infectious mononucleosis: Definition from Answers.com

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]

This article is about mononucleosis caused by Epstein–Barr virus. For mononucleosis caused by cytomegalovirus, see Cytomegalovirus.

EBV infectious mononucleosis
Classification and external resources
Infectious mononucleosis, peripheral smear, high power showing reactive lymphocytes
ICD-10	B 27.0
ICD-9	075
DiseasesDB	4387
MedlinePlus	000591
eMedicine	emerg/319 med/1499 ped/705
MeSH	D007244

Infectious mononucleosis (IM; also known as EBV infectious mononucleosis, Pfeiffer's disease, Filatov's disease^[1] and sometimes colloquially as the kissing disease from its oral transmission or simply as mono in North America and as glandular fever in other English-speaking countries) is an infectious, widespread viral disease caused by the Epstein–Barr virus (EBV), one type of herpes virus, to which more than 90% of adults have been exposed.^[2] Occasionally, the symptoms can recur at a later period.^[3] Most people are exposed to the virus as children, when the disease produces no noticeable or only flu-like symptoms. In developing countries, people are exposed to the virus in early childhood more often than in developed countries. As a result, the disease in its observable form is more common in developed countries. It is most common among adolescents and young adults.^[4]

Especially in adolescents and young adults, the disease is characterized by fever, sore throat and fatigue, along with several other possible signs and symptoms. It is primarily diagnosed by observation of symptoms, but suspicion can be confirmed by several diagnostic tests.

The syndrome was described as an infectious process by Nil Filatov in 1887 and independently by Emil Pfeiffer in 1889.^[5]^[6]^[1]

Contents

1 Signs and symptoms
2 Pathophysiology
3 Diagnosis
- 3.1 Differential diagnosis
4 Treatment
- 4.1 Medications
5 Prognosis
6 Notes

Signs and symptoms

Main symptoms of IM^[7]^[8]^[9]

The classic symptoms of mononucleosis are a sore throat, fever, fatigue, malaise, pharyngeal inflammation, vomiting, petechiae and loss of appetite. Common signs include lymphadenopathy (enlarged lymph nodes), splenomegaly (enlarged spleen), hepatitis (refers to inflammation of hepatocytes—cells in the liver) and hemolysis (the bursting of red blood cells). Older adults are less likely to have a sore throat or lymphadenopathy, but are instead more likely to present with hepatomegaly (enlargement of the liver) and jaundice. Rarer signs and symptoms include thrombocytopenia (lower levels of platelets), with or without pancytopenia (lower levels of all types of blood cells), splenic rupture, splenic hemorrhage, upper airway obstruction, pericarditis and pneumonitis. Another rare manifestation of mononucleosis is erythema multiforme.^[10]^[11]

Mononucleosis is sometimes accompanied by secondary cold agglutinin disease, an autoimmune disease, in which abnormal circulating antibodies directed against red blood cells can lead to a form of autoimmune hemolytic anemia. The cold agglutinin detected is of anti-i specificity.^[12]^[13] Patients with infectious mononucleosis are sometimes misdiagnosed with a streptococcal pharyngitis (because of the classical clinical triad of fever, pharyngitis and adenopathy) and are given antibiotics such as ampicillin or amoxicillin as treatment. Some studies indicate about 80–90% of patients with acute Epstein–Barr virus infection treated with such antibiotics develop a red, diffuse rash.^[14]

Pathophysiology

Infectious mononucleosis occurs with infection by the Epstein–Barr virus.^[15] A similar condition can be caused by cytomegalovirus, but that one gives a negative on the heterophile antibody test.^[3] Because of this, some sources indicate infectious mononucleosis is caused by the Epstein–Barr virus.^[16]

The infection is spread via saliva, and has an incubation period of four to seven weeks.^[17] Symptoms usually persist for two to three weeks,^[18] but fatigue is often more prolonged.^[4]

