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Infectious Mononucleosis

Definition

Infectious mononucleosis is a contagious illness caused by the Epstein-Barr virus, which can affect the liver, lymph nodes, and oral cavity. While mononucleosis is not usually a serious disease, its primary symptoms of fatigue and lack of energy can linger for several months.

Description

Infectious mononucleosis, frequently called "mono" or the "kissing disease," is caused by the Epstein-Barr virus (EBV) found in saliva and mucus. The virus affects a type of white blood cell called the B lymphocyte, producing characteristic atypical lymphocytes that may be useful in the diagnosis of the disease.

While anyone, even young children, can develop mononucleosis, it occurs most often in young adults between the ages of 15 and 35, and is especially common in teenagers. The mononucleosis infection rate among college students who have not previously been exposed to EBV has been estimated to be about 15%. In younger children, the illness may not be recognized.

The disease typically runs its course in four to six weeks in people with normally functioning immune systems. People with weakened or suppressed immune systems, such as AIDS patients or those who have had organ transplants, are particularly vulnerable to the potentially serious complications of infectious mononucleosis.

— Susan J. Montgomery


 
 
Dictionary: infectious mononucleosis

n.

A common, acute, infectious disease, usually affecting young people, caused by Epstein-Barr virus and characterized by fever, swollen lymph nodes, sore throat, and lymphocyte abnormalities. Also called glandular fever.


 
Sci-Tech Encyclopedia: Infectious mononucleosis

A disease of children and young adults, characterized by fever and enlarged lymph nodes and spleen. EB (Epstein-Barr) herpesvirus is the causative agent.

Onset of the disease is slow and nonspecific with variable fever and malaise; later, cervical lymph nodes enlarge, and in about 50% of cases the spleen also becomes enlarged. The disease lasts 4–20 days or longer. Epidemics are common in institutions where young people live. EB virus infections occurring in early childhood are usually asymptomatic. In later childhood and adolescence, the disease more often accompanies infection—although even at these ages inapparent infections are common. See also Epstein-Barr virus.

 
Dental Dictionary: infectious mononucleosis
(mon′ōnōō′klē ō′sis)
n

(acute benign lymphadenosis, “kissing disease,” “student’s disease”), an acute infectious viral disease most commonly affecting young adults and older children. Manifestations include fever, sore throat, cervical lymphadenopathy, petechial hemorrhages of the soft palate, and, at times, purpura with thrombocytopenia. Early leukopenia and relative lymphocytosis occur, with later increases in the number of large leuko-cytoid lymphocytes. The heterophil (usually sheep cell) antibody titer is significantly increased in most instances.

 
Children's Health Encyclopedia: Infectious Mononucleosis

Definition

Infectious mononucleosis is a contagious illness caused by the Epstein-Barr virus that can affect the liver, lymph nodes, and oral cavity. While mononucleosis is not usually a serious disease, its primary symptoms of fatigue and lack of energy can linger for several months.

Description

Infectious mononucleosis, frequently called "mono" or the "kissing disease," is caused by the Epstein-Barr virus (EBV) found in saliva and mucus. The virus affects a type of white blood cell called the B lymphocyte, producing characteristic atypical lymphocytes that may be useful in the diagnosis of the disease.

The disease typically runs its course in four to six weeks in people with normally functioning immune systems. People with weakened or suppressed immune systems, such as AIDS patients or those who have had organ transplants, are particularly vulnerable to the potentially serious complications of infectious mononucleosis.

Demographics

While anyone, even young children, can develop mononucleosis, it occurs most often in young adults between the ages of 15 and 35 and is especially common in teenagers. The mononucleosis infection rate among college students who have not previously been exposed to EBV has been estimated to be about 15 percent. In younger children, the illness may not be recognized.

