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Infectious medicine

Dr. Nihad A. Al-jeboori

INFECTIOUS MONONUCLEOSIS (IM) Virology and epidemiology The disease is caused by the Epstein-Barr virus (EBV), a gamma herpes virus. In developing countries and poorer societies in developed nations subclinical infection in childhood is virtually universal. In richer communities, particularly among upper socioeconomic groups, primary infection may be delayed until adolescence or early adult life. Under these circumstances about 50% of infections result in typical IM. The virus is usually acquired from asymptomatic excreters. Saliva is the main means of spread, either by droplet infection or environmental contamination in childhood, or by kissing among adolescents and adults. There is a good correlation between sexual maturity and IM, and the age/sex distribution of the disease resembles that of gonorrhoea. IM is not highly contagious, isolation is unnecessary and documented outbreaks seldom occur. Clinical features A presumptive diagnosis of IM must include one or more of the following clinical features: lymphadenopathy, especially posterior cervical, pharyngeal inflammation or exudates, fever, splenomegaly, palatal petechiae, periorbital oedema, clinical or biochemical evidence of hepatitis, and a non-specific rash. The diagnosis of IM outside the usual age range is difficult. In children under 10 years the illness is mild and short-lived, but in adults over 30 years of age it can be severe and prolonged. In both groups pharyngeal symptoms are often absent. IM may present with jaundice, as a PUO or with an unusual complication. Complications Of Infectious Mononucleosis Common Severe pharyngeal oedema Antibiotic-induced rash Chronic fatigue syndrome (10%) Uncommon 1) Neurological

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Infectious medicine

Dr. Nihad A. Al-jeboori

Cranial nerve palsies Polyneuritis Transverse myelitis Meningoencephalitis 2) Haematological Haemolytic anaemia Thrombocytopenia 3) Renal Glomerulonephritis Interstitial nephritis 4) Cardiac Myocarditis Pericarditis 5) Pulmonary Interstitial pneumonitis Rare Ruptured spleen Respiratory obstruction Arthritis Agranulocytosis Agammaglobulinaemia

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Infectious medicine

Dr. Nihad A. Al-jeboori

Malignancy EBV is a transforming virus and has been causally linked to a variety of malignancies in addition to lymphomas in transplant recipients . These include Burkitt lymphoma Tumors in HIV-infected patients(Non-Hodgkin lymphomas (NHL)&Smooth muscle tumors) Hodgkin lymphoma Nasopharyngeal and other head and neck carcinomas T cell lymphoma

Investigations To establish the diagnosis, 20% or more of peripheral lymphocytes must have an atypical morphology and the serum must contain the characteristic heterophile antibody. This antibody, present during the acute illness and convalescence, agglutinates erythrocytes of other species, e.g. sheep and horse. It has a specific absorption pattern, detected by the classical Paul-Bunnell titration or by a more convenient slide test such as the 'Monospot'. Sometimes antibody production is delayed, so an initially negative test should be repeated. However, many children and 10% of adolescents with IM do not produce heterophile antibody at any stage. Specific EBV serology (immunofluorescence) can be used to confirm the diagnosis if necessary. Acute infection is characterised by: antiviral capsid (VCA) antibodies in the IgM class antibodies to EBV early antigen (EA)

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Infectious medicine

Dr. Nihad A. Al-jeboori

absent antibodies to EBV nuclear antigen (anti-EBNA). Management Treatment is largely symptomatic: for example, aspirin gargles to relieve a sore throat. If a throat culture yields a -haemolytic streptococcus, a course of erythromycin should be prescribed. Amoxicillin and similar semi-synthetic penicillins should be avoided because they commonly induce a maculo-papular rash in patients with IM . When pharyngeal oedema is severe a short course of corticosteroids, e.g. prednisolone 30 mg daily for 5 days, may help to relieve the swelling. Return to work or school is governed by the patient's physical fitness rather than laboratory tests. However, contact sports should be avoided until splenomegaly has completely resolved because of the danger of splenic rupture. Unfortunately, about 10% of patients with IM suffer a chronic relapsing syndrome.

ACQUIRED CYTOMEGALOVIRUS INFECTION Virology and epidemiology Cytomegalovirus (CMV) is a beta herpes virus. Like EBV, it circulates readily among children, especially in crowded communities. Although most primary infections are asymptomatic, many children continue to excrete virus for months or years. A second peak in virus acquisition occurs among teenagers and young adults. CMV infection is persistent, and is characterised by subclinical cycles of active virus replication and by persistent low-level virus shedding. Most post-childhood infections are therefore acquired from asymptomatic excreters who shed virus in saliva, urine, semen and genital secretions. Sexual transmission and oral spread are common among adults, but infection may also be acquired by women caring for children with asymptomatic infections. The peak incidence occurs between the ages of 25 and 35, rather later than with EBV-related mononucleosis.

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Infectious medicine

Dr. Nihad A. Al-jeboori

Clinical features Most post-childhood CMV infections are subclinical, although some young adults develop a mononucleosis-like syndrome which accounts for 20-50% of heterophile antibody-negative IM. Some patients have a prolonged influenza-like illness lasting 2 weeks or more. Physical signs such as a palpable liver and spleen resemble those of IM, but in CMV mononucleosis hepatomegaly is relatively more common, while lymphadenopathy, pharyngitis and tonsillitis are found less often. Jaundice is uncommon and usually mild. Unusual complications include neurological involvement, autoimmune haemolytic anaemia, pericarditis, pneumonitis and arthropathy. Investigations Atypical lymphocytosis is not as prominent as in IM and heterophile antibody tests are negative. LFTs are often abnormal, with an alkaline phosphatase level raised out of proportion to transaminases. Serological diagnosis depends on the detection of CMVspecific IgM antibody. Management Amoxicillin and similar antibiotics should not be prescribed because of the risk of a skin reaction. Most cases of primary CMV infection in immunocompetent hosts are associated with minimal or no symptoms. Among patients with symptomatic CMV infection, especially the mononucleosis syndrome, the illness is generally self-limited, with complete recovery over a period of days to weeks. Antiviral therapy is not usually indicated. Currently, there are several agents available for the systemic therapy of CMV infection, including ganciclovir, valganciclovir, foscarnet, and cidofovir. The efficacy and toxicities of these agents have been evaluated extensively only in immunocompromised patients. The clinical utility of these agents in the immunocompetent host remains unproven. Gestational CMV infection Most CMV infections in pregnancy are subclinical. However, heterophile antibodynegative 'glandular fever' in pregnancy requires full investigation, as CMV can cause congenital infection and disease at any stage of gestation. The risk of spread to the fetus

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Infectious medicine

Dr. Nihad A. Al-jeboori

is around 40%, and 10% of infected infants will have long-term central nervous system sequelae.