How long someone with the virus stays contagious after symptoms are gone is uncertain, but the most contagious period is thought to last about six weeks after the onset of symptoms. Some studies indicate a person can spread the infection for many months after the symptoms are completely gone, with one particular study indicating as long as 18 months.^[19]

The virus replicates first within epithelial cells in the pharynx (which causes pharyngitis, or sore throat), and later primarily within B cells (which are invaded via their CD21). The host immune response involves cytotoxic (CD8-positive) T cells against infected B lymphocytes, resulting in enlarged, atypical lymphocytes (Downey cells).^[20]^[21]

When the infection is acute (recent onset, instead of chronic), heterophile antibodies are produced.^[11]

Diagnosis

Exudative pharyngitis in a person with infectious mononucleosis

Cervical lymphadenopathy in someone with infectious mononucleosis

The most commonly used diagnostic criterion is the presence of 50% lymphocytes with at least 10% atypical lymphocytes (large, irregular nuclei),^[10] while the person also has fever, pharyngitis and adenopathy. Furthermore, it should be confirmed by a serological test.^[11] The atypical lymphocytes resembled monocytes when they were first discovered, thus the term "mononucleosis" was coined. Diagnostic tests are used to confirm infectious mononucleosis, but the disease should be suspected from symptoms prior to the results from hematology.^[22] These criteria are specific; however, they are not particularly sensitive and are more useful for research than for clinical use. Only half the patients presenting with the symptoms held by mononucleosis and a positive heterophile antibody test (monospot test) meet the entire criteria. One key procedure is to differentiate between infectious mononucleosis and mononucleosis-like symptoms.

A few studies on infectious mononucleosis have been conducted in a primary care environment, the best of which studied 700 patients, of which 15 were found to have mononucleosis upon a heterophile antibody test. More useful in a diagnostic sense are the signs and symptoms themselves. The presence of splenomegaly, and posterior cervical, axillary and inguinal adenopathies are the most useful to suspect a diagnosis of infectious mononucleosis. On the other hand, the absence of cervical adenopathy and fatigue are the most useful to dismiss the idea of infectious mononucleosis as the correct diagnosis. The insensitivity of the physical examination in detecting splenomegaly means it should not be used as evidence against infectious mononucleosis.^[11]

In the past, the most common test for diagnosing infectious mononucleosis was the heterophile antibody test, which involves testing heterophile antibodies by agglutination of guinea pig, sheep and horse red blood cells. As with the aforementioned criteria, this test is specific but not particularly sensitive (with a false-negative rate of as high as 25% in the first week, 5–10% in the second and 5% in the third).^[11] About 90% of patients have heterophile antibodies by week 3, disappearing in under a year. The antibodies involved in the test do not interact with the Epstein–Barr virus or any of its antigens.^[10] More recently, more sensitive tests have been developed, such as the immunoglobulin G (IgG) and immunoglobulin M (IgM) tests. IgG, when positive, reflects a past infection, whereas IgM reflects a current infection. When negative, these tests are more accurate in ruling out infectious mononucleosis. However, when positive, they feature similar sensitivities to the heterophile antibody test. Therefore, these tests are useful for diagnosing infectious mononucleosis in people with highly suggestive symptoms and a negative heterophile antibody test. Another test searches for the Epstein–Barr nuclear antigen, while it is not normally recognizable until several weeks into the disease, and is useful for distinguishing between a recent-onset of infectious mononucleosis and symptoms caused by a previous infection. Elevated hepatic transaminase levels is highly suggestive of infectious mononucleosis, occurring in up to 50% of patients.^[11]

A fibrin ring granuloma may be present.

Differential diagnosis

Diagnosis of acute infectious mononucleosis should also take into consideration acute cytomegalovirus infection and Toxoplasma gondii infections. These diseases are clinically very similar by their signs and symptoms. Because their management is much the same, it is not always helpful, or possible, to distinguish between EBV mononucleosis and cytomegalovirus infection. However, in pregnant women, differentiation of mononucleosis from toxoplasmosis is associated with significant consequences for the fetus.

