Infectious Disease Book

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MononucleosisAka: Acute Mononucleosis Syndrome, Epstein-Barr Virus, Epstein Barr Virus, EBV-Induced Mononucleosis, EBV

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  1. Etiology
    1. Epstein-Barr Virus
      1. Human Herpes Virus (Herpesviridae)
      2. Infects B Cells (B-Cell Lymphotrophic)
    2. Adults who have been infected and are carriers: 90%
  2. Transmission
    1. Transmission through infected Saliva (kissing)
    2. Oral secretions transmit for up to 6 months
  3. Epidemiology
    1. Adolescents and young adults
      1. Incidence ages 10 to 19 years: 6-8 per 1,000/year
      2. Incidence ages <10 years: <1 case per 1,000/year
        1. Likely underestimates Incidence
        2. Often these children have subacute presentations
      3. Peak Incidence
        1. Girls: 14-16 years old
        2. Boys: 16-18 years old
    2. Commonly occurs in congested, confined spaces
      1. College Students
      2. Military recruits
  4. Incubation
    1. Range: 4-8 weeks (may be as short as 2 weeks)
  5. Symptoms
    1. Fever (in >97% of cases)
      1. Persists for 7-10 days
    2. Chills
    3. Malaise
    4. Fatigue (Test Sensitivity: 93%)
    5. Myalgia
    6. Severe Sore Throat
  6. Signs
    1. Exudative Pharyngitis (>97%)
    2. Prominent cervical Lymphadenopathy (>97%)
      1. Posterior cervical Lymphadenopathy most common
      2. Axillary and Inguinal Lymphadenopathy also common
    3. Pharyngeal erythema and edema (85%)
    4. Splenomegaly (75%)
    5. Palatal Petechiae (50%)
    6. Periorbital edema (33%)
    7. Hepatomegaly (20%)
  7. Labs
    1. Throat Culture
      1. Exclude coexisting Streptococcal Pharyngitis
      2. Concurrent Strep Pharyngitis Incidence: 4-30%
      3. If positive, avoid Amoxicillin due to rash
    2. Lymphocyte predominance: >50%
    3. Lymphocyte atypia >10%
      1. Very specific to EBV
      2. No further tests needed if Lymphocyte atypia present
      3. HemeoncLymphocyteAtypia.jpg
    4. Heterophil Antibody Test (Monospot Test)
      1. Efficacy: 95% sensitive and Specific
    5. Antibodies to EBV antigens:
      1. Acute phase antibodies: xEA, xIgM VCA
      2. Convalescent Antibody: xIgG VCA
      3. Recovered State: xIgG VCA, xEBNA
  8. Differential Diagnosis
    1. See Mononucleosis Differential Diagnosis
  9. Diagnosis
    1. See Mononucleosis Diagnostic Approach
  10. Management
    1. Symptomatic
      1. Rest
      2. Non-caffeinated fluids for adequate hydration
      3. Analgesics (NSAIDs or Acetaminophen)
      4. See Pharyngitis Symptomatic Treatment
    2. Avoid strenuous Exercise or contact sport
      1. Risk of splenic rupture
      2. Return to play
        1. Three weeks: Moderate training allowed
          1. No Splenomegaly
          2. No fever
          3. Liver Function Tests Normal
          4. Asymptomatic
        2. Four weeks: strenuous activity allowed
    3. Severe odynophagia or Airway compromise
      1. Oral Prednisone 30-50mg PO qd tapered 10-14 days or
      2. Oral Dexamethasone 0.3 mg/kg
        1. May require repeat doseing
    4. Antibiotics
      1. Only indicated for coexisting Strep Throat
      2. Rash develops in 90% of EBV patients on antibiotics
        1. Especially with Ampicillin
    5. Other ineffective agents
      1. No benefit with Acyclovir
      2. No benefit with Ranitidine
  11. Complications
    1. Meningoencephalitis
    2. Guillain-Barre Syndrome
    3. Bell's Palsy
    4. Pneumonitis
    5. Pericarditis
    6. Myocarditis
    7. Peritonsillar Abscess: 0.2%
    8. Rheumatic Fever: 0.2%
    9. Syndrome of inappropriate Antidiuretic Hormone (SIADH)
    10. Splenic rupture (days 4-21): 0.1-0.2% Incidence
    11. Airway Obstruction
    12. Hemolytic Anemia
    13. Thrombocytopenia
    14. Acute Interstitial Nephritis
    15. Retrobulbar neuritis
  12. Associated Conditions
    1. Chronic Fatigue Syndrome (possibly same viral agent)
  13. Course
    1. Athletes require 3-6 months to return to prior fitness
    2. Fatigue or Hypersomnia persists 6 months in 9-22%
    3. Fatigue present
      1. Initial: 77%
      2. Month 1: 28%
      3. Month 2: 21%
      4. Month 6: 13%
    4. Hypersomnia present
      1. Initial: 45%
      2. Month 1: 18%
      3. Month 2: 14%
      4. Month 6: 9%
    5. Arthralgias present
      1. Initial: 23%
      2. Month 1: 15%
      3. Month 2: 6%
      4. Month 6: 9%
    6. References
      1. Rea (2001) J Am Board Fam Pract 14:234
  14. Resources: Patient Education
    1. AAFP Family Doctor Patient Education Handout
      1. http://www.familydoctor.org/handouts/077.html
  15. References
    1. Katz in Gershon (2004) Krugman's ID, p. 143-55
    2. Gantz in Noble (2001) Primary Care, p. 267-71
    3. Ebell (2004) Am Fam Physician 70(7):1279

