1. Infectious mononucleosis Monocytic angina
Dr hab. n. med. Ewa Majda-Stanisławska

2. EBV is associated with the development of malignancies
Burkitt's lymphoma,
lymphoproliferative disease,
Hodgkin's lymphoma,
primary central nervous system (CNS) lymphomas in AIDS,
nasopharyngeal carcinoma
based on seroepidemiologic data and the detection of EBV genomes in these tumors.

3. Seroprevalence
Antibodies are acquired earlier in life in developing than in industrialized countries,
By adulthood 90% to 95% of most populations have demonstrable EBV antibodies,
In USA and in GB, EBV seroconversion occurs before the age of 5 years in about 50% of the population. ,
A second wave of seroconversion occurs midway through the second decade of life.

4. Methods of Spread
Low titer of EBV is present in throat washings of infected patients
The virus persists in the B-cell compartment for the life of the infected host
It can be cultured from:
throat washings from 10% to 20% of normal healthy adults,
from 50% of kidney transplant recipients,
from greater proportions of those critically ill with leukemia or lymphoma

5. Methods of Spread
EBV is a widespread agent that is not particularly contagious
Most cases of infectious mononucleosis are probably contracted by intimate contact between susceptible individuals and asymptomatic shedders of EBV
Among young adults, spread of the virus may be facilitated by the transfer of saliva with kissing.

6. Clinical characteristics
sore throat,
fever,
lymphadenopathy
serologically by the transient appearance of heterophile antibodies
hematologically by a mononuclear leukocytosis that consists, in part, of atypical lymphocytes

7. The age of the patient has a profound influence on the clinical expression of EBV infection
In children, primary EBV infection is often asymptomatic.
Young children may be more likely to exhibit rashes, neutropenia, or pneumonia
Clinically apparent infections in very young children are heterophile negative in about one half of the cases.

8. Incubation period of acute infectious mononucleosis is 30 to 50 days

9. General patient’s complaints
The onset may be abrupt,
But usually there are several days of prodromal symptoms :
chills,
sweats,
feverish sensations,
anorexia,
malaise,
loss of taste for cigarettes is common,
retro-orbital headaches,
myalgias,
feelings of abdominal fullness
sore throat, which may be the most severe the patient has experienced.

11. Signs - fever Fever is present in more than 90%
The fever usually peaks in the afternoon with temperatures of 38° C to 39° C,
In most cases, fever resolves over a 10- to 14-day period

13. Signs - rash
A rash, which may be macular, petechial, scarlatiniform, urticarial, or erythema multiforme-like, is present in about 5% of patients.
The administration of ampicillin or amoxicillin produces a pruritic, maculopapular eruption in 90% to 100% of the patients
The ampicillin-related rash does not necessarily predict future intolerance to ampicillin or amoxicillin

14. Periorbital edema has been reported in up to one third of cases in some series, but it has been observed less frequently in others.

15. Signs - pharyngitis Tonsillar enlargement is usually present,
Occasionally tonsils are meeting at the midline.
The pharynx is erythematous with an exudate in about one third of cases
Palatal petechiae may be seen in 25% to 60% of cases
The petechiae are usually multiple, 1 to 2 mm in diameter, occur in crops lasting 3 to 4 days, and are usually seen at the junction of the hard and soft palate

16. Signs - lymphadenopathy
Cervical adenopathy, usually symmetrical, is present in 80% to 90% of patients,
Posterior adenopathy is most common,
Submandibular and anterior adenopathies are quite frequent as well,
Axillary and inguinal adenopathies also occur,
Individual nodes are freely movable, are not spontaneously painful, and are only mildly tender to palpation

17. Signs - hepatosplenomegaly
Abdominal examination may detect hepatomegaly in 10% to 15% of cases,
Jaundice is present in approximately 5% of cases.
Splenomegaly is present in about one half of cases if sought carefully over the course of the illness.
The splenomegaly is usually maximal at the beginning of the second week of illness and regresses over the next 7 to 10 days.

18. Complications Autoimmune hemolytic anemia occurs in 0.5% to 3%
Most patients with infectious mononucleosis recover uneventfully
Complications are rare, and mostly reversable
Autoimmune hemolytic anemia occurs in 0.5% to 3%
Mild thrombocytopenia
Splenic rupture is a rare but dramatic
neurologic: encephalitis , cerebellitis

19. Laboratory diagnosis
The central hematologic manifestation of the illness is a circulating lymphocytosis.
Relative and absolute mononuclear lymphocytosis is found in about 70% of the cases.
The lymphocytosis peaks during the second or third week of illness,
monocytes and lymphocytes account for 60% to 70% WBC
the total white cell counts of 12,000 to 18,000/mm3.
Higher white cell counts are not uncommon, occasional patients manifest 30,000 to 50,000 leukocytes/mm3.
Atypical lymphocytes are the hematologic hallmark of infectious mononucleosis and account for about 30% of the differential count at their zenith

22. Other diseases occuring with atypical lymphocytes
CMV infection,
Primary HIV,
Viral hepatitis,
Toxoplasmosis,
Rubella,
Mumps,
Roseola
Drug reactions

23. Latex agglutination test Monotest
Detects heterophile antibodies, originally described by Paul and Bunnell as sheep erythrocyte agglutinins,
They are present in about 90% of the cases at some point during the illness

24. Other Laboratory Abnormalities
Liver function test results are abnormal in almost all cases of infectious mononucleosis.
Aspartate aminotransferase, alanine aminotransferase, and lactate dehydrogenase are elevated, usually of mild degree
The alkaline phosphatase level is elevated in about 60% of the cases.
Mild elevation of the bilirubin level is noted in approximately 45%

25. TREATMENT
Largely supportive because more than 95% of the patients recover uneventfully without specific therapy.
The level of activity is generally tailored to what the individual patient can tolerate comfortably.
To avoid trauma to the spleen, contact sports or heavy lifting should be avoided during the first month of illness and until any splenomegaly has resolved. Acetaminophen or nonsteroidal anti-inflammatory agents can be helpful in relieving the sore throat and in suppressing the fever.
Sore throat may be further alleviated by gargling with warm salt water.

26. Treatment
Corticosteroids should not generally be used in uncomplicated infectious mononucleosis
They decrease the period of febrility and hasten the resolution of tonsillopharyngeal symptoms
May be helpful in cases of:
Tonsillar enlargement causing airway compromise
Autoimmune hemolytic anemia,
Severe thrombocytopenia,
Aplastic anemia.
CNS involvement