EBV, a herpesvirus, is a common human pathogen, infecting roughly 95% of adults worldwide. It mainly spreads through direct contact with infected saliva, often via kissing, from people who do not show symptoms. Although initial infection is usually asymptomatic, 35–50% of adolescents might develop IM within a month of exposure. The virus then remains latent in the body for life [18, 19]. At the time of this writing, this is the first study to characterize EBV infection in Saudi Arabia’s southwestern population. The shift from traditional serological techniques to molecular approaches has significantly enhanced both diagnostic precision and patient monitoring capabilities. Given their markedly superior sensitivity and specificity compared to serology alone, PCR-based assays have revolutionized EBV detection [20, 21]. Hence, we retrospectively collected data from 133 EBV-positive cases detected by PCR over a 4-year period (2020–2023). Our findings show an overall prevalence of 17.5% during this time. This relatively lower prevalence, compared to other studies, is likely because our cohort included all age groups, whereas seroprevalence in some populations, like Chinese children, can exceed 90% after age 8 [22]. In the United States, the seroprevalence among children aged 6–19 years was 66.5%, increasing with age from 54.1% in younger children to 82.9% in older adolescents [10]. Research in Qatar indicated a seroprevalence of 97.9% among healthy blood donors [23].
Interestingly, we observed a continuous increase in EBV-positive cases from 2020 to 2022, followed by a remarkable decrease in 2023 (p = 0.01*) (Table 1). Our data also suggest a bimodal seasonal distribution with peaks in Q1 and Q3, although this pattern was disrupted in 2023 (Fig. 1). Furthermore, the date of the test was a significant predictor of EBV infection in Southwestern Saudi Arabia between 2020 and 2023 (β = −0.187, p = 0.03) (Table 4). These observed trends likely reflect a combination of seasonal factors influencing EBV transmission, evolving diagnostic practices, or changes in surveillance during and after the COVID-19 pandemic. Our findings can be explained by important post-COVID-19 shifts in EBV testing and referral practices, as indicated by scientific results. Numerous studies have highlighted frequent EBV coinfection in COVID-19 patients, which is associated with greater disease severity and mortality. The systemic reactivation of EBV observed in these patients led healthcare providers to consider it a potential complication, consequently driving increased clinical interest and demand for EBV testing [24,25,26,27,28,29,30]. Additionally, studies indicate that EBV reactivation following COVID-19 infection might be linked to neurological and psychiatric symptoms, often described as “brain fog.” This connection necessitates increased EBV testing during extended COVID-19 assessments [31]. Although our study could not prove the clinical outcomes of coinfection due to a lack of COVID-19 status in our dataset, the specific role of EBV in the pathogenesis of COVID-19 requires further investigation. Furthermore, to explore whether this decrease continues after 2023 or increases again and to understand the underlying causes, the substantial decrease in EBV positivity rates in 2023 warrants further investigation.
The majority of the EBV-positive patients in our study were Saudi nationals, n = 103 (77.4%), which reflects the population structure of the region (Population Structure Statistics). This explains why we had a very small percentage, n = 30 (22.6%) of EBV cases among other nationalities when we investigated demographic factors (Table 2). This was a previous study conducted in a single hospital (Al-Jedaani Hospital, Jeddah, Saudi Arabia) that included all children aged 1 month to 15 years in the period from January 1, 2018, to December 31, 2019. This study indicated that there was no sex difference in EBV positivity [16]which agreed with our analysis (Table 2). EBV infection is strongly correlated with age; indeed, it is a common virus that infects most individuals at some point in their lives. Our data specifically revealed a strong and statistically significant correlation between EBV infection and age (p < 0.001**) (Table 2). Furthermore, logistic regression analysis indicated that age (β = −0.411, p = 0.029) was a significant predictor of EBV infection in Southwestern Saudi Arabia from 2020 to 2023. Age exhibits negative correlations, indicating that with each additional year of age, the risk of infection decreases (Table 4). The predominant demographic characteristics of the patients were children aged 1–5 years (toddler group), accounting for n = 57 (42.9%) of the sample. Children aged between 6 and 12 years, n = 44 (33.1%), were subsequently included (Table 2). The transmission dynamics of EBV may vary with age and geographical location. EBV is typically acquired at earlier ages in Asia than in Europe and North America [12]. Zaki’s study included all children aged 1 month to 15 years in the period from January 1, 2018, to December 31, 2019. He reported that primary EBV infection in healthy children is more prevalent among younger age groups and infrequently affects adolescents [16]. Among Chinese children, the EBV seroprevalence surpassed 50% by the age of 3 and exceeded 90% after the age of 8 [22]. However, in England, the EBV seroprevalence increased from 60.4% among children aged 11–14 years to 68.6% among adolescents aged 15–18 years and eventually stabilized by early adulthood (93.0% among those aged 22–24 years) [32]. Moreover, EBV is widespread among children in China, with viral loads rising when coinfected with bacteria or other viruses [33]. EBV infection often co-occurs with other pathogens, such as HIV, CMV, and Plasmodium falciparum. These coinfections can profoundly impact the course and severity of EBV-associated diseases. They achieve this by modulating immune responses and promoting both viral persistence and tumorigenesis. Ultimately, coinfection can lead to a more complex clinical presentation and is associated with severe morbidity and mortality [17, 34, 35]. Our analysis found that some EBV patients were coinfected with bacterial or viral pathogens. After all, diagnosing EBV in younger children can be challenging. Depending on the clinical context, suspicion might lead to either underdiagnosis or overdiagnosis. Young children with EBV often show nonspecific symptoms, such as prolonged fever or upper respiratory issues, which are common in many viral infections. This can create a “diagnostic blind zone,” in which EBV tests are overlooked, leading to missed diagnoses. Conversely, if clinical suspicion for EBV is highly perhaps because of a family history, daycare outbreaks, or recent professional training—excessive testing might occur. Clinicians may also test more readily when they observe unique EBV symptoms in young children. Our findings highlight the need for further research into ethnic disparities and underscore the importance of prioritizing pediatric groups in targeted public health interventions.
