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Successful treatment of Epstein–Barr virus infection associated with myocarditis

Epstein‐Barr virus (EBV) is one of the herpes viruses that cause infectious mononucleosis. This disease mostly affects adolescents, but may occur at an earlier age in developing countries. 1,2 It has been postulated that clinical symptoms are due to EBV-induced humoral and cellular immunity and that only limited pathology is caused by viral replication. 2 In symptomatic cases, after an incubation period of 3‐7 weeks, the classical triad of fever, pharyngitis and adenopathy is seen. Mononucleosis is usually a benign, self-limited, lymphoproliferative disorder with rare complications involving hematologic, hepatorenal, splenic, dermatologic, immunologic and cardiopulmonary systems. Myocarditis is an unusual complication of infectious mononucleosis, occurring with an incidence of 0‐6% in several large clinical series. 1 The EBV infection is mostly managed with supportive care. There are clinical trials of steroid therapy, with and without acyclovir, for selected cases. 3‐6 Acyclovir is a nucleoside analog with antiviral activity against the herpes viruses. Steroid therapy may inhibit T cell activation, cytokine production and EBV-induced autoantibody production that may be responsible for some complications of infectious mononucleosis. 2 Nevertheless, there is a general reluctance to use steroids routinely in the treatment of EBV infection, because of unknown long-term effects on the natural immunity to EBV and the possible complications of encephalitis and myocarditis. 3,6‐8