Acute HIV infection can mimic signs similar to those of infectious mononucleosis, and tests should be performed for pregnant women for the same reason as toxoplasmosis.^[11]

Other conditions from which to distinguish infectious mononucleosis include leukemia, tonsillitis, diphtheria, common cold and influenza (flu).^[10]

Treatment

Infectious mononucleosis is generally self-limiting, so only symptomatic and/or supportive treatments are used.^[23] Rest is recommended during the acute phase of the infection, but activity should^{[citation needed]} be resumed once acute symptoms have resolved. Nevertheless, heavy physical activity and contact sports should be avoided to mitigate the risk of splenic rupture, for at least one month following initial infection or splenomegaly has resolved, as determined by a treating physician.^[8]

Medications

In terms of pharmacotherapies, NSAIDs, such as ibuprofen, may be used to reduce fever and pain. Prednisone, a corticosteroid, is commonly used as an anti-inflammatory to reduce symptoms of pharyngeal pain, odynophagia, or enlarged tonsils, although its use remains controversial due to the rather limited benefit and the potential of side effects.^[24]^[25] Intravenous corticosteroids, usually hydrocortisone or dexamethasone, are not recommended for routine use^[26] but may be useful if there is a risk of airway obstruction, severe thrombocytopenia, or hemolytic anemia.^[27]^[28] There is little evidence to support the use of aciclovir, although it may reduce initial viral shedding.^[29] 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.^[30]^[31] Although antivirals are not recommended for patients presenting with simple infectious mononucleosis, they may be useful (in conjunction with steroids) in the management of patients with severe EBV manifestations, such as EBV meningitis, peripheral neuritis, hepatitis, or hematologic complications.^[32] Antibiotics are not used, as they are ineffective against viral infections. The antibiotics ampicillin and later the related amoxicillin^[33] are relatively contraindicated in the case of any coinciding bacterial infections during mononucleosis because their use precipitates a nonallergic rash in close to 99% of the patients.^[34]

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 (with the exception of the two mentioned above) should be administered to treat the strep throat. Opioid analgesics are also relatively contraindicated due to risk of respiratory depression.^[28]

Prognosis

Serious complications are uncommon, occurring in less than 5% of cases:^[35]^[36]

CNS complications include meningitis, encephalitis, hemiplegia, Guillain-Barré syndrome, and transverse myelitis. EBV infection has also been proposed as a risk factor for the development of multiple sclerosis (MS),^[37] but this has not been confirmed.
Hematologic: Hemolytic anemia (direct Coombs test is positive) and various cytopenias, and bleeding (caused by thrombocytopenia) can occur.^[12]
Mild jaundice
Hepatitis with EBV is rare.
Upper airway obstruction from tonsillar hypertrophy is rare.
Fulminant disease course of immunocompromised patients is rare.
Splenic rupture is rare.
Myocarditis and pericarditis are rare.

Once the acute symptoms of an initial infection disappear, they often do not return. But once infected, the patient carries the virus for the rest of his or her life. The virus typically lives dormantly in B lymphocytes. Independent infections of mononucleosis may be contracted multiple times, regardless of whether the patient is already carrying the virus dormantly. Periodically, the virus can reactivate, during which time the patient is again infectious, but usually without any symptoms of illness.^[3] Usually, a patient has few, if any, further symptoms or problems from the latent B lymphocyte infection. However, in susceptible hosts under the appropriate environmental stressors, the virus can reactivate and cause vague physical symptoms (or may be subclinical), and during this phase the virus can spread to others. Similar reactivation or chronic subclinical viral activity in susceptible hosts may trigger multiple host autoimmune diseases, such as systemic lupus erythematosus, rheumatoid arthritis, Sjogren's syndrome, antiphospholipid antibody syndrome, and multiple sclerosis. Such chronic immunologic stimulation may also trigger multiple type of cancers, particularly lymphoma—strongest cancer associations with EBV are nasopharyngeal carcinomas, Burkitt's lymphoma, and Hodgkin's lymphoma. EBV's potential to trigger such a wide range of autoimmune diseases and cancers probably relates to its primary infection of B lymphocytes (the primary antibody-producing cell of the immune system) and ability to alter both lymphocyte proliferation and lymphocyte antibody production.^[3]^[38]^[39]