EBV is associated with a wide spectrum of both benign and malignant diseases. Symptoms may manifest as fever or even as more severe outcomes, including cancer symptoms. EBV is oncogenic and is responsible for approximately 200,000 deaths related to cancer each year [7]. Furthermore, it significantly contributes to the development of autoimmune diseases. Consequently, EBV constitutes a notable public health challenge [36,37,38]. In this study, various diagnoses were detected among EBV patients, highlighting their diverse impacts on human health. Additionally, it provides important insights into clinical testing practices, which could be valuable to understand when to consider EBV testing and what conditions are most commonly associated with positive results. To make appropriate clinical care decisions, it is essential to recognize EBV-associated diseases. Grouping these diagnoses into nine categories allows for better organization and identification of the most prevalent conditions (Table 3). The prevalence of infectious diseases, n = 38 (28.6%) of EBV-positive cases, indicates that EBV testing is commonly conducted in cases of suspected viral infections or fever of unknown origin. Hematological diseases also showed high prevalence, n = 27 (20.3%), confirming the link between EBV and lymphoproliferative disorders and other blood-related complications (Table 3). Notably, the “Other diagnosis” category represented a substantial proportion, n = 31 (23.3%). The patients in this category do not fit into the main diagnostic categories, such as Dental caries and Down’s syndrome (supplementary data). Showing the diverse clinical spectrum of conditions and supporting nonspecific symptoms associated with EBV positivity.
Clinical attention is required regarding the distribution of diagnostic categories by gender (p = 0.04, Fig. 2B). While infectious diseases dominated both male and female cohorts, the observed disparities in hematological and liver diseases warrant additional investigation. The increased prevalence of hematological diseases and liver diseases in males aligns with established epidemiological trends [39, 40]. Interestingly, we found that age was correlated not only with EBV infection but also with clinical diagnosis (Table 2 and Fig. 2C). Children aged 1–5 years (toddler group) constitute the predominant group infected by EBV, and the majority of them are diagnosed with infectious diseases (Fig. 2C). Previously, in Saudi Arabia, IM syndrome was found to be more prevalent in early childhood. However, nontypical presentations occur more frequently in infants [16]. Although EBV is associated with a range of diseases, it does not exclusively determine the elevated prevalence of certain conditions. This underscores the necessity for additional investigations into other contributing factors [41].
Other factors, such as genetic variables, can affect the severity and consequences of EBV infection. In particular, HLA (Human Leukocyte Antigen) and immune response genes are associated with increased susceptibility to EBV infection [12, 42]. Interestingly, various strains and variants of EBV are linked to different diseases; however, it is yet to be determined if these variations correlate with ethnicity or geography [43]. Additionally, socioeconomic status impacts EBV infection; for non-Hispanic Whites, a higher household education level correlates with a lower incidence [44].
Treatment for EBV in Saudi Arabia aligns with global best practices, primarily focusing on managing symptoms and mitigating consequences, as there is no definitive cure. Supportive therapy, antivirals, and corticosteroids could be used based on the clinical condition. For EBV-associated cancers, treatment may involve chemotherapy and immunotherapy. Currently, no approved EBV vaccine is available, although several are under research. Understanding how EBV transmits and characterizing different affected populations is crucial for developing future vaccines and immunization strategies [45]. Our findings underscore the need for enhanced EBV surveillance in Saudi Arabia, especially among high-risk groups like children aged 1–12 years. The identified distinct clinical patterns and demographic associations highlight the importance of integrating EBV testing into broader diagnostic protocols for pediatric and immunocompromised populations. Moving forward, national-level surveillance programs incorporating both molecular and serological testing are crucial for a comprehensive understanding of EBV transmission dynamics, reactivation rates, and disease burden.
Limitations
This study has several important limitations to consider. First, its retrospective nature means we cannot establish causal relationships between EBV infection and the observed clinical conditions. Second, selection bias might be present because EBV testing was likely based on clinical suspicion rather than systematic screening, which could skew our prevalence and clinical associations. Third, we relied solely on molecular detection (PCR) without complementary serological testing. This limits our ability to understand the infection phase (primary, latent, or reactivation). Fourth, we could not systematically assess or analyze coinfections, including those with COVID-19, due to incomplete data, which restricted our ability to explore potential interaction effects. Fifth, we did not include EBV-negative patients as a comparator group. This would have been a significant challenge given the large disparity between negative (627) and positive (133) cases, and collecting/organizing such data would have required considerable time and coordination. Sixth, conducting the study in a single geographical region (the southwestern region) limits the generalizability of our findings to other parts of Saudi Arabia or internationally, and to different healthcare settings. Finally, given that our data came from hospital-based records, the results might not fully represent EBV infection patterns in the general population, especially among asymptomatic or mildly affected individuals who did not seek medical care.