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Infectious Mononucleosis Epstein-Barr Virus [EBV] McKenna Craig McKenna Craig “The Kissing Disease” (Google Images) Epstein-Barr Virus The Epstein-Barr Virus is a form Symptoms The incubation period of IM is 30-50 days of herpes virus that causes a condition in the affected host called Infectious Mononucleosis [IM] (SingerLeshinsky). Infectious Mononucleosis is often times referred to as Pfeiffer's Disease and Filatov's Disease named after two men that described this disease as an infectious process of the body in the 1880’s (Boe, 1). The majority of cases of Infectious Mononucleosis are primarily tied to EBV (Vouloumanou, 1). However, there are some instances when this condition is specifically observed with a T-cell dysfunction (Vouloumanou, 1). Therefore, it is important to make a distinction between the two causes of IM when planning a course of treatment for an individual. after the individual has been exposed to EBV (SingerLeshinsky). IM is a self-limiting disease that often presents itself through flulike symptoms including a sore throat, swollen lymph nodes, fever and fatigue (Singer-Leshinsky). Symptoms of malaise, low-grade fever and headaches are included in the prodromal period of the infection (Singer-Leshinsky). Other common symptoms may include vomiting, diminished appetite and petechiae (Boe, 1).These symptoms are usually presented for an average of one to several weeks and in some cases, several months (FactSheet: IM, 1). In adults, the disease will present itself with prolonged periods of fever and liver malfunctions (Putukian, 312).There is a direct correlation between symptoms of Infectious Mononucleosis and the amount of cytokines that are released from activated T cells (Singer-Leshinsky). The larger the amount of virus particles detected in the body, the larger the amount of cytokines released from T helper cells which will cause a more severe presentation of symptoms (SingerLeshinsky). With further tests, the doctor may find inflammation of the spleen or liver (FactSheet: IM, 1). Etiology of EBV Infectious Mononucleosis is caused by a virus called Epstein-Barr Virus (Singer-Leshinsky). The name ‘Mononucleosis’ is based on the viruses targeted attack site: the mononuclear lymphocytes (Singer-Leshinsky). Viruses carry out specific functions by replicating themselves within living cells (Smith and Helenius, 1). Viruses synthesize their genome by taking over cellular machinery of the host which allows them to meticulously manipulate the cell and incorporate their genes and proteins into the host cell genome (Smith and Helenius, 1). The host cell recognizes the nucleic acid of the virus as part of itself which allows the animal virus, in this case Epstein-Barr Virus, to be guided by the host cell through the process of molecular transformation (Smith and Helenius, 1). Exudate in the Tonsils (Google Images) Mode of Transmission Epstein-Barr Virus is spread through saliva (Boe, 1). The transmission of this virus requires very close contact with an infected individual which can be done through kissing or through sharing drinking cups (Singer-Leshinsky). This form of herpes virus attacks the epithelial cells of the oropharynx and tonsils (Singer-Leshinsky). An infection in the tonsil crypts causes the epithelial cells to undergo a process called viral shedding (Singer-Leshinsky). Viral shedding occurs most frequently during the first year postinfection but can continue to shed particles throughout life and will continue to transmit the virus to others (Singer-Leshinsky). virus has been known to invade B lymphocytes, T lymphocytes, squamous epithelial cells, glandular epithelial cells and natural killer cells (Singer-Leshinsky). If T cells of the adaptive immune system are ineffective against Epstein-Barr Virus, there will be a proliferation of B cells that can result in B-lymphocyte malignancies and lymphomas (Singer-Leshinsky). Inflammation of the spleen can be seen in 50% of patients dealing with Infectious Mononucleosis (Rinderknecht, 1,377). Spontaneous splenic rupture (SSR) will be presented through abdominal pain and possibly even cardiac arrest (Rinderknecht, 1,377). SSR occurs in 0.1% to 0.2% of all IM cases (Rinderknecht, 1,377). Populations at Risk Infectious Mononucleosis is Course of Infectious Mononucleosis (Wikipedia) Key Virulence Factors Virulence factors of EBV allow the virus particles to infect B lymphocytes which results in the rapid replication and release of EpsteinBarr Virus specific antibodies (Singer-Leshinsky). The detection of EBV specific antibodies in a blood sample will indicate that the individual is infected with EBV (Singer-Leshinsky). The manipulation of cells by the Epstein-Barr Virus permits the development of Infectious Mononucleosis (Singer-Leshinsky). Even though natural killer T cells and cytotoxic T cells keep the virus in control, limit the further development of IM and regulate chronic infection, it is possible for EBV to remain in a latent state within infected B cells as a lifelong reservoir (Singer-Leshinsky). Major Risk Factors Sever and potentially life threatening complications of Infectious Mononucleosis include edema in mucous membranes, lymphoid hyperplasia which may cause upper respiratory obstruction and splenic rupture (Singer-Leshinsky). The found equally in all groups regardless of gender, sexual orientation, race or ethnicity. This disease peaks in adolescents and young adults between the ages of 1524 (Rinderknecht, 1,377). IM does not usually occur in older adults because chances are high that they have already been exposed to the Epstein-Barr Virus (SingerLeshinsky). If infection happens to occur in an older adult, the disease will present itself with clinical manifestations of hepatitis (Singer-Leshinsky). Athletes