Notes

^ ^a ^b synd/1811 at Who Named It?
^ http://www.kenyon.edu/x26163.xml
^ ^a ^b ^c ^d "Epstein-Barr Virus and Infectious Mononucleosis". CDC A–Z Index. National Center for Infectious Diseases. 16. http://www.cdc.gov/ncidod/diseases/ebv.htm. Retrieved December 6, 2009.
^ ^a ^b "Infectious Mononucleosis (mono, EBV mononucleosis)". Health.state.ny.us. http://www.health.state.ny.us/diseases/communicable/mononucleosis/fact_sheet.htm. Retrieved 2009-11-27.
^ Н. Филатов: Лекции об острых инфекционных болезнях у детей (N. Filatov: Lektsii ob ostrikh infeksionnîkh boleznyakh u dietei). 2 volumes. Moscow, A. Lang, 1887.
^ E. Pfeiffer: Drüsenfieber. Jahrbuch für Kinderheilkunde und physische Erziehung, Wien, 1889, 29: 257–264.
^ MedicineNet - infectious mononucleosis article Retrieved on 7 Mars, 2009
^ ^a ^b WebMD > Infectious Mononucleosis Last Updated: September 19, 2007. Retrieved on 7 Mars, 2009
^ (History section of) eMedicine Specialties > Infectious Diseases > Infectious Mononucleosis. Author: Burke A Cunha, MD, Professor of Medicine
^ ^a ^b ^c ^d Longmore, Murray; Ian Wilkinson, Tom Turmezei, Chee Kay Cheung (2007). Oxford Handbook of Clinical Medicine, 7th edition. Oxford University Press. p. 389. ISBN 0-19-856837-1.
^ ^a ^b ^c ^d ^e ^f ^g Ebell MH (November 2004). "Epstein-Barr virus infectious mononucleosis". American Family Physician 70 (7): 1279–87. PMID 15508538.
^ ^a ^b Ghosh, Amit K.; Habermann, Thomas (2007). Mayo Clinic Internal Medicine Concise Textbook. Informa Healthcare. ISBN 1-4200-6749-4.
^ Rosenfield RE; Schmidt PJ, Calvo RC, McGinniss MH (1965). "Anti-i, a frequent cold agglutinin in infectious mononucleosis". Vox Sanguinis 10 (5): 631–634. doi:10.1111/j.1423-0410.1965.tb01418.x. PMID 5864820.
^ Kagan, B (1977). "Ampicillin rash". Western Journal of Medicine 126 (4): 333–335. PMC 1237570. PMID 855325. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1237570.
^ "infectious mononucleosis" at Dorland's Medical Dictionary
^ http://www.gorhams.dk/html/the_lymphatic_system.html | title=The Lymphatic System |publisher="Lymphangiomatosis & Gorham's disease Alliance |accessdate=2010-02-08
^ Cozad J (March 1996). "Infectious mononucleosis". The Nurse Practitioner 21 (3): 14–6, 23, 27–8. doi:10.1097/00006205-199603000-00002. PMID 8710247.
^ "Glandular fever - NHS". National Health Service (NHS). 2010-09-09. http://www.nhs.uk/Conditions/Glandular-fever/Pages/Introduction.aspx. Retrieved 2010-09-09.
^ "How Long Is Mono Contagious?". Kidshealth.org. http://kidshealth.org/teen/infections/common/mono_contagious.html. Retrieved 2009-11-27.
^ ped/705 at eMedicine
^ Infectious mononucleosis.
^ Hoagland RJ (June 1975). "Infectious mononucleosis". Primary care 2 (2): 295–307. PMID 1046252.
^ Mark H. Beers ... (2006). Beers MH, Porter RS, Jones TV, Kaplan JL, Berkwits M, editors.. ed. The Merck manual of diagnosis and therapy (18th ed.). Whitehouse Station (NJ): Merck Research Laboratories. ISBN 0-911910-18-2.
^ National Center for Emergency Medicine Informatics - Mononucleosis http://www.ncemi.org/cse/cse0314.htm
^ Candy B, Hotopf M (2006). Candy, Bridget. ed. "Steroids for symptom control in infectious mononucleosis". Cochrane Database Syst Rev 3: CD004402. doi:10.1002/14651858.CD004402.pub2. PMID 16856045.
^ Candy B, Hotopf M. (2006). Candy, Bridget. ed. "Steroids for symptom control in infectious mononucleosis". Cochrane Database of Systematic Reviews 3 (4): CD004402. doi:10.1002/14651858.CD004402.pub2. PMID 16856045.
