The Epstein-Barr Virus (EBV) has infected nearly 95% of the global adult population.¹  EBV leads to many symptoms, and is often associated with excessive daytime sleepiness (EDS) and fatigue.² In this article, we will take a closer look at EBV and its association with sleep problems. 

What is EBV?

Discovered in 1964, EBV (also known as Human Herpesvirus 4) is classified as a herpesvirus which targets a set of immune cell in the body, called B cells or B lymphocytes.¹ It is the first virus identified as a cancer-causing virus (by the World Health Organisation (WHO)).³

EBV is a highly contagious virus that is typically spread through saliva (for example, from sharing food, coughing, sneezing, or kissing). It causes glandular fever and infectious mononucleosis (known commonly as ‘mono’ or the kissing disease). It is usually spread during the viral incubation period (i.e., following exposure to the virus but prior to the onset of symptoms), though it can also spread through blood transfusion. 

EBV is similar to other herpes viruses; it is a double-stranded DNA enveloped by glycoproteins which help the virus to attach to and enter host cells (B cells and epithelial cells), where it replicates and spreads. EBV triggers B cells to differentiate into memory B cells. These are part of our adaptive immune system. An adaptive immune system ‘remembers’ the infecting organism and quickly develops a response to it and one that is more robust. Memory B cells will circulate in our systems dormant, until they are triggered and thereby reactivated.

Once we are infected, EBV can remain latent in our systems for our lifespan and cannot be fully eradicated.³

EBV can be detected through blood tests. Diagnostic tests include:

• Full blood count (detecting low white blood cell and high platelet count)
• Monospot antibody test (detecting infectious mononucleosis caused by EBV)
• Liver function test to look for elevated levels of one enzyme (alanine aminotransferase)
• EBV-specific antibody tests (IgG and IgM antibodies) 

Symptoms of EBV infection

EBV infection can lead to many symptoms, the severity of which will differ from person to person. Those with weakened immune systems are more likely to develop more severe forms of the infection. 

Symptoms include the following, though this is not an exhaustive list:

• Headaches
• Digestive disturbance (nausea, vomiting, and loss of appetite)
• Fever
• Sore throat
• Aches and pains
• Fatigue
• Excessive sleepiness
• Enlarged spleen
• Rash
• Swollen liver

Sleep disturbances following EBV infection

Fatigue is a common symptom of EBV infection,  and is the symptom that most often lingers for many months after the acute phase.^1,2 Indeed, infectious mononucleosis caused by the EBV has associations with the development of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS).⁴ ME/CFS following an EBV infection can be debilitating, particularly for adults. Adolescents can suffer more severe symptoms, evidence shows but their prognosis is better over time compared to adults.

ME/CFS is characterised by tiredness and the worsening of symptoms following physical or cognitive exertion (known as post-exertional malaise, PEM). Other symptoms such as a cognitive impairment and experiencing ‘unrefreshing sleep’ may also occur.⁴ ME/CFS is associated with reduced quality of life and higher rates of absence from school. 

Another sleep disturbance that can occur following EBV infection is excessive daytime sleeping (EDS). EDS (also called hypersomnia) is characterised by regular napping during the day but still falling asleep at night, and a longer sleep duration.^5,6  It can occur alongside other conditions, including psychiatric conditions (like depression and bipolar disorder), other sleep disturbances (such as narcolepsy and sleep apnoea), and ME/CFS.⁶  

In one study, it was found that four participants developed narcolepsy type 1 with EBV infection and one developed EDS with cataplexy (sudden muscle weakness).⁷ Narcolepsy type 2 (also called idiopathic hypersomnia, a form of narcolepsy without cataplexy) occurred most commonly 1 year following EBV infections (in 8 out of 10 of participants), compared to other viral infections such as influenza investigated in this study. Of those eight with narcolepsy type 2, three developed EDS. 

