Table of Contents
EBV / glandular fever / infectious mononucleosis
- Epstein-Barr Virus (EBV) is the virus that causes glandular fever (infectious mononucleosis or IM)
- a frequent infection, particularly in young adults, mainly due to spread via saliva such as kissing or sharing drinks
- EBV is transmitted via intimate contact with body secretions, primarily oropharyngeal secretions.
- EBV infects the B cells in the oropharyngeal epithelium.
- The organism may also be shed from the uterine cervix, implicating the role of genital transmission in some cases.
- On rare occasion, EBV is spread via blood transfusion.
- A rapid and efficient T-cell response results in control of the primary EBV infection and lifelong suppression of EBV.
- Ineffective T-cell response (such as in those on immunosuppressants for Mx of transplants) may result in excessive and uncontrolled B-cell proliferation, resulting in B-lymphocyte malignancies
clinical features of acute EBV infection
- incubation period 1-2 months
- most patients are asymptomatic (50% of 5yr olds and 90% of adults show serologic evidence of past infection)
- when infection occurs during adolescence, it causes infectious mononucleosis pharyngitis picture in ~50%
- when infection occurs in the elderly, it mainly causes a viral hepatitis picture
adolescent infectious mononucleosis
- fatigue may be profound initially, but usually settles after a variable period but often takes 3 months, but may be longer in some resulting in Chronic fatigue syndrome
- reporting of prominent fatigue: 41% during acute illness; 71% at 1 month; 43% at 2 months; 9% at 6 months;
- pharyngitis - often pustular with bilateral large inflamed “kissing” tonsils which may compromise airway, and later, palatial petechiae (these also can occur in Strept tonsillitis)
- splenomegaly may be present but usually returns to normal by 3 weeks
- rarely may result in splenic rupture (1-2% of symptomatic cases) - thus contact sports should be avoided if splenomegaly is present
- abnormal LFTs are common but jaundice occurs in < 10% of young adults and in ~30% of the elderly with acute EBV
- early, transient, faint macular rash is common but easily missed
- early and transient bilateral upper-lid edema
- widespread macular rash may occur, but particularly likely if the patient has received amoxycillin
- leukocytosis, rather than leukopenia, often with atypical lymphocytes > 20% +/- thrombocytopenia
- Monospot IM screen may be negative in the first week or two and overall has a sensitivity of 85% (in children over age 2yrs) and specificity of 100%
- those with negative Monospot but suggestive clinical picture may need weekly Monospot tests for up to 6 weeks.
- ESR is usually raised (but is not so in Strep tonsillitis!)
- rarely may cause:
- acalculous cholecystitis
- mesenteric adenitis
- optic neuritis
- transverse myelitis
- aseptic meningitis
- cranial nerve (CN) palsies (particularly CN VII)
- Guillain-Barré syndrome
- selective immunodeficiency to EBV, which occurs in persons with X-linked lymphoproliferative syndrome, may result in severe, prolonged, or even fatal infectious mononucleosis
- fatal hepatic necrosis is a rare complication, and is more likely in males
ED Mx of presumed acute EBV pharyngitis/tonsillitis
- FBE, IM screen +/- LFTs are generally performed
- if significant dysphagia or potential airway risk, admit for iv fluids and iv dexamethasone
- patients with splenomegaly should be warned to avoid contact sports
- if clearly EBV and not Strept tonsillitis, avoid antibiotics, and particularly amoxycillin as likely to develop a florid rash
- encouraged to rest as much as possible and to refrain from active physical activity for 3 weeks
- seek specialist advice if immunocompromised or rare complication
long term sequelae
- neoplasia risk:
- endemic Burkitt lymphoma in children in malarial countries such as Africa
- Hodgkin's lymphoma - 3x risk; 40% of HL cases in Western countries are EBV genome-positive
- Non-Hodgkin's lymphoma
- hairy leukoplakia
- leiomyomas and leiomyosarcomas in immunocompromised children
- nasopharyngeal carcinoma appears to be always caused by EBV, high prevalence in southern China and other parts SE Asia
- Most instances of post-transplant lymphoproliferative disorder (PTLD) are associated with EBV.
- B-cell lymphomas (post-transplant lymphoma PTL) risk if on immunosuppressants for Mx of transplants
- there is evidence that infection with the virus is associated with a higher risk of certain autoimmune diseases, especially dermatomyositis, systemic lupus erythematosus, rheumatoid arthritis, and Sjögren's syndrome
ebv.txt · Last modified: 2016/04/15 06:10 by 127.0.0.1