Epstein-Barr Virus

Original Editors - Nicole Clark from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Nicole Clark, Lucinda hampton, Admin, Elaine Lonnemann, Kim Jackson, WikiSysop and Wendy Walker  

Introduction

Infectious mononucleosis (also known as glandular fever) is the term for infection with Epstein-Barr Virus (EBV). The infection classically occurs in teenagers and young adults, hence its other name kissing disease. It is usually a clinical diagnosis, with confirmation by serum testing, but may have suggestive findings on imaging

• Mononucleosis classically presents with fever, lymphadenopathy, and tonsillar pharyngitis. See image R
• The term “infectious mononucleosis” was first used in the 1920s to describe a group of students with a similar pharyngeal illness and blood laboratory findings of lymphocytosis and atypical mononuclear cells.
• Later Epstein-Barr virus (EBV) was established as the cause of mononucleosis after an exposed healthcare worker developed a positive heterophile test (a rapid test which detects infectious mononucleosis that is caused by the Epstein Barr Virus)

Etiology

The cause of mononucleosis is the Epstein-Barr virus (EBV), a type of herpesvirus spread by contact, typically with salivary secretions.

• The duration of oral shedding is not entirely clear, but high levels of shedding can continue for a median of 6 months after illness onset.
• Transmission is generally person-to-person, but EBV is not considered a highly contagious disease.

Besides EBV other causes include:

• CMV
• Adenovirus
• Hepatitis A
• HIV
• Toxoplasma
• Rubella

Epidemiolgy

It is estimated that up to 95% of adults in the world are eventually seropositive to EBV (widely disseminated in all population groups).

• Exposure to EBV, but often a subclinical infection, especially in children. Young adults (15-24) are more likely to be symptomatic.
• Mononucleosis is uncommon in adults:  approximately 2% of all pharyngeal disease in adults is attributable to this disease.
• Adults are generally not susceptible to clinical illness because of previous exposure.
• In the United States, clinically evident infection occurs at rates estimated at 30 times higher in whites than in blacks (possibly because if acquired at a young (childhood) age, EBV is often subclinical ie earlier EBV exposures in blacks, and a higher frequency of asymptomatic infection as young children).
• After exposure, the EBV infects the epithelial cells of the salivary glands and the oropharynx. Lymphocytes residing in the tonsils get exposed to the virus and then enter the bloodstream. Lymphoid hyperplasia is common and may be seen as generalized lymphadenopathy, tonsillitis, and hepatosplenomegaly.
• The infection of the B-lymphocytes results in the production of immunoglobulins (heterophile antibodies).

Characteristics/Clinical Presentation

• Fever
• Tonsillitis
• Lymphadenopathy and splenomegaly
• Occasionally hepatosplenomegaly
• Fatigue
• Occasionally: rash

Complications

• Splenic rupture: may be spontaneous
• Splenic infarction

Associated Co-morbidities

While there are very few co-morbidities associated with mono, a select group of studies as shown a correlation between Chronic Fatigue Syndrome (CFS) and Mononucleosis. According to research the Epstein Barr Virus has many similar clinical features. It has yet to be determined whether or not the conditions are synonymous or just present with similar symptoms due to their viral nature of transmision.

Medications

Since Mono is not a bacterial infection, anti-biotics are not typically prescribed to help fight off the infection. Viral infections, such as mono are more typically managed with over the counter medications such as Tylenol and Ibuprofen (Advile). In more complex cases patients may be prescribed corticosteriods to help control any systemic effects occuring from the virus.

 

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http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001617/figure/A000591.B9069/?report=objectonly

Diagnostic Tests/Lab Tests/Lab Values

A combination of clinical examination, lab tests, and positive Monospot test are used to diagnosis Mononucleosis. Antibodies in the serum are elevated during the acute phase of the illness and can last for 3-4 weeks. This must be differentiated from Chronic Fatigue because these same antibody levels were at one time shown to be increased with CFS as well. In the initial clinical evaluation a strep test should also be performed to rule that out as a possible cause for the fever and swollen glands. Elevated white blood cell count will be noted during lab work and may remain this way for up to 4 months.                                                                                                       

Etiology/Causes

Mono is caused by the Epstein-Barr virus, a form of herpesvirus. EBV is one of the most common virus in the United States and does not disappear once symptoms supposide like some viruses. Some of the EBV cells remain dormant in their host for the rest of the patient's life. The virus is passed through saliva and close contact. It has also been shown that mono can be caused from other viral organisms such as cytomegalovirus. Mononucleosis is spread sharing beverages, utensils, lip balm, and most commonly known is kissing. Infectious mononucleosis can be caused from Acute Cytomegalovirus (CMV) infection, condition caused by a member of the herpes virus family. Once symptoms have subsided the individual is still caring the virus, it has just become dormant. A few of the viral cells will remain permanently and the person may have an acute flare up years down the road.

Systemic Involvement

Enlargement of the spleen is the most serious systemic complication that can arise from Mono. In very rare, extreme cases the spleen may rupture if not treated properly. This would be evident by sudden, sharp, stabbing pain in the left side of the upper abdomen.

