Pediatrics II: INFECTIOUS MONONUCLEOSIS,

CYTOMEGALOVIRUS, MUMPS [VIRAL INFECTIONS

Part 3]
Dr. Dizon
Trans by: Aileen Valdez
Life is short as the day is long. Brooke Fraser

INFECTIOUS MONONUCLEOSIS
Pics
*Exudative tonsillitis
*Strawberry tongue; white strawberry if with whitish plaques
*Bull-neck appearance

Epidemiology

Low socioeconomic strata

Infancy and childhood

Industrialized countries
Adolescents and young adults

Viral shedding
Oral secretions >6 months after acute
infection then intermittently for life
Male and female secretions
Transmission

Adults and adolescents

Penetrative sexual intercourse
Deep kissing

Children
Exchange of saliva
Clinical Manifestations

Classic triad (adults and adolescents)

Fatigue
Pharyngitis
Generalized lymphadenopathy

Incubation period 30-50 days

Prodromal period 1-2 weeks

Fever
Headache
Abdominal pain
Malaise
Myalgia
Severe sore throat

Physical examination
Generalized lymphadenopathy 90%
o Anterior and posterior cervical
o Submandibular
o Axillary and inguinal
o Epitrochlear
Splenomegaly 50%
Hepatomegaly 10%
Rashes 3-15%
Diagnosis

CBC

Leukocytosis (10,000-20,000 cell/cm3)

20-40% of leukocytes are atypical
lymphocytes
Thrombocytopenia
Heterophile antibody test
IgM antibodies
Antibodies that agglutinate sheep or
horse RBC

Titers of >1:28 or 1:40 are positive

Ab
VCA:
IgM
VCA:
IgG

Specific EBV antibody test

VCA (viral capsid antigen) IgM and IgG
EA (early antigen)
o EA-D diffuse-staining
component
o EA-R cytoplasmic restricted
component
EBNA (nucleic acid antigen)
Appearance
At
Presentation
Peaks late in
the acute
phase
Peaks 3-4
wks

Duration
1-3
months
Lifelong

Significance
Best indicator of
primary infection
Marker for prior or
current infection

3-6
months

EA-R

Several wks

Months
to years

EBNA

3-4 months

Lifelong

Indicator of acute
phase
High titer of IgA
anti EA-D is found
in NPC
Indicator of
reactivation
Present in high
titers in EBVassociated Burkitts
lymphoma
Marker for primary
infection

EA-D

Complications

Subcapsular splenic hemorrhage or splenic

rupture

Airway obstruction

Headache, seizures and ataxia

Alice in wonderland syndrome (metamorphopsia)

Meningitis

Facial nerve palsy

Transverse myelitis

Encephalitis

Guillain-Barre syndrome

Hemolytic anemia

Burkitts lymphoma

Nasopharyngeal carcinoma
Attitude is a little thing that makes a big difference.
Winston Churchill

CYTOMEGALOVIRUS INFECTIONS
Epidemiology

Sources of infection
Saliva, breast milk, cervical and vaginal
secretions, urine, semen, stools, blood,
and tissue or organ transplants

Transmission
Direct person-to-person
Indirect through fomites
Perinatal
Clinical Manifestations

Mononucleosis-like syndrome
Fatigue, malaise, myalgia

Headache, fever
Hepatosplenomegaly, liver enzymes
Atypical lymphocytes
Negative heterophile antibody test
Cytomegalic inclusion disease (congenital)
Subclinical 90%
Mild 5%
Severe 5%

Congenital infection (CID)

IUGR
Hepatosplenomegaly
Jaundice
Thrombocytopenia & purpura
Microcephaly
Intracerebral calcifications
Chorioretinitis
Sensorineural hearing loss
Perinatal infection
Breast milk 50%
Cervical & vaginal secretions 6-12%
Majority are asymptomatic
Pneumonitis
Sepsis
Neurologic sequelae
Psychomotor retardation
Immunocompromised Patients
Hepatitis
Chorioretinitis
Gastrointestinal disease

Diagnosis

Virus isolation
Massive enlargement of infected cells
(cytomegalic cells) with large intranuclear
and a smaller intracytoplasmic inclusion
bodies

Antigen detection

PCR
Treatment

Ganciclovir + IVIG

Foscarnet
Prevention

Avoid contact with secretions

Passive immunoprophylaxis
IVIG or CMV IVIG
o Bone marrow transplant
recipients

Active
Live attenuated vaccine based on Towne
strain
There is no one giant step that does it. Its a lot of little
steps. Peter A. Cohen

MUMPS (Parotitis)
Epidemiology

Before the vaccine 5-9 years old

With vaccine available young adults

Viral shedding
Saliva 7 days before to 7 days after
appearace of salivary gland swelling
Urine 1st to 14th day after the onset of
salivary gland swelling
Transmission

Direct contact

Airborne droplets

Fomites contaminated by saliva and urine

Clinical Manifestations

Mumps virus targets the salivary glands, central

nervous system (CNS), pancreas, testes, and, to a
lesser extent, thyroid, ovaries, heart, kidneys,
liver, and joint synovia

Incubation period 12-25 days (16-18)

Subclinical 30-40%

Prodromes 1-2 days

Fever
Muscular pain
Headache
Malaise

Salivary gland swelling with tenderness

Parotid
Submandibular

Pancreatitis
Mild or subclinical
Epigastric pain, fever, chills, vomiting,
prostration
Increased amylase
Myocarditis
Arthritis
Migratory polyarthralgia and arthritis in
adults
Affects knees, ankles, shoulders and
wrists
Thyroiditis
Diffuse and tender swelling
Antithyroid antibodies develop
Deafness
1/15,000 cases
Usually unilateral
May be transient or permanent
Ocular complications

Immunity permanent
Prevention

Active vaccination Jeryl Lynn strain

~~~END~~~

Ingestion of sour or acidic food or liquids may

enhance the pain in the parotid area

Pics
*May be unilateral or bilateral

Diagnosis

Clinical

Laboratory tests
Elevated serum amylase
Leucopenia with lymphocytosis
Viral isolation saliva, CSF, blood, urine,
brain and other infected tissues
Detection of viral antigen by direct
immunofluorescence
Detection of viral nucleic acid by PCR
Serology
o ELISA
o CFT
o Neutralization
Treatment

Supportive

Diet adjusted to patients needs

Arthritis
Nonsteroidal anti-inflammatory agents
Corticosteroid
Complications

Orchitis and epididymitis

Most common in adolescents and adults
30% are bilateral
30-40% atrophy
Infertility rare

Oophoritis
No evidence of infertility