Causes and Symptoms

The EBV that causes mononucleosis is related to a group of herpes viruses, including those that cause cold sores, chickenpox, and shingles. Most people are exposed to EBV at some point during their lives. Mononucleosis is most commonly spread by contact with virus-infected saliva through coughing, sneezing, kissing, or sharing drinking glasses or eating utensils.

In addition to general weakness and fatigue, symptoms of mononucleosis may include any or all of the following:

  • sore throat and/or swollen tonsils
  • fever and chills
  • nausea and vomiting, or decreased appetite
  • swollen lymph nodes in the neck and armpits
  • headaches or joint pain
  • enlarged spleen
  • jaundice
  • skin rash

Complications that can occur with mononucleosis include a temporarily enlarged spleen or inflamed liver. In rare instances, the spleen may rupture, producing sharp pain on the left side of the abdomen, a symptom that warrants immediate medical attention. Additional symptoms of a ruptured spleen include light-headedness, rapidly beating heart, and difficulty breathing. Other rare, but potentially life-threatening, complications may involve the heart or brain. The infection may also cause significant destruction of the body's red blood cells or platelets.

Symptoms do not usually appear until four to seven weeks after exposure to EBV. An infected person can be contagious during this incubation time period and for as many as five months after the disappearance of symptoms. Also, the virus will be excreted in the saliva intermittently for the rest of their lives, although the individual will experience no symptoms. Contrary to popular belief, the EBV is not highly contagious. As a result, individuals living in a household or college dormitory with someone who has mononucleosis have a very small risk of being infected unless they have direct contact with the person's saliva.

Diagnosis

If symptoms associated with a cold persist longer than two weeks, mononucleosis is a possibility; however, a variety of other conditions can produce similar symptoms. If mononucleosis is suspected, a physician will typically conduct a physical examination, including a "Monospot" antibody blood test that can indicate the presence of proteins or antibodies produced in response to infection with the EBV. These antibodies may not be detectable, however, until the second or third weeks of the illness. Occasionally, when this test is inconclusive, other blood tests may be conducted.

Treatment

The most effective treatment for infectious mononucleosis is rest and a gradual return to regular activities. Individuals with mild cases may not require bed rest but should limit their activities. Any strenuous activity, athletic endeavors, or heavy lifting should be avoided until the symptoms completely subside, since excessive activity may cause the spleen to rupture.

The sore throat and dehydration that usually accompany mononucleosis may be relieved by drinking water and fruit juices. Gargling salt water or taking throat lozenges may also relieve discomfort. In addition, taking over-the-counter medications, such as acetaminophen or ibuprofen, may relieve symptoms, but aspirin should be avoided because mononucleosis has been associated with Reye's syndrome, a serious illness aggravated by aspirin.

While antibiotics do not affect EBV, the sore throat accompanying mononucleosis can be complicated by a streptococcal infection, which can be treated with antibiotics. Cortisone anti-inflammatory medications are also occasionally prescribed for the treatment of severely swollen tonsils or throat tissues.

Prognosis

While the severity and length of illness varies, most people diagnosed with mononucleosis are able to return to their normal daily routines within two to three weeks, particularly if they rest during this time period. It may take two to three months before a person's usual energy levels return. One of the most common problems in treating mononucleosis, particularly in teenagers, is that people return to their usual activities too quickly and then experience a relapse of symptoms. Once the disease has completely run its course, the person cannot be reinfected.

Prevention

Although there is no way to avoid becoming infected with EBV, paying general attention to good hygiene and avoiding sharing beverage glasses or having close contact with people who have mononucleosis or cold symptoms can help prevent infection.

Parental Concerns

The main concern for parents of children with mononucleosis is to keep the child resting until he or she fully recovers from the illness. Parents should also be aware of the symptoms of more serious complications of the liver and spleen, and should seek medical attention for a child who complains of severe abdominal pain, light-headedness, rapid heartbeat, or difficulty breathing.

Resources

Books

Jensen, Hal B. "Epstein-Barr Virus." In Nelson Textbook of Pediatrics. Edited by Richard E. Behrman et al. Philadelphia: Saunders, 2004.

