Infectious mononucleosis: Difference between revisions

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==Background==
==Background==
*Caused by Epstein-Barr virus
*Caused by Epstein-Barr virus
**CMV and HHV-6 may cause mononucleosis-like illnesses
**[[CMV]] and HHV-6 may cause mononucleosis-like illnesses


==Clinical Features==
==Clinical Features==
*Triad of:
*Triad of:
**Fever
**[[Fever]]
**Pharyngitis
**[[Pharyngitis]]
**Lymphadenopathy
**[[Lymphadenopathy]]
*Symptoms
*Symptoms
**abrupt or insidious, ha, fever & malaise common w/ st & lad to follow
**Abrupt or insidious
**[[Rash]] in 10-15% usu btwn 4th-6th day of illness
**[[Headache]], [[fever]], and malaise common, [[sore throat]] and lymphadenopathy follow
***red macular or maculopapular morbilliform rash of trunk & upper arms
**[[Rash]] in 10-15% usually between 4th-6th day of illness
***occ involves face, thigh & legs, periorbital & eyelid edema in 50% of cases
***Red macular or maculopapular morbilliform [[rash]] of trunk & upper arms
*Previously treated at strep throat
***Occasionally involves face, thigh and legs, periorbital & eyelid edema in 50% of cases
**Morbilliform rash can develop<ref>Luzuriaga K and Sullivan JL. Infectious mononucleosis. N Engl J Med. 2010; 362:1993-2000.</ref>
*Previously treated as [[strep pharyngitis]]
***95% of patients on amoxicillin or ampicillin
**Morbilliform [[rash]] can develop<ref>Luzuriaga K and Sullivan JL. Infectious mononucleosis. N Engl J Med. 2010; 362:1993-2000.</ref>
***95% of patients on [[amoxicillin]] or [[ampicillin]]
***40-60% with other beta-lactams
***40-60% with other beta-lactams
*Illness typically 2-4 weeks, but malaise and fatigue may last for months


==Differential Diagnosis==
==Differential Diagnosis==
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{{Peds Rash DDX}}
{{Peds Rash DDX}}


==Diagnosis==
==Evaluation==
===Work-up===
===Work-up===
*CBC
*CBC
*BMP
**Lymphocytosis (≥50% lymphocytes)
*LFTs
**10% or more atypical lymphocytes
*[[LFTs]]
**Elevations in AST and ALT is expected up to 5x
*Heterophile antibody (monospot) test
*Heterophile antibody (monospot) test
**Up to 25% of patients in 1st week of symptoms may have false negative test<ref>Pitetti RD, Laus, S, and Wadowsky, RM. Clinical evaluation of a quantitative real time polymerase chain reaction assay for diagnosis of primary Epstein-Barr virus infection in children. Pediatr Infect Dis J. 2003; 22:736–739.</ref>
**10% of adult patients with EBV infection will be persistently negative
**Up to 50% of pediatric patients will be persistently negative<ref>Papesch M and Watkins R. Epstein-Barr virus infectious mononucleosis. Clin Otolaryngol Allied Sci. 2001; 26(1):3-8.</ref>
*EBV IgM Assay
*EBV IgM Assay
 
**Carries 97% sensitivity and 94% specificity at symptom onset<ref>Bruu, AL, et al. Evaluation of 12 commercial tests for detection of Epstein-Barr virus-specific and heterophile antibodies. Clin Diagn Lab Immunol. 2000; 7:451–456.</ref>
===Evaluation===
*Suspected mononucleosis during pregnancy (also need to rule out other pathology):
*Clinical features
**[[Epstein-Barr virus]], [[cytomegalovirus]], and [[HIV]]
*Lab features
**CBC
***Lymphocytosis (≥50% lymphocytes)
***10% or more atypical lymphocytes
**LFTs
***Elevations in AST and ALT is expected up to 5x
**Heterophile antibody (monospot) test
***Up to 25% of pts in 1st week of symptoms may have false negative test<ref>Pitetti RD, Laus, S, and Wadowsky, RM. Clinical evaluation of a quantitative real time polymerase chain reaction assay for diagnosis of primary Epstein-Barr virus infection in children. Pediatr Infect Dis J. 2003; 22:736–739.</ref>
***10% of adult pts w/ EBV infection will be persistently negative
***Up to 50% of pediatric pts will be persistently negative<ref>Papesch M and Watkins R. Epstein-Barr virus infectious mononucleosis. Clin Otolaryngol Allied Sci. 2001; 26(1):3-8.</ref>
**EBV IgM Assay
***Carries 97% sensitivity and 94% specificity at symptom onset<ref>Bruu, AL, et al. Evaluation of 12 commercial tests for detection of Epstein-Barr virus-specific and heterophile antibodies. Clin Diagn Lab Immunol. 2000; 7:451–456.</ref>
*Amoxicillin reaction is helpful in diagnosis
**Amoxicillin in pt w/ EBV will cause maculopapular rash in most
*Suspected mononucleosis during pregnancy (also need to r/o other pathology):
**Epstein Barr Virus, Cytomegalovirus, and HIV


