Infectious mononucleosis

Infectious mononucleosis (also known as "mono" or the "kissing disease") is a disease caused by primary Epstein-Barr virus (EBV) infection. It is clinically similar to streptococcal pharyngitis, because of its similar manifestations such as fever, sore throat, lymphadenopathy and hepatosplenomegaly, but unlike pharyngitis, it does not respond to antibiotic therapy. It is one of the relatively common diseases in the Czech Republic (2–2.5 thousand cases per year).

Much less often (in about 20% of cases) it is the so-called infectious mononucleosis syndrome usually caused by cytomegalovirus (CMV), or rarely by adenoviruses, HIV, HHV-6 or Toxoplasma gondii.

Epidemiology
The source of the infection is a sick person or a healthy carrier. Convalescent can also be a healthy carrier, EBV remains in the body in a latent form throughout one's life and can be reactivated (as with other herpes infections). The population is infected from an early age, and children under 2 years of age usually have no symptoms. The highest incidence is in adolescence, in adolescents and young adults between 15 to 24 years of age. Infectious mononucleosis is almost non-existent in adults over 40 years.

Patogenesis
EBV is transmitted through saliva via intimate contact (kissing, shared food) or by blood transfusion. The incubation period is between 4 days to 4 weeks. The virus infects the epithelium of the pharynx. From there, it enters B-lymphocytes and causes polyclonal activation of B cells, so that B-lymphocytes begin to produce antibodies. Subsequently, the virus travels to all of the organs, which causes the activation of cellular immunity (cytotoxic T-lymphocytes and NK-cells) and thus suppresses the infection in the body. If cellular immunity is not activated, uncontrollable severe to fatal lymphoproliferative disorder (X-linked lymphoproliferative syndrome, "XLP") may continue.

The acute phase of the disease is terminated by activated suppressor T cells, which appear in the peripheral blood as atypical lymphocytes (also known as "Pfeiffer's cells"). Some of the infected B-lymphocytes can still survive and become the source of late salivary excretion of the virus. The patient acquires a long-term immunity.

Clinical picture
The onset may be sudden or gradual with prodromes such as headache or abdominal pain, sore throat, myalgia, nausea, loss of appetite, fatigue, sweating, fever (in 90% of children; may reach up to 40 °C and last from 10 to 14 days). However, a typical triad is present:
 * pseudomembranous angina (sometimes referred as false - membrane angina = (hypertrophic tonsils with bilateral coating),
 * cervical lymphadenopathy (in 90% of cases; submandibular lymph nodes, cervical lymph nodes, occipital nodes and sometimes also axillary or inguinal ones are enlarged),
 * hepatosplenomegaly (hepatomegaly is present in 1/3 cases, splenomegaly in almost 1/2 cases – being most visible in the 2nd week).

The following may also appear:


 * petechiae (a rash of many tiny red spots) (Holzel's sign) in 25-60% of cases,
 * swelling of the eyelids (Bass symptom) in 1/3 cases,
 * rash of various natures,
 * subicterus,
 * rhinophonia,
 * bad breath (foetor ex ore).

The disease subsides within 2 to 4 weeks, but fatigue, weakness and loss of appetite can persist for several months.

Diagnostics



 * A complete blood count: leukocytosis with lymphocytosis and monocytosis with large atypical lymphocytes, neutropenia and mild thrombocytopenia.
 * Liver function tests: elevation of aminotransferases and L-lactate dehydrogenase (usually 2-3 times higher than the upper limit of the normal value, sometimes it may be up to 10 times).
 * CRP can be increased, depending on the presence of bacterial superinfection.
 * The diagnosis consists of detection of heterophile antibodies (Paul-Bunnel test – which often appears negative among young children; OCH-Ericson test) and specific antibodies by ELISA (VCA – viral-capsid antigen, EA - early antigen, EBNA – Epstein-Barr nuclear antigen), or eventually by PCR.
 * Primary infection: increase in IgM and IgG against VCA, then EA, but Ig against EBNA is missing.
 * Latency: positive Ig against EBNA.
 * Reactivation of infection: IgG against VCA, EBNA, EA and sometimes IgM against VCA.

Complications



 * Airway obstruction caused by tonsillar hypertrophy and lymphadenopathy.
 * Haematological: autoimmune haemolytic anemia, mild thrombocytopenia without bleeding, rarely aplastic anemia.
 * Neurological: serous meningitis and meningoencephalitis, polyradiculoneuritis, cerebilitis, Guillain-Barré syndrome.
 * Pulmonary: interstitial pneumonia.
 * A ruptured spleen: most often in 2nd or 3rd week of the illness; manifestations: abdominal pain and symptoms of hemorrhagic shock.
 * Rare: myocarditis, pericarditis, acute acalculous cholecystitis, chorioretinitis, rhabdomyolysis.
 * Duncan's syndrome: fatal course of primary EBV infection in boys with primary immunodeficiency (X-linked lymphoproliferative syndrome).

Léčba
Léčba je symptomatická. Doporučuje se klidový režim, jaterní dieta, hepatoprotektiva, vitaminy, antipyretika, obklad na krk, kloktadlo.


 * Antibiotika se podávají jen při superinfekci (předpokládané či prokázané).
 * Kortikoidy při výrazném nálezu v krku a při problémy s polykáním, dechovými obtížemi apod.

Po prodělání infekční mononukleózy je vhodná půlroční dispenzarizace (celkový stav, krevní obraz, jaterní testy).


 * Onemocnění podléhá hlášení, izolace není nutná.
 * Profylaxe a prevence neexistují.

Při podání ATB aminopenicilinové řady dochází v 90–100 % případů k výsevu výrazného červeného splývajícího makulopapulózního exantému někdy až hemoragického charakteru.

Souvisejíci články

 * Herpesviridae • EBV

Externí odkazy

 * H. Ambrožová: Infekční mononukleóza

Reference
Syndrom infekční mononukleózy je onemocnění klinicky velmi podobné infekční mononukleóze, ale nesplňuje všechna laboratorní kritéria a chybí heterofilní protilátky. Klinicky se projevuje jako krční lymfadenopatie a dalšími symptomy, které jsou méně časté (nález v krku, hepatosplenomegalie).
 * Toto onemocnění způsobuje:
 * lidský CMV,
 * vzácně pak HIV, virus rubeoly, adenoviry, Toxoplasma gondii, HHV-6 a HHV-7.

Zdroj, přenos a inkubační doba se liší podle původce. Diagnózu určíme na základě lymfadenopatie, atypických lymfocytů, zvýšení aminotransferáz v krvi bez nárůstu laktát-dehydrogenázy a sérologického průkazu původce. Prognóza je dobrá, léčíme symptomy (tělesný klid a jaterní dieta).

Rozlišení etiologických agens není příliš významné s výjimkou rozpoznání primoinfekce HIV, které má zásadní důležitost pro pacienta a jeho okolí.

Externí odkazy

 * Infekční mononukleóza (článek z časopisu Pediatrie pro praxi)