area to look beyond low iron, B12 and thyroid function. Reactivated Epstein Barr virus is something that I see very frequently with persistent fatigue, especially when it comes on suddenly and may also be accompanied by a low-grade sore throat, swollen lymph nodes and body aches.
In recent years, the role of ‘stealth infections’ in chronic illness has been at the forefront of naturopathic and functional medicine. This includes Epstein Barr virus, and also Lyme disease, Lyme co-infections, Herpes viruses and more. These infections are most often linked to autoimmune diseases, but can also be part of the underlying picture of most chronic conditions.
What is Epstein Barr virus?
Epstein Barr virus, or EBV is part of the herpes virus family, and apparently 80-90% of people have been exposed. When you are exposed as a child, symptoms are extremely minor, and in teens or early 20’s, they are fit the classic mononucleosis presentation: fever, very swollen lymph nodes, sore throat, and in some cases jaundice and enlarged spleen. Recovery usually takes a few weeks, but occasionally can take several months in more severe cases. Many people have no recollection of having EBV or mononucleosis when they were younger.
What is EBV reactivation?
There are certain circumstances that can cause a reactivation of the Epstein Barr Virus. This was first documented post-transplant, has also been seen in astronauts! (1) More recent studies show that EBV reactivates during periods of chronic psychological stress (2), and this is the situation that I see most commonly, especially in women in their 40’s. Reactivation can also be caused by long-lasting insomnia, anemia, low vitamin D levels, and other infections – gut dysbiosis, Lyme, HSV1/2, Parvovirus, HHV6, and others.
Interestingly, a recent study found positive Epstein-Barr virus detection in COVID-19 patients, and in these cases there was higher incidence of fever and inflammation (3). Perhaps the immune stress of COVID-19 infection allows reactivation of EBV and creates more severe symptoms. It’s certainly something to be on the watch for, especially in those who seem to take a long time in their recovery – perhaps reactivated EBV is creating some of the lingering symptoms.
Symptoms or reactivated EBV:
Reactivated EBV typically looks like a prolonged flu without a significant fever, with symptoms such as:
- intense fatigue
- swollen lymph nodes
- muscle and joint pain
- depression or low mood
- possibly chronic sore throat
- lab testing may find abnormal liver function tests, but not always
Reactivated EBV can be a relatively simple illness that lasts for a few months, with or without treatment. It can also be a more complex condition, often with co-infections like Lyme disease or H. Pylori, and associated with mitochondria damage and further immune dysregulation.
It is usually possible to accurately diagnose reactivated EBV with the correct lab testing. In Ontario, these tests are done through Public Health, so they need to be requested by a family doctor or nurse practitioner (not a Naturopathic Doctor), although in many other jurisdictions they can be ordered directly.
- Epstein Barr Virus (EBV) – EBV VCA IgG/EA/EBNA
- Epstein Barr Virus (EBV) – EBV VCA IgM
- (Note: the “Monospot” test is not reliable for reactivated Epstein Barr Virus.)
How to interpret results:
- EBV VCA IgM (Viral Capsid Antigen) – Positive = positive in acute infection and recent reactivation
- EBV VCA IgG (Viral Capsid Antigen) – Positive = had or currently have EBV infection (stays positive for life after infection)
- EBV EBNA (Nuclear Antibody) – Positive = past infection (stays positive for life)
- EBV EA IgG (Early Antigen) – Positive = active or reactivated EBV infection. Most helpful to measure progress of treatment.
To summarize, the typical result of reactivated EBV are:
- VCA IgM positive; and
- EA (early antigen) positive
The Autoimmune Connection:
There are several possible mechanisms that link the EBV and autoimmunity. These range from molecular mimicry (where the immune system mistakes similar body proteins and attacks the thyroid and the virus); CD8+ T-cell deficiency leading to poor control of EBV infection, and an to an overactive immune response to the organ where EBV has infected; a higher viral load of EBV in those with autoimmunity compared to those without; and ‘bystander activation’ of the immune system in response to an ongoing infection, among others.
It is also important to note that if the body is in a state of chronic stress or poor nutrition, the immune system as a whole is not functioning optimally, meaning it will be much more difficult to manage a chronic infection such as reactivated EBV.
In the case of Hashimoto’s thyroiditis, we often see that thyroid antibody levels can dramatically reduce when the Epstein Barr virus is treated. If this is found early in the diagnosis, especially when your thyroid hormone levels are normal or ‘subclinical’, we may even reverse the course of hypothyroidism completely.
Other conditions associated with EBV:
Reactivated EBV is also associate with some other health conditions, that may not be fully autoimmune:
- Chronic fatigue syndrome
- Chronic pain (muscles & joints)
These conditions tend to fit into the chronic reactivated EBV state mentioned above, and almost always include mitochondria stress and other factors too.
Treatment for Reactivated Epstein Barr Virus:
1. Rest and reduce stress
This is the most important step in the treatment of reactivated EBV. Chronic high stress and lack of sleep have a profound effect on the immune system, and in this case symptoms of EBV can arise. It may also be necessary to completely stop all moderate and high-intensity exercise for a while to allow the body to fully heal and repair.
2. Optimize nutrition
Optimal nutrition when fighting a virus includes sufficient protein, high-antioxidant foods (think colourful vegetables and fruits), foods rich in beta carotene (orange vegetables especially). Minimal grains and sugars can also be helpful to reduce immune system stress and improve nutrient density.
3. Natural anti-virals
Please note that anti-viral supplements or medications alone will rarely correct this issue 100%. It is essential to rest and address stress especially.
Natural anti-virals can include supplements such as Monolaurin, St. John’s wort, Olive leaf extract, Lemon balm, L-Lysine, Echinacea and Licorice root at top on the list. Treatment is chosen based on other factors present (ex. sore throat, yeast issues, fatigue, etc.) to select the best options from this list.
4. Immune support
Immune support from nutrition (above) and also through supplements such as Vitamins C and D, Zinc, mushroom extracts and echinacea can improve the immune response to the virus.
5. Adaptogens herbs (for stress)
Along with taking a serious look at your current life stresses, herbs such as Ashwagandha, Reishi mushroom, Holy basil and Licorice root can be helpful to modulate the stress hormone response and speed up recovery.
Other areas that may need to be addressed:
Naturopathic and functional medicine approach is to address the whole person, not just the virus. This means looking at why it reactivated, a very close look at stress levels and stress management, and underlying imbalance in other systems that can be contributed to overall load on the body: hormone balance, gut health, toxic load, mitochondria health, inflammation and more.
If you suspect that reactivated Epstein Barr virus may a cause of your fatigue, the first step is to get tested. Remember that a ‘Monospot’ test which is used to diagnose acute EBV or mononucleosis, will not pick up reactivate EBV. You need the test panel described above.
This is a treatable condition! In most causes with complicated fatigue or chronic illness, the hardest part is the diagnostic portion – trying to figure out why. From there, we can take steps to treat the whole body to repair.