Katz, Ben Z. "Epstein-Barr Virus (Mononucleosis and Lymphoproliferative Disorders)." In Principles and Practice of Pediatric Infectious Diseases, 2nd ed. Edited by Sarah S. Long et al. St. Louis, MO: Elsevier, 2003.

Periodicals

Auwaerter, P. G. "Infectious mononucleosis: return to play." Medical Clinics of North America 23 (July 2004): 485–97.

Organizations

National Institute of Allergy and Infectious Disease. Building 31, Room 7A-50, 31 Center Drive MSC 2520, Bethesda, MD 20892–2520. Web site: www.niaid.nih.gov/default.htm.

[Article by: Susan J. Montgomery Rosalyn Carson-DeWitt, MD]


 
Britannica Concise Encyclopedia: infectious mononucleosis

Common infection, caused by Epstein-Barr virus. It occurs most often at ages 10 – 35. Infected young children usually have little or no illness but become immune. Popularly called "the kissing disease," it is spread mostly by oral contact with exchange of saliva. It usually lasts 7 – 14 days. The most common symptoms are malaise, sore throat, fever, and lymph-node enlargement. Liver involvement is usual but rarely severe. The spleen often enlarges and in rare cases ruptures fatally. Less frequent features include rash, pneumonia, encephalitis (sometimes fatal), meningitis, and peripheral neuritis. Relapse and second attacks are rare. Diagnosis may require blood analysis. There is no specific therapy.

For more information on infectious mononucleosis, visit Britannica.com.

 
Sports Science and Medicine: infectious mononucleosis

An acute communicable viral disease that is an important and common infection in athletes, affecting mainly adolescents and young adults. The virus is transmitted by direct contact, airborne droplets, or shared utensils. The infection causes fatigue, sore throat, fever, liver disorder, and swollen lymph glands. A common complication is an enlarged spleen, which can be ruptured easily by a blow to the abdomen. Owing to the symptoms, athletes are usually unable to train during the early stage of the infection, but because of the high risk of splenic rupture, strenuous exercise, and alcohol consumption is inadvisable for the first months following infection. Participation in contact or collision sports should be resumed only if the spleen is not enlarged.

 
Columbia Encyclopedia: infectious mononucleosis
(mŏn'ənū'klēō'sĭs) , acute infectious disease of older children and young adults, occurring sporadically or in epidemic form, also known as mono, glandular fever, and kissing disease. The causative organism is a herpesvirus known as Epstein-Barr virus. The disease occurs most often in patients between the ages of 15 and 35. The virus is present in the saliva; it is usually spread by sharing a glass or kissing. Symptoms usually take 30 to 50 days to develop.

Diagnosis of mononucleosis follows the exhibition of a large number of abnormal white blood cells (lymphocytes) on microscopic blood examination. These blood cells have a single nucleus that give the disease its name. Symptoms are varied but include enlarged lymph nodes, sore throat, fever, enlarged spleen in about half the cases, and excessive fatigue. Occasional rashes and throat and mouth infections occur. Liver inflammation is common. Fatalities are very rare and, when they do occur, usually result from splenic rupture. General therapeutic measures include bed rest and treatment of symptoms.

 
Wikipedia: infectious mononucleosis
Infectious mononucleosis
Classification & external resources
Infectious_Mononucleosis_3.jpg
Infectious Mononucleosis smear showing reactive (atypical) lymphocytes, in blue.
ICD-10 B27.
ICD-9 075
DiseasesDB 4387
MedlinePlus 000591
eMedicine emerg/319  med/1499 ped/705
MeSH D007244

Infectious mononucleosis, (also known as the kissing disease, or Pfeiffer's disease, in North America as mono and more commonly known as glandular fever in other English-speaking countries) is seen most commonly in adolescents and young adults, characterized in teenagers by fever, sore throat, muscle soreness, and fatigue. Mononucleosis typically produces a very mild illness in small children. White patches on the tonsils or in the back of the throat may also be seen (resembling strep throat). Mononucleosis is usually caused by the Epstein-Barr virus (EBV), which infects B cells (B-lymphocytes), producing a reactive lymphocytosis and atypical T cells (T-lymphocytes) known as Downey bodies.