In two case reports, EDS presented in elderly patients with EBV encephalitis (inflammation of the brain).⁵ It is suggested that EDS can manifest in cases of viral encephalitis and should be detected and treated with antiviral medication as early as possible. Other studies indicate that suffering from infectious mononucleosis may predispose some to hypersomnia, with immune dysregulation and autoinflammatory reactions potentially underlying this.⁸

The evidence base for the associations between EBV infections and sleep disturbance is growing, and the particular role of EBV in triggering excessive sleeping or hypersomnolence should be explored going forward. 

Management and treatment 

EBV can only be treated symptomatically and cannot be eradicated entirely. 

Fatigue and excessive sleepiness can negatively impact upon a person’s quality of life but there are ways to support and improve sleeping habits.⁶  Some recommended sleep hygiene habits include:

• Avoid drinking alcohol or caffeine
• Avoid medicines that induce drowsiness 
• Avoid working too late into the night
• Try to go to bed at the same time every day
• Create an environment that is conducive to sleep (quiet, not too warm, and no screens)

Summary

EBV causes a highly common and highly contagious viral infection, that is the cause of glandular fever and infectious mononucleosis. It is easily transmitted through saliva (for example, when coughing, sneezing or kissing). Fatigue and sleep disturbances are frequently experienced following EBV infection. Some of the common sleep disturbances associated with EBV infection are chronic fatigue syndrome, excessive daytime sleepiness (or hypersomnia), and narcolepsy. These conditions can significantly reduce quality of life and mean more absence from school or work. Improving sleep hygiene can help improve the symptoms of these sleep disturbances.

FAQs

Does Epstein-Barr cause sleep problems?

Yes, excessive daytime sleepiness (EDS) can develop following an EBV infection. 

Can Epstein-Barr virus cause problems later in life?

EBV infection can cause mutations in cells that may lead to certain cancers (such as nasopharyngeal cancers). In severe cases, it can also cause other complications such as swelling of the heart, brain, spinal cord, and optic nerve. 

What aggravates Epstein-Barr virus?

EBV aggravation means that the EBV has been reactivated. There are many factors that can contribute to this. These include but are not restricted to: stress, a weakened immune system from another illness, menopause, or other hormonal changes in the body.

How do you calm an Epstein-Barr flare up?

It is important to manage the symptoms of an EBV infection, by staying hydrated, resting well, and taking over-the-counter medication for pain and fever.

Do you sleep a lot with glandular fever?

In short, yes. Glandular fever caused by the EBV causes excessive tiredness. The symptoms typically clear up within 2-4 weeks, however fatigue can be experienced for up to 6 months post-infection as chronic fatigue.

Does mono affect your sleep?

Infectious mononucleosis, caused by the EBV, can make you tired and make you want to sleep more often. This tiredness can last for four or more weeks. However, complete bed rest is not always necessary and it depends on the severity of the symptoms experienced.

How do you fight EBV fatigue?

Get plenty of rest by going to bed early and sleeping for longer periods of time. Take regular breaks, reduce physical activity and exertion, and stay hydrated. These are all essential steps to take to fight fatigue related to EBV infection. 

When to seek help for EBV?

EBV symptoms will typically resolve within 2-4 weeks and most EBV cases do not cause serious health problems. However, in rare cases, EBV symptoms do not improve. 

If you have a high fever, a severe sore throat that does not improve with over-the-counter medications or naturally over a few days, swollen glands that make it hard to swallow, or if you experience breathing difficulties, please seek medical attention. 

Signs of the infection spreading to your brain include a severe headache that won’t go away or a stiff neck. If these symptoms are experienced, contact your medical care provider immediately. 

When should I seek help for sleep disturbances?

If you are experiencing sleep disturbances that are negatively affecting your day-to-day life, speak to a doctor. In some cases, medication can be given for the sleep disturbances mentioned in this article. Sleep habits could be improved through forms of therapy (such as cognitive behavioural therapy) and also through sleep hygiene tactics.