^ "Infectious Mononucleosis". WebMD. January 24, 2006. http://www.webmd.com/hw/infection/hw168622.asp. Retrieved 2006-07-10.
^ ^a ^b Antibiotic Expert Group. Therapeutic guidelines: Antibiotic. 13th ed. North Melbourne: Therapeutic Guidelines; 2006.
^ Torre D, Tambini R (1999). "Acyclovir for treatment of infectious mononucleosis: a meta-analysis". Scand. J. Infect. Dis. 31 (6): 543–7. doi:10.1080/00365549950164409. PMID 10680982.
^ Balfour HH, Hokanson KM, Schacherer RM (2007). "A virologic pilot study of valacyclovir in infectious mononucleosis". J. Clin. Virol. 39 (1): 16–21. doi:10.1016/j.jcv.2007.02.002. PMID 17369082.
^ Simon (March 2003). "The Effect of Valacyclovir and Prednisolone in Reducing Symptoms of EBV Illness In Children: A Double-Blind, Placebo-Controlled Study". International Pediatrics 18 (3): 164–169.
^ Rafailidis PI, Mavros MN, Kapaskelis A, Falagas, ME (2010). "Antiviral treatment for severe EBV infections in apparently immunocompetent patients". J. Clin. Virol. 49 (3): 151–7. doi:10.1016/j.jcv.2010.07.008. PMID 20739216.
^ Mulroy R (March 1973). "Amoxycillin rash in infectious mononucleosis". Br Med J 1 (5852): 554. doi:10.1136/bmj.1.5852.554. PMC 1588712. PMID 4266345. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1588712.
^ van der Linden PD, van der Lei J, Vlug AE, Stricker BH (August 1998). "Skin reactions to antibacterial agents in general practice". J Clin Epidemiol 51 (8): 703–8. doi:10.1016/S0895-4356(98)00041-9. PMID 9743319. "infectious mononucleosis increased the risk of rash in amoxicillin users with a factor of 58."
Yet another reported risk is given in:
* Wargo KA, McConnell V, Jennings M (September 2005). "Amoxicillin/telithromycin-induced rash in infectious mononucleosis". Ann Pharmacother 39 (9): 1577. doi:10.1345/aph.1G140. PMID 16046485. "Approximately 70-100% of patients who receive a ß-lactam antibiotic while infected with the Epstein–Barr virus will develop a maculopapular rash"
^ Jensen, Hal B (June 2000). "Acute complications of Epstein-Barr virus infectious mononucleosis". Current Opinion in Pediatrics (Lippincott Williams & Wilkins, Inc.) 12 (3): 263–268. doi:10.1097/00008480-200006000-00016. ISSN 1040-8703. PMID 10836164.
^ Aghenta A; Osowo, A; Thomas, J (May 2008). "Symptomatic atrial fibrillation with infectious mononucleosis". Canadian Family Physician (College of Family Physicians of Canada) 54 (5): 695–696. PMC 2377232. PMID 18474702. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2377232.
^ Ascherio A, Munger KL (2007). "Environmental risk factors for multiple sclerosis. Part I: the role of infection". Ann. Neurol. 61 (4): 288–99. doi:10.1002/ana.21117. PMID 17444504.
^ Sitki-Green D, Covington M, Raab-Traub N (February; 77(3): 2003). "Compartmentalization and Transmission of Multiple Epstein-Barr Virus Strains in Asymptomatic Carriers". Journal of Virology 77 (3): 1840–1847. doi:10.1128/JVI.77.3.1840-1847.2003. PMC 140987. PMID 12525618. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=140987.
^ Hadinoto V, Shapiro M, Greenough TC, Sullivan JL, Luzuriaga K, Thorley-Lawson DA (February 1, 2008). "On the dynamics of acute EBV infection and the pathogenesis of infectious mononucleosis". Blood 111 (3): 1420–1427. doi:10.1182/blood-2007-06-093278. PMC 2214734. PMID 17991806. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2214734.