Mononucleosis is typically transmitted from asymptomatic individuals through saliva (hence "the kissing disease"), or by sharing a drink, or sharing eating utensils. It may also be transmitted through blood. The disease is far less contagious than is commonly thought. In rare cases a person may have a high resistance to infection.[citation needed] The disease is so-named because the count of mononuclear leukocytes (white blood cells with a one-lobed nucleus) rises significantly. There are two main types of mononuclear leukocytes: monocytes and lymphocytes. They normally account for about 35% of all white blood cells. With infectious mononucleosis, this can rise to 50-70%. Also, the total white blood count may increase to 10,000-20,000 per cubic millimeter.

Symptoms

Symptoms usually appear 1-2 months after infection, and may resemble strep throat, or other bacterial or viral respiratory infections. The typical symptoms and signs of mononucleosis are:

  • Fever—this varies from mild to severe, but is seen in nearly all cases.
  • Tender and enlarged/swollen lymph nodes—particularly the posterior cervical lymph nodes, on both sides of the neck.
  • Sore throat—White patches on the tonsils and back of the throat are often seen
  • Fatigue (sometimes extreme fatigue)

Some patients also display:

After an initial prodrome of 1-2 weeks, the fatigue of infectious mononucleosis often lasts from 1-2 months. The virus can remain dormant in the B cells indefinitely after symptoms have disappeared, and resurface at a later date. Many people exposed to the Epstein-Barr virus do not show symptoms of the disease, but carry the virus and can transmit it to others. This is especially true in children, in whom infection seldom causes more than a very mild illness which often goes undiagnosed. This feature, along with mono's long (4 to 6 week) incubation period, makes epidemiological control of the disease impractical. About 6% of people who have had infectious mononucleosis will relapse.

Mononucleosis can cause the spleen to swell. Rupture may occur without trauma, but impact to the spleen is also a factor. Other complications include hepatitis (inflammation of the liver) causing elevation of serum bilirubin (in approximately 40% of patients), jaundice (approximately 5% of cases), and anemia (a deficiency of red blood cells). In rare cases, death may result from severe hepatitis or splenic rupture.

Reports of splenomegaly (enlarged spleen) in infectious mononucleosis suggest variable prevalence rates of 25% to 75%. Among pediatric patients, a splenomegaly rate of 50% is expected,[1] with a rate of 60% reported in one case series.[2] Although splenic rupture is a rare complication of infectious mononucleosis, it is the basis of advice to avoid contact sports for 4-6 weeks after diagnosis.

Usually, the longer the infected person experiences the symptoms the more the infection weakens the person's immune system and the longer he/she will need to recover. Cyclical reactivation of the virus, although rare in healthy people, is often a sign of immunological abnormalities in the small subset of organic disease patients in which the virus is active or reactivated.

Although all cases of mononucleosis are caused by the E.B. virus, cytomegalovirus can produce a similar illness, usually with less throat pain. Due to the presence of the atypical lymphocytes on the blood smear in both conditions, some physicians confusingly used to include both infections under the diagnosis of "mononucleosis," though EBV is by definition the infection that must be present for this illness. Symptoms similar to those of mononucleosis can be caused by adenovirus, acute HIV infection and the protozoan Toxoplasma gondii.