Herpesvirus 4, Human (C0014644)

Definition (MSH)The type species of LYMPHOCRYPTOVIRUS, subfamily GAMMAHERPESVIRINAE, infecting B-cells in humans. It is thought to be the causative agent of INFECTIOUS MONONUCLEOSIS and is strongly associated with oral hairy leukoplakia (LEUKOPLAKIA, HAIRY;), BURKITT LYMPHOMA; and other malignancies.
Definition (CSP)infects B-cells in humans; thought to be the causative agent of infectious mononucleosis and is strongly associated with oral hairy leukoplakia, Burkitt lymphoma, and other malignancies.
Definition (NCI)A common virus that remains dormant in most people. It has been associated with certain cancers, including Burkitt's lymphoma, immunoblastic lymphoma, and nasopharyngeal carcinoma.
Definition (NCI)A species of Herpetoviridae that is responsible for infectious mononucleosis (glandular fever). Discovered in 1964, this virus has been associated with Burkitt's lymphoma in South African children and with nasopharyngeal carcinoma in Asian populations.
ConceptsVirus (T005)
EnglishBurkitt Herpesvirus, Burkitt Lymphoma Virus, Burkitt's Lymphoma Virus, Burkitts Lymphoma Virus, E B Virus, EB virus, EBV, Epstein barr virus, HERPESVIRUS 4 GAMMA HUMAN, HERPESVIRUS HUMAN 04, HHV 4, HUMAN HERPESVIRUS 04, Human Herpesvirus 4, human herpesvirus 4 group, Human herpesvirus type 4, INFECT MONONUCLEOSIS VIRUS, Infectious Mononucleosis Virus, Infectious Mononucleosis Viruses
Spanishvirus del herpes humano tipo 4
CreditsDerived from the NIH UMLS (Unified Medical Language System)


Infectious Mononucleosis (C0021345)

Definition (MSH)A common, acute infection usually caused by the Epstein-Barr virus (HERPESVIRUS 4, HUMAN). There is an increase in mononuclear white blood cells and other atypical lymphocytes, generalized lymphadenopathy, splenomegaly, and occasionally hepatomegaly with hepatitis.
Definition (CSP)acute disease characterized by fever and swollen lymph nodes and an abnormal increase of mononuclear leucocytes or monocytes in the bloodstream; not highly contagious; some believe it can be transmitted by kissing.
ConceptsDisease or Syndrome (T047)
ICD9075
BasqueMONONUKLEOSI ZOLDURAGARRIA
DanishMononukleose
DutchMononucleosis infectiosa
EnglishGammaherpesviral mononucleosis, Glandular fever, INFECT MONONUCLEOSIS, Infectious Mononucleosis, Infective mononucleosis, Monocytic angina, Mononucleosis, MONONUCLEOSIS INFECT, Pfeiffer's disease
FinnishMONONUKLEOOSI
FrenchMononucleose infectieuse
Hebrewmononukliozis
Hungarianmononucleosis infectiosa
ItalianMononucleosi infettiva
NorwegianMONONUKLEOSE
PortugueseMononucleose infecciosa
Spanishangina monocítica, angina monocitica, enfermedad de Pfeiffer, fiebre glandular, mononucleosis gammaherpesviral, mononucleosis infecciosa, mononucleosis por herpesvirus del grupo gamma, mononucleosis por virus herpes del grupo gamma
SwedishSMITTSAM KORTELFEBER/MONONUCLEOS
CreditsDerived from the NIH UMLS (Unified Medical Language System)



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