Infectious diseases · Viral systemic diseases (A80–B34, 042–079)

Oncovirus

DNA virus: HBV (Hepatocellular carcinoma) · HPV (Cervical cancer, Anal cancer) · Kaposi's sarcoma-associated herpesvirus (Kaposi's sarcoma) · Epstein-Barr virus (Nasopharyngeal carcinoma, Burkitt's lymphoma, Primary central nervous system lymphoma) · MCPyV (Merkel cell cancer) · SV40

RNA virus: HCV (Hepatocellular carcinoma) · HTLV-I (Adult T-cell leukemia/lymphoma)

Immune disorders

HIV (AIDS)

Central
nervous system

Encephalitis/ meningitis	DNA virus: JCV (Progressive multifocal leukoencephalopathy) RNA virus: MeV (Subacute sclerosing panencephalitis) · LCV (Lymphocytic choriomeningitis) · Arbovirus encephalitis · Orthomyxoviridae (probable) (Encephalitis lethargica) · RV (Rabies) · Chandipura virus · Herpesviral meningitis · Ramsay Hunt syndrome type II

Myelitis	Poliovirus (Poliomyelitis, Post-polio syndrome) · HTLV-I (Tropical spastic paraparesis)

Eye	Cytomegalovirus (Cytomegalovirus retinitis) · HSV (Herpetic keratitis)

Cardiovascular

CBV (Pericarditis, Myocarditis)

Respiratory system/
acute viral nasopharyngitis/
viral pneumonia

DNA virus	Epstein-Barr virus (EBV infection/Infectious mononucleosis) · Cytomegalovirus

RNA virus	IV: SARS coronavirus (Severe acute respiratory syndrome) V, Orthomyxoviridae: Influenzavirus A/B/C (Influenza/Avian influenza) V, Paramyxovirus: Human parainfluenza viruses (Parainfluenza) · RSV · hMPV

Digestive system

Oropharynx/Esophagus	MuV (Mumps) · Cytomegalovirus (Cytomegalovirus esophagitis)

Gastroenteritis/ diarrhea	DNA virus: Adenovirus (Adenovirus infection) RNA virus: Rotavirus · Norovirus · Astrovirus · Coronavirus

Hepatitis	DNA virus: HBV (B) RNA virus: CBV · HAV (A) · HCV (C) · HDV (D) · HEV (E) · HGV (G)

Pancreatitis	CBV

Urogenital

BK virus · MuV (Mumps)

M: VIR

virs(prot)/clss

cutn/syst (hppv/hiva, infl/zost/zoon)/epon

drugJ(dnaa, rnaa, rtva, vacc)

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infectious mononucleosis