COMMUNICABLE DISEASES Infectious Mononucleosis “Glandular Fever” “Monocytic Angina” Professor Qayser Sahib Al Habeeb Specialist in Internal and Community Medicine Department of Family and Community Medicine College of Medicine - University of Duhok

Infectious Mononucleosis “Glandular Fever” “Monocytic Angina” An acute viral syndrome “often” caused by Epstein Barr Virus that infects B-Lymphocytes

other viral infections ( CMV, HHV-6 , HIV-1 ) and Toxoplasmosis can A variety of other viral infections ( CMV, HHV-6 , HIV-1 ) and Toxoplasmosis can produce a similar clinical syndrome

Viral Replication (Lytic infection) and B-cells are the site of both; Viral Replication (Lytic infection) and Viral Persistence (Latent infection)

with equal sex distribution Cases are usually sporadic with equal sex distribution In children primary EBV infection is usually asymptomatic whereas in adolescents and adults glandular fever is the usual presentation

Occurrence: --- In developing countries, subclinical infection in childhood is virtually universal. --- In developed countries, infection may be delayed until adolescence or early adult life; most common in high school&university students Under these circumstances ~ 50% of those infected will develop typical clinical disease.

I P : from 4 to 6 weeks MOT : ● direct or indirect saliva contact i.e. close oral contact or sharing eating utensils. ● recent evidence suggests that infection often results from spread during sexual intercourse. ● rarely follows blood transfusion.

Period of communicability: --- At least few weeks. --- EBV is not highly contagious and isolation of cases is unnecessary --- Prolonged pharyngeal excretion may persist for a year or more --- 15 %– 20 % or more of EBV antibody positive healthy individuals are “long term oro pharyngeal carriers”

It is currently believed that these healthy people, who nevertheless secrete EBV particles, are the primary reservoir for transmission of EBV among humans

Immunity: ► Every one is susceptible to infection. ► Infection confers a high degree of resistance. ►Reactivation of EBV may occur in immunosuppressed individuals.

Pathology: Infection local epithelial cells & B lymphocytes dissemination of infected B cells production of T cell response by atypical mononucleosis lymphoid hyperplasia with lymphadenopathy Spleenomegaly & hepatomegaly

a prodrome of fever, fatigue, and headache is followed by Clinical Features: a prodrome of fever, fatigue, and headache is followed by classical triad of sore throat + fever + lymphadenopathy with full recovery after 6-8 weeks in the vast majority of cases.

Pruritic maculopapular rash Signs: - Exudative tonsilitis and peritonsillar edema - Petechae at junction of hard and soft palate, - Cervical (especially posterior cervical), axillary and inguinal lymph nodes (discrete non tender) Splenomegaly 50% hepatomegaly 15% jaundice 5% Pruritic maculopapular rash 90% after antibiotics

Exudative Pharyngitis in a Patient with Infectious Mononucleosis

Infectious mono, peripheral smear, high power showing reactive lymphocytes

Amoxicillin Rash ( (itchy macular

Complications Rare and include 1- pharyngeal and tracheal obstruction 2- blood: hemolytic anemia & thrombocytopenia 3- meningoencephalitis,hepatitis, myocarditis, pneumonitis, GB syndrome. 4- splenic rupture 5- chronic fatigue & depression 6- ≈ 10% of patients with IM suffer a chronic relapsing syndrome.

Diagnosis: ● Leucocytosis with relative and absolute lymphocytosis ● Presence of atypical lymphocytes (activated T cells) ● mild ↑in (AST) in ≈ 90%

● Positive heterophil antibody test : paul bunnell test or rapid monospot test used for diagnostic screening ( (+ve in 85%of acute cases ● heterophil –ve cases are confirmed by the gold standard test : IgM Ab to Viral Capsid Antigen (VCA)

Differential Diagnosis: Herpes virus 6, cytomegalovirus or toxoplasmosis may cause a syndrome resembling glandular fever, both clinically and hematologically.

Treatment: Symptomatic + -- short course of steroid for tonsillopharyngeal edema……………... (airway obstruction) -- avoid alcohol………. (worsens hepatitis) -- avoid exercise………. (splenic rupture)

-- antibiotics are not indicated unless throat culture yields a ß-hemolytic streptococcus -- avoid ampicillin & amoxicillin since they commonly cause an itchy macular rash.

Practically all cases make full recovery in few weeks to few months. Prognosis: Practically all cases make full recovery in few weeks to few months. Death is rare but may result from: ► respiratory obstruction ► hemorrhage; (splenic rupture or thrombocytopenia) ► encephalitis.

with different malignancies has been documented e.g. Association with different malignancies has been documented e.g. burkitts lymphoma, some forms of Hodgkins disease, nasopharyngeal carcinoma & oral hairy leucoplakia (AIDS patients)

Preventive and control measures: ◙ There is no vaccine available. ◙ Basic hygiene can help prevent many diseases including glandular fever. ◙ Teach children not to share spoons, forks , cups, soft drink cans ……etc. ◙ Adults should not share personal items such as glasses, cigarettes, lipstick or other items that may be covered in saliva. ◙ Isolation is not necessary. ◙ There is no treatment and antibiotics are not indicated.

Thank you