==Management==
==Management==
*Supportive
*Supportive
*Avoid contact sports
*Avoid contact sports for 1-2 months<ref>O'Connor TE, Skinner LJ, Kiely P, Fenton JE. Return to contact sports following infectious mononucleosis: the role of serial ultrasonography. Ear Nose Throat J. 2011 Aug;90(8):E21-4.</ref> (decrease risk of splenic rupture)


==Disposition==
==Disposition==
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[[Category:ID]]
[[Category:ID]]
[[Category:Peds]]
[[Category:Pediatrics]]

Revision as of 22:35, 5 October 2019

Background

  • Caused by Epstein-Barr virus
    • CMV and HHV-6 may cause mononucleosis-like illnesses

Clinical Features

  • Triad of:
  • Symptoms
    • Abrupt or insidious
    • Headache, fever, and malaise common, sore throat and lymphadenopathy follow
    • Rash in 10-15% usually between 4th-6th day of illness
      • Red macular or maculopapular morbilliform rash of trunk & upper arms
      • Occasionally involves face, thigh and legs, periorbital & eyelid edema in 50% of cases
  • Previously treated as strep pharyngitis
  • Illness typically 2-4 weeks, but malaise and fatigue may last for months

Differential Diagnosis

Acute Sore Throat

Bacterial infections

Viral infections

Noninfectious

Other

Pediatric Rash

Evaluation

Work-up

  • CBC
    • Lymphocytosis (≥50% lymphocytes)
    • 10% or more atypical lymphocytes
  • LFTs
    • Elevations in AST and ALT is expected up to 5x
  • Heterophile antibody (monospot) test
    • Up to 25% of patients in 1st week of symptoms may have false negative test[3]
    • 10% of adult patients with EBV infection will be persistently negative
    • Up to 50% of pediatric patients will be persistently negative[4]
  • EBV IgM Assay
    • Carries 97% sensitivity and 94% specificity at symptom onset[5]
  • Suspected mononucleosis during pregnancy (also need to rule out other pathology):

Management

  • Supportive
  • Avoid contact sports for 1-2 months[6] (decrease risk of splenic rupture)

Disposition

  • Discharge

References

  1. Luzuriaga K and Sullivan JL. Infectious mononucleosis. N Engl J Med. 2010; 362:1993-2000.
  2. Melio, Frantz, and Laurel Berge. “Upper Respiratory Tract Infection.” In Rosen’s Emergency Medicine., 8th ed. Vol. 1, n.d.
  3. Pitetti RD, Laus, S, and Wadowsky, RM. Clinical evaluation of a quantitative real time polymerase chain reaction assay for diagnosis of primary Epstein-Barr virus infection in children. Pediatr Infect Dis J. 2003; 22:736–739.
  4. Papesch M and Watkins R. Epstein-Barr virus infectious mononucleosis. Clin Otolaryngol Allied Sci. 2001; 26(1):3-8.
  5. Bruu, AL, et al. Evaluation of 12 commercial tests for detection of Epstein-Barr virus-specific and heterophile antibodies. Clin Diagn Lab Immunol. 2000; 7:451–456.
  6. O'Connor TE, Skinner LJ, Kiely P, Fenton JE. Return to contact sports following infectious mononucleosis: the role of serial ultrasonography. Ear Nose Throat J. 2011 Aug;90(8):E21-4.