Daily Bolus of LR: Mononucleosis

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October 20, 2011 by dailybolusoflr


· Is caused by the Epstein-Barr virus (EBV)

· Is found in patients who have their primary EBV infection during or after the second decade of life (ages 15-24 are the highest percentage) and is typically through exposure to infected saliva (hence its name as the “kissing disease”)

· The most common presenting symptoms are sore throat and fatigue

· The classic triad of presenting signs is pharyngitis, fever and lympadenopathy

o There is a co-infection rate with Group A strep up to 30%

o Patients should be screened for this so that they can be treated to prevent rheumatic fever

o Amoxicillin/Ampicillin should be avoided as treatment, as patients with mononucleosis almost uniformly develop a morbilliform rash when exposed to the drug

· Splenomegaly may be found on exam, but is typically present if ultrasound examination is performed

· Patients may also have palatal petechiae, periorbital edema and/or rash, but these are found in the minority of patients

· Differential is broad and thus laboratory tests are used to aid is making the diagnosis

o Lymphocytosis (>50% lymphocytes) in which atypical lymphocytes are present can be useful

o Detection of at least 10% atypical lymphocytes has a specificity of about 92% and sensitivity of about 75%

o Elevated LFTs are common in older children and adults

o Heterophile antibody tests (monospot) have a specificity of about 94% and sensitivity of about 85%

· Treatment is typically supportive only

· It is also important to note that due to splenomegaly and the risk of splenic rupture most patients are advised not to return to contact sports for at least 3 weeks after the onset of symptoms

· Complications:

o Hematologic (25 to 50% of cases): generally mild and include hemolytic anemia, thrombocytopenia, aplastic anemia, TTP or HUS, and DIC

o Neurologic complications (1 to 5% of cases): include Guillain–Barré, facial-nerve palsy, meningoencephalitis, aseptic meningitis, transverse myelitis, and optic neuritis

o Rare: include splenic rupture (0.5 to 1% of cases) and upper airway obstruction (1% of cases) due to lymphoid hyperplasia and mucosal edema

Ref: N Engl J Med 2010; 362:1993-2000

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