commonly develop Infectious Mononucleosis due to close proximity and easy spread of the virus (Krafczyk, 10). Splenic rupture is most likely to occur within the first three weeks of infections so it is important to monitor the athlete’s condition before allowing them to participate in physical activity, (Krfczyk, 10) especially contact and collision sports (Putukian, 310). Epidemiology Incidence in the United States is 500 cases per every 10,000 people per year (SingerLeshinksy). Approximately 70% of people in the U.S. are infected by Epstein-Barr Virus by the age of 30 (Chamberlain, 1). Infectious Mononucleosis is not a reportable disease. Therefore case numbers cannot be found on a Utah governmental website (Utah-Office of Epidemiology). Diagnosis The long incubation period of this infection makes it difficult to diagnose the patient with IM (Putukian, 309). Diagnosis of Infectious Mononucleosis is done through presentation of classic symptoms and evaluation of blood samples (Boe, 1). White blood cell count will vary with each case but is usually higher than normal (Boe, 1). Lymphocytes can proliferate up to 60% above the normal number which is referred to as lymphocytosis (Boe, 1). There will be a 10% increase in atypical lymphocytes which are activated cytotoxic T cells (Singer-Leshinsky). The increased white blood cell count can oftentimes be mistakenly evaluated as leukemia (Boe, 1). However, lymphocytosis in Infectious Mononucleosis will contain a variety of cells whereas leukemia will have a fairly uniform proliferation of lymphocyte types (Boe, 1). Neutrophils tend to decrease in number while eosinophils, basophils and typical monocytes are slightly increased (Boe, 1). Hematologic tests are important for analyzing IM in the blood but serologic tests are crucial for confirming existence of infected cells (Singer-Leshinsky). A heterophile antibody or monospot latex agglutination test can be performed to evaluate the presence of IgM antibodies to antigens found on surfaces of EBV infected B cells (Singer-Leshinsky). patients are advised to refrain from excessive alcohol use as toxicity in the liver may occur (Putukian, 312). Prevention Epstein-Barr Virus has a low transmissibility, therefore it is unnecessary to isolate the patient from others (Putukian, 312). IM is an infectious disease and should be handled with common practices of hand washing with antibacterial soap and changing gloves between every patient is crucial (Putukian, 312). The patient should refrain from kissing, sharing cups or utensils and close contact with another individual (Putukian, 312). (Google Images) References 1. 2. Atypical Lymphocytes amongst RBCs (Google Images) Treatment Management of IM is primarily done through supportive measures and geared toward alleviating present symptoms (Putukian, 312). This can be done through rest, acetaminophen and maintaining adequate levels of fluid and hydration (Putukian, 312). To treat a sore throat, the patient can gargle with warm salt water, using throat lozenges and sprays or a 2% lidocaine solution (Putukian, 312). Aclovylir may be given to the patient through an IV or an oral solution (Putukian, 312). Aclovylir may slow down the process of viral shedding but lacks a significant benefit for suppression of symptoms (Putukian, 312). Corticosteroids can be administered to the patient if there is severe airway complications, dysphagia, myocarditis, hemolytic anemia or an enlarged spleen (Putukian, 312). Treatment of adolescents with aspirin should be avoided as it will cause increased risk of bleeding and thrombocytopenia (Putukian, 312). All IM 3. 4. 5. 6. 7. 8. 9. 10. Singer-Leshinsky S. Pathogenesis, diagnostic testing, and management of mononucleosis. JAAPA: Official Journal Of The American Academy Of Physician Assistants [serial online]. May 2012;25(5):58-62. Available from: MEDLINE, Ipswich, MA. Accessed December 1, 2013. Boe G. Infectious Mononucleosis: A Brief Review. Journal Of Continuing Education Topics & Issues [serial online]. 2013;15(1):26-28. Available from: CINAHL with Full Text, Ipswich, MA. Accessed September 15, 2013 Vouloumanou E, Rafailidis P, Falagas M. Current diagnosis and management of infectious mononucleosis. Current Opinion In Hematology [serial online]. 2012;19(1):14-20. Available from: CINAHL with Full Text, Ipswich, MA. Accessed September 15, 2013. Smith, Alice E., and Ari Helenius. "How Viruses Enter Animal Cells." How Viruses Enter Animal Cells. Science Magazine, 9 Apr. 2004. Accessed December 3, 2013. FactSheet: Infectious mononucleosis. New South Wales Public Health Bulletin [serial online]. September 2005;16(9-10):168. Available from: MEDLINE, Ipswich, MA. Accessed September 15, 2013. Putukian M, O'Connor F, Landry G, et al. Mononucleosis and athletic participation: an evidence-based subject review. Clinical Journal Of Sport Medicine: Official Journal Of The Canadian Academy Of Sport Medicine [serial online]. July 2008;18(4):309-315. Available from: MEDLINE, Ipswich, MA. Accessed September 15, 2013. Rinderknecht A, Pomerantz W. Spontaneous splenic rupture in infectious mononucleosis: case report and review of the literature. Pediatric Emergency Care [serial online]. December 2012;28(12):1377-1379. Available from: CINAHL with Full Text, Ipswich, MA. Accessed September 15, 2013. Krafczyk M, Vikram M. Infectious Mononucleosis in the Athlete. International Journal Of Athletic Therapy & Training [serial online]. November 2012;17(6):10-13. Available from: CINAHL with Full Text, Ipswich, MA. Accessed September 15, 2013. Chamberlain, Neal R. "INFECTIOUS MONONUCLEOSIS." Infectious Mononucleosis (EBV). Osteopathic Medical School, 21 Jan. 2010. Accessed December 3, 2013. "Utah - Office Of Epidemiology." Utah - Office Of Epidemiology. Bureau of Epidemiology, Accessed December 3, 2013.