Related Subjects:
|Herpes Varicella-Zoster (Shingles) Infection
|Chickenpox Varicella Infection
|Varicella Cerebral Vasculopathy
|Herpes Viruses
|Herpes Zoster Ophthalmicus (HZO) Shingles
|MonkeyPox
|Mumps
|Measles
|Rubella (German Measles)
|Epstein-Barr Virus infection
|Cytomegalovirus (CMV) infections
|CMV retinitis infections
💡 90% of patients with Infectious Mononucleosis develop a rash if given ampicillin or amoxicillin – a classic diagnostic clue.
📖 About
- One of the main causes of Infectious Mononucleosis (Glandular Fever).
- Very common infection – 90% of adults show past EBV exposure.
- Clinical picture can mimic CMV or Toxoplasmosis → always check, especially in pregnancy or immunocompromised.
🦠 Virology
- EBV = a gamma herpesvirus.
- Spread via saliva droplets → classically “the kissing disease” 😘.
- Often subclinical in childhood; symptomatic illness more likely in adolescents/young adults.
- 50% of infections cause clinical symptoms.
- Not highly contagious → isolation not required.
🩺 Clinical Features
- Often subclinical.
- Non-specific flu-like illness: headache, malaise, fever 🤒.
- Severe sore throat + tonsillar enlargement.
- Generalised tender lymphadenopathy (cervical, axillary, inguinal).
- Hepatitis → jaundice, raised LFTs.
- Splenomegaly (⚠️ risk of rupture).
- Skin features: erythema multiforme, petechiae, periorbital oedema.
- Rare CNS: encephalitis, meningitis. Disease severity ↑ with age.
🤰 Pregnancy
- If heterophile antibodies negative → check CMV serology.
- CMV can mimic EBV, but active CMV in pregnancy can cause congenital abnormalities.
- Toxoplasmosis also mimics – must exclude.
📌 Causes of Infectious Mononucleosis-like Syndrome
- Epstein-Barr virus (EBV)
- Cytomegalovirus (CMV)
- Human Herpesvirus-6 (HHV-6)
- HIV seroconversion
- Toxoplasmosis
⚠️ Long-Term Complications
- Nasopharyngeal carcinoma 🎭
- Burkitt’s lymphoma
- Post-transplant lymphoproliferative disease
- HIV-related immunoblastic lymphoma
- Chronic fatigue syndrome
- Duncan’s syndrome (X-linked lymphoproliferative syndrome due to SAP gene mutation)
🔎 Differentials
- Streptococcal sore throat (no hepatosplenomegaly or atypical lymphocytes).
- CMV infection.
- Toxoplasmosis.
- Viral hepatitis.
- HIV seroconversion.
- Lymphoma / Leukaemia.
🧪 Investigations
- FBC: mononuclear lymphocytosis with atypical lymphocytes, neutropenia, thrombocytopenia.
- LFT: raised ALT, raised bilirubin.
- Atypical CD8+ T lymphocytes → can mimic acute leukaemia.
- Monospot (Paul-Bunnell test): detects heterophile antibodies. Positive in week 2, may need repeat if negative initially.
- EBV serology: IgM EBV EA (early antigen) + negative IgG EBV confirms acute infection.
- Viral PCR (if needed).
📊 Causes of Atypical Lymphocytosis
- EBV
- HIV seroconversion
- Viral hepatitis
- Mumps
- Rubella
💊 Management
- Supportive: rest, fluids, paracetamol/NSAIDs. Fatigue may last 6 weeks.
- ⚠️ Avoid ampicillin/amoxicillin → rash in 90% of cases.
- Advise against contact sports until splenomegaly resolves (risk of rupture).
- For airway compromise / severe pharyngeal oedema → prednisolone 30–60 mg OD × 5 days.
- Treat streptococcal superinfection with IV benzylpenicillin or erythromycin (not amoxicillin).
- No role for antivirals against EBV.
📌 Key Exam Pearls
- Ampicillin rash = diagnostic clue 🎯.
- Splenomegaly → avoid contact sports.
- Monospot test = heterophile antibodies (Paul-Bunnell).
- Consider CMV/toxoplasmosis in pregnancy.
Cases - Epstein–Barr Virus (EBV) Infection
- Case 1 - Infectious Mononucleosis (Glandular Fever):
An 18-year-old university student presents with sore throat, fever, malaise, and cervical lymphadenopathy. Exam: tonsillar enlargement with exudates, splenomegaly. Bloods: lymphocytosis with atypical lymphocytes. Monospot test positive.
Diagnosis: EBV infectious mononucleosis.
Management: Supportive (hydration, rest, paracetamol/NSAIDs). Avoid amoxicillin (rash risk) and contact sports for 4 weeks due to splenic rupture risk.
- Case 2 - EBV-Associated Malignancy (Burkitt Lymphoma):
A 9-year-old boy from East Africa presents with a rapidly enlarging jaw mass. Biopsy shows “starry sky” appearance with medium-sized B-cells. EBV DNA detected in tumour tissue.
Diagnosis: EBV-associated endemic Burkitt lymphoma.
Management: Intensive multi-agent chemotherapy; supportive care; oncology referral.
- Case 3 - EBV-Driven Lymphoproliferation in Immunosuppressed Host:
A 45-year-old renal transplant patient on immunosuppressants develops fever, night sweats, weight loss, and lymphadenopathy. Lymph node biopsy shows EBV-positive B-cell proliferation consistent with post-transplant lymphoproliferative disorder (PTLD).
Diagnosis: EBV-associated PTLD.
Management: Reduction of immunosuppression, rituximab-based therapy, possible chemotherapy in refractory cases.
Teaching Commentary 🧾
EBV is a gamma-herpesvirus transmitted via saliva (“kissing disease”). Primary infection in adolescents/young adults → infectious mononucleosis. Complications: splenic rupture, hepatitis, haemolytic anaemia. EBV is oncogenic, associated with Burkitt lymphoma, Hodgkin lymphoma, nasopharyngeal carcinoma, and PTLD.
Diagnosis: heterophile antibody test (Monospot), EBV-specific serology, PCR.
Treatment: usually supportive, except in EBV-driven malignancies or PTLD where chemotherapy, immunotherapy, or reduction of immunosuppression is required.