Atypical presentations of mononucleosis/EBV infection

In small children, the course of the disease is frequently asymptomatic. The course of the disease can also be chronic. Some patients suffer fever, tiredness, lassitude (abnormal fatigue), depression, lethargy, and chronic lymph node swelling, for months or years. This variant of mononucleosis has been referred to as chronic EBV syndrome or chronic fatigue syndrome, although the most recent medical studies have discounted the link between chronic EBV infection and chronic fatigue syndrome (CFS). In case of a weakening of the immune system, a reactivation of the Epstein-Barr Virus is possible; in CFS there is evidence of immune activation also.

Although studies conducted by the CDC and others have discounted a link between EBV and CFS, some patients anecdotally report that chronic fatigue lasting for years after mono is part of a CFS. This confusion seems to lie in the nature of the link (note any association does not prove or disprove causality) and possible misapprehension as to the syndromic nature of CFS. Current studies suggest there is an association between infectious mononucleosis and CFS [1]. "Chronic fatigue states" appear to occur in 10% of those who contract mononucleosis[2] Some confusion here may be due to the use of a new, broadened revision of the CFS research criteria, which has been criticised as overly inclusive. Although chronic fatigue may then be a rather common side effect of infectious mononucleosis, it should be noted that CFS is more than "chronic fatigue", requiring at least four other symptoms, and a number of findings have been published which are not typical of EBV infection, although some complications may be shared (see "Mortality/morbidity" below). Additionally some CFS patients do not describe fatigue as their worst problem.

Perhaps a majority of chronic post infectious "fatigue states" appear not to be caused by a chronic viral infection, but be triggered by the acute infection. Direct and indirect evidence of persistent viral infection has been found in CFS, for example in muscle and via detection of an unusually low molecular weight RNase L enzyme, although the commonality and significance of such findings is disputed. Hickie et al contend that mononucleosis appears to cause a hit and run injury to the brain in the early stages of the acute phase, thereby causing the chronic fatigue state. This would explain why in mononucleosis, fatigue very often lingers for months after the Epstein Barr Virus has been controlled by the immune system. However, it has also been noted in several (although altogether rare) cases that the only "symptom" displayed by a mononucleosis sufferer is elevated moods and higher energy levels, virtually the opposite of CFS and comparable to hypomania. Just how infectious mononucleosis changes the brain and causes fatigue (or lack thereof) in certain individuals remains to be seen. Such a mechanism may include activation of microglia in the brain of some individuals during the acute infection, thereby causing a slowly dissipating fatigue

Laboratory tests

An atypical lymphocyte.
Enlarge
An atypical lymphocyte.

The laboratory hallmark of the disease is the presence of so-called atypical lymphocytes (a type of mononuclear cell, see image) on the peripheral blood smear. In addition, the overall white blood cell count is almost invariably increased, particularly the number of lymphocytes.

Mononucleosis causes so-called heterophile antibodies, which cause agglutination (sticking together) of non-human red blood cells, to appear in the patient's blood. The monospot is a non-specific test that screens for mononucleosis by looking for these antibodies. Confirmation of the exact etiology can be obtained through tests to detect specific antibodies to the causative viruses. The spot test may be negative in the first week, so negative tests are often repeated at a later date. Since the spot test is usually negative in children less than 6-8 years old, an EBV serology test should be done on them if mononucleosis is suspected. An older test for heterophile antibodies is the Paul-Bunnell test, in which the patient's serum is mixed with sheep red blood cells and checked for agglutination of these cells.

Treatment

Infectious mononucleosis is generally self-limiting and only symptomatic and/or supportive treatments are used.[3] Rest is recommended during the acute phase of the infection, but activity should be resumed once acute symptoms have resolved. Nevertheless heavy physical activity and contact sports should be avoided to abrogate the risk of splenic rupture, for at least one month following initial infection and until splenomegaly has resolved, as determined by ultrasound scan.[3]

In terms of pharmacotherapies, acetaminophen/paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs) may be used to reduce fever and pain – aspirin is not used due to the risk of Reye's syndrome in children and young adults. Intravenous corticosteroids, usually hydrocortisone or dexamethasone, are not recommended for routine use[4] but may be useful if there is a risk of airway obstruction, severe thrombocytopenia, or hemolytic anemia.[5][6]

