1. WELCOME APPLICANTS! January 13, 2011

4. Epstein-Barr Virus  Identified in 1964 in Burkitt lymphoma  Lab technician became ill with mononucleosis EBV seroconversion  Ubiquitous  Harbored by nearly all adults  No seasonal variation or clustering of cases

5. Epstein-Barr Virus  Most infected by oral route  “kissing disease”  Other modes of transmission  Blood transfusions  Bone Marrow transplants  Sexually transmitted

6. Epstein-Barr Virus  Incubation period 30-50 days  Age at infection varies with living conditions  Age 2 to 3 20% to 80% infected  Industrialized countries: More common primary EBV in adolescents IM in 30% to 50% of these cases

7. Infectious Mononucleosis

8. Illness Script Infectious Mononucleosis Fever Sore Throat (exudative pharyngitis) Malaise Lymphadenitis (Cervical) +/- Hepatosplenomegaly Atypical Lymphocytosis

9. Infectious Mononucleosis  Highly suggestive findings  Palatal petechiae  Splenomegaly  Posterior cervical adenopathy  Absence of cervical lymphadenopathy and fatigue make the diagnosis much less likely.

10. Clinical Manifestations  Rash  4% of older patients  With antibiotic (ampicillin) administration  Nonallergic morbilliform rash  Seen in nearly 100%.  Benzyl-penicilloyl-specific IgM

11. Rare Clinical Manifestations  CNS (5%)  Aseptic meningitis  Encephalitis  Optic neuritis  CN palsies  Transverse myelitis  Guillian-Barre

12. Rare Clinical Manifestations  Hematologic  Splenic rupture  Thrombocytopenia  Neutropenia  Hemolytic anemia  Others  Respiratory Compromise  Pneumonia  Orchitis  Myocarditis

13. Diagnostic Tests  Viral culture is difficult  Diagnosis implicated by:  Characteristic clinical signs  Lymphocytosis (>50%) Absolute (> 4500/  L)  Atypical Lymphocytosis (>10%)  Confirmed by:  Criteria above + positive heterophile

14. Heterophile Test (Monospot)  Heterophile antibodies react to antigens from unrelated species  Monospot- Latex agglutination assay using horse erythrocytes and patient serum.  Peak levels at 2-6 weeks  May remain elevated for up to 1 year  Sensitivity 85% Less sensitive in children < age 3.  Specificity 100%

15. Diagnostic Testing  Other antibody Testing (useful if heterophile negative)  anti-VCA IgM Some evidence for active/recent infection  anti-EBNA Excludes active primary infection

16. Treatment  “Take it easy”  No contact sports until spleen no longer palpable  Avoid ampicillin and amoxicillin  Steroids reserved for most severe of cases

17. Associated Conditions  X-linked Lymphoproliferative Disease (XLP)  Defect in signaling lymphocytic activation molecule- associated protein  Characterized by Nodular B-cell lymphomas +/- CNS involvement Profound hypogammaglogulinemia Aplastic anemia Severe infectious mono early in life 4% survival

18. Associated Conditions  EBV associated B-Cell Lymphoproliferative Disease  10% of transplant recipients  Donor organ is common vehicle of EBV infection  Occurs early after transplant Time of most severe immunosuppression

19. Other Associated Conditions  Hemophagocytic Lymphohistiocytosis  Chronic Active EBV Infection  Malignancies  Burkitt Lymphoma  Nasopharyngeal Carcinoma  Hodgkin Disease  T-Cell Lymphoma  Gastric carcinoma