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Infectious Mononucleosis, Epstein-Barr Virus Infections

- Hematologic (rare) - Thrombocytopenia, slight to moderate, early in illness - Hemolytic anemia with marked neutropenia during early weeks - Aplastic anemia - Agammaglobulinemia

para>Splenic rupture may be fatal if not recognized. Occurrence is estimated at 0.1%.

Patient Monitoring

  • Avoid contact sports, heavy lifting, and excess exertion until spleen and liver have returned to normal size (ultrasound can verify in athletic populations).
  • Eliminate alcohol and exposure to other hepatotoxic drugs or herbal supplements until LFTs normalize.
  • Closely monitor patients during the first 2 to 3 weeks after the onset of symptoms since complication rates are highest during this period.
  • Alert patients that symptoms (malaise, fatigue, intermittent sore throat, lymphadenopathy) may persist for months.

DIET

No restrictions. Hydration during acute phase is important.

PROGNOSIS

  • Most recover in ~4 weeks.
  • Fatigue may persist for months.

COMPLICATIONS

  • Neurologic (rare)Aseptic meningitis, meningoencephalitisBell palsy; Guillain-Barr © syndromeTransverse myelitisCerebellar ataxiaAcute psychosis
  • Hematologic (rare)Thrombocytopenia, slight to moderate, early in illnessHemolytic anemia with marked neutropenia during early weeksAplastic anemiaAgammaglobulinemia
  • Pneumonitis
  • Splenic ruptureRare, but most often occurs in the first 21 days of illness

REFERENCES

11 Grywalska E, Rolinski J. Epstein-Barr virus-associated lymphomas. Semin Oncol. 2015;42(2):291-303.22 Dowd JB, Palermo T, Brite J, et al. Seroprevalence of Epstein-Barr virus infections in the U.S. children ages 6-19, 2003-2010. PLoS One. 2013;8(5):e64921.33 Thorley-Lawson DA, Hawkins JB, Tracy SI, et al. The pathogenesis of Epstein-Barr virus persistent infection. Curr Opin Virol. 2013;3(3):227-232.44 Chovel-Sella A, Ben Tov A, Lahav E, et al. Incidence of rash after amoxicillin treatment in children with infectious mononucleosis. Pediatrics. 2013;131(5):e1424-e1427.55 Odumade OA, Hogquist KA, Balfour HHJr. Progress and problems in understanding and managing primary Epstein-Barr virus infections. Clin Microbiol Rev. 2011;24(1):193-209.

ADDITIONAL READING

  • Almohmeed YH, Avenell A, Aucott L, et al. Systematic review and meta-analysis of the sero-epidemiological association between Epstein Barr virus and multiple sclerosis. PLoS One. 2013;8(4):e61110.
  • Klein G, Klein E, Kashuba E. Interaction of Epstein-Barr virus (EBV) with human B-lymphocytes. Biochem Biophys Res Commun. 2010;396(1):67-73.

ICD10

  • B27.00 Gammaherpesviral mononucleosis without complication
  • B27.09 Gammaherpesviral mononucleosis with other complications
  • B27.01 Gammaherpesviral mononucleosis with polyneuropathy
  • B27.02 Gammaherpesviral mononucleosis with meningitis

ICD9

075 Infectious mononucleosis

SNOMED

  • 271558008 Infectious mononucleosis (disorder)
  • 186668002 Gammaherpesviral mononucleosis (disorder)
  • 402121009 Epstein-Barr virus infection (disorder)

CLINICAL PEARLS

  • In cases of acute symptomatic infectious mononucleosis, 98% present with fever, sore throat, cervical node enlargement, and tonsillar hypertrophy.
  • False-negative monospot (heterophile antibody) common in the first 10 to 14 days of illness. 90% will have heterophile antibodies by week 3 of illness.
  • Lymphocytosis (not monocytosis) is common in infectious mononucleosis.