There is little evidence to support the use of aciclovir, although it may reduce initial viral shedding.[7] However, the antiviral drug valacyclovir has recently been shown to lower or eliminate the presence of the Epstein-Barr virus in subjects afflicted with acute mononucleosis, leading to a significant decrease in the severity of symptoms.[8][9][10] Antibiotics are not used, being ineffective against viral infections, with amoxicillin and ampicillin contraindicated (for other infections) during mononucleosis as their use can frequently precipitate a non-allergic rash. In a small percentage of cases, mononucleosis infection is complicated by co-infection with streptococcal infection in the throat and tonsils (strep throat). Penicillin or other antibiotics should be administered to treat the strep throat, but are not effective against EBV. Opioid analgesics are also contraindicated due to risk of respiratory depression.[5]

Mortality/morbidity

Fatalities from mononucleosis are extremely rare in developed nations. Potential mortal complications include splenic rupture, bacterial superinfections, hepatic failure and the development of viral myocarditis.

Uncommon, nonfatal complications exist, including various forms of CNS and hematological affection.

References

  1. ^ Hickie I, Davenport T, Wakefield D, Vollmer-Conna U, Cameron B, Vernon SD, Reeves WC, Lloyd A; Dubbo Infection Outcomes Study Group. Post-infective and chronic fatigue syndromes precipitated by viral and non-viral pathogens: prospective cohort study.

    BMJ. 2006 Sep 16;333(7568):575

  2. ^ Hickie I, Davenport T, Wakefield D, Vollmer-Conna U, Cameron B, Vernon SD, Reeves WC, Lloyd A; Dubbo Infection Outcomes Study Group. Post-infective and chronic fatigue syndromes precipitated by viral and non-viral pathogens: prospective cohort study. BMJ. 2006 Sep 16;333(7568):575
  3. ^ a b Beers MH, Porter RS, Jones TV, Kaplan JL, Berkwits M, editors. The Merck manual of diagnosis and therapy. 18th ed. Whitehouse Station (NJ): Merck Research Laboratories; 2006. ISBN 0-911910-18-2
  4. ^ Candy B, Hotopf M. (2006). "Steroids for symptom control in infectious mononucleosis". Cochrane Database Sys Rev (4): CD004402. DOI:10.1002/14651858.CD004402.pub2. 
  5. ^ a b Antibiotic Expert Group. Therapeutic guidelines: Antibiotic. 13th ed. North Melbourne: Therapeutic Guidelines; 2006.
  6. ^ Healthwise Inc. Infectious Mononucleosis. New York: WebMD; c1995–2006 [updated 2006 Jan 24; cited 2006 Jul 10]. Available from: http://www.webmd.com/hw/infection/hw168622.asp
  7. ^ Torre D, Tambini R. Acyclovir for treatment of infectious mononucleosis: a meta-analysis. Scand J Infect Dis 1999;31(6):543-7. PMID 10680982
  8. ^ Balfour et al. (December 2005) A controlled trial of valacyclovir in infectious mononucleosis. Presented at the 45th Interscience Conference on Antimicrobial Agents and Chemotherapy, Washington, DC., December 18, 2005. Abstract V1392
  9. ^ Simon et al. (March 2003) The Effect of Valacyclovir and Prednisolone in Reducing Symptoms of EBV Illness In Children: A Double-Blind, Placebo-Controlled Study. International Pediatrics. Vol. 18, No. 3. pp. 164-169.
  10. ^ Balfour et al. (May 2007) A virologic pilot study of valacyclovir in infectious mononucleosis. Journal of Clinical Virology. Volume 39, Issue 1. pp. 16-21.
  11. ^ Ascherio A, Munger KL. Environmental risk factors for multiple sclerosis. Part I: the role of infection. Ann Neurol. 2007 Apr;61(4):288-99.
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