The liver may also become involved in some cases. Hepatitis, or inflammation can occur in some cases or the patient may experience jaundice which is characterized by yellowing of the skin and whites of the eyes. If any abdominal pain or yellowing of the skin occurs medical attention should be sought immediately.

File:2011-infectious-mononucleosis.jpg

http://www.medicinenet.com/infectious_mononucleosis/article.htm

 

Medical Management (current best evidence)

Usually the medical management for mononucleosis is self-treatment. Normally, all symptoms are resp;ved within a month but can last for up to four months. Your doctor will advise you to get plenty of rest, gargle with salt water to sooth sore throat, take Tylenol or Ibuprofen for any present fever or headache, and avoid sports or heavy lifting in the event of an enlarged spleen. In more severe cases corticosteroids maybe prescribed to reduce swelling of throat, tonsils, or spleen. Patients with mono should avoid contact with other individuals if running a fever to reduce the risk of contamination. If in contact with others while the virus is active, avoid sharing utensils or drinking after others to minimize the risk of spreading the virus.

Physical Therapy Management (current best evidence)

Infectious Mononucleosis

PREFERRED PRACTICE PATTERNS 6B:

Impaired Aerobic Capacity/Endurance Associated with Deconditioning Infectious mononucleosis is probably contagious before symptoms develop until the fever subsides and the oral and pharyngeal lesions disappear. Although infectious mononucleosis appears to be only mildly contagious, adherence to standard precautions, especially good handwashing and avoidance of shared dishware or food items with other people, is essential in preventing the HCW from contracting this condition. The person with infectious mononucleosis should be cautioned against engaging in excessive activity, especially contact sports, which could result in splenic rupture or lowered resistance to infection. Usually this guideline is appropriate for a period of at least 1 month. Any sign of splenic rupture (e.g., abdominal or upper quadrant pain, Kehr's sign, sudden left shoulder pain, or shock) requires immediate medical evaluation. Any soft tissue mobilization or myofascial techniques necessary in the left upper quadrant, especially up and under the rib cage, must take into consideration the enlarged liver and/or spleen; indirect techniques away from the spleen are indicated. In rare cases mononucleosis impairs the CNS. Any change in neurologic status must be evaluated and reported to the physician. Changes in respiration or signs and symptoms of airway obstruction may require emergency intervention.

With permission from Elsevier

Differential Diagnosis

Since Mono is caused by a strand of herpevirus there are other conditions that may present with similar symptoms. It is always important for patient to consult with M.D. to rule out possibilty of any of the following:

• Diphtheria
• Herpes Simplex
• HIV Infection and AIDS
• Mumps
• Roseola Infantum
• Rubella
• Peritonsillar Abscess
• Pharyngitis
• Retropharyngeal Abscess
• Scarlet Fever

Also, there are several complications that can occur if patient's are not taking care of themselves once sypmtoms are present. Many of these condition are rare but dangerous: 

• Hemolytic anemia
• Hepatitis with jaundice (more common in patients older than 35)
• Inflammation of the testicles (orchitis)
• Guillain-Barre syndrome
• Meningitis
• Seizures
• Bell's Palsy
• Uncoordinated movements
• Strep Throat
• Spleen rupture (rare)

Case Reports/ Case Studies

• Cosmopoulos K, Pegtel M, Hawkins J, Moffett H, Novina C, Middledorp J, Thorly-Lawson DA. Comprehensive profiling of Epstein-Barr virus microRNAs in nasopharyngeal carcinoma.  J Virol. 2009 Mar;83(5):2357-67. Epub 2008 Dec 17.
• Candy B, Chalder T, Cleare AJ, Wessely S, White PD, Hotopf M. Recovery from infectious mononucleosis: a case for more than symptomatic therapy? A systematic review. Department of Psychological Medicine, Guy's, King's and St. Thomas' School of Medicine, London. Br J Gen Pract. 2002 October; 52(483): 844–851
• Candy B, Chalder T, Cleare AJ, Peakman A, Skowera A, Wessely S, Weinman J, Zuckerman M, Hotopf M. Predictors of fatigue following the onset of infectious mononucleosis. Department of Psychological Medicine, Public Health Laboratory and Medical Microbiology, Guy's, King's and St Thomas' School of Medicine and Institute of Psychiatry, London. Psychol Med. 2003 Jul;33(5):847-55.
• Katz BZ, Shiraishi Y, Mears CJ, Binns HJ, Taylor R. Chronic fatigue syndrome after infectious mononucleosis in adolescents. Department of Pediatrics, Division of Infectious Diseases, Northwestern University Feinberg School of Medicine and Children's Memorial Hospital, Chicago, Illinois 60614, USA. [email protected] Pediatrics. 2009 Jul;124(1):189-93.
• Buchwald DS, Rea TD, Katon WJ, Russo JE, Ashley RL. Acute infectious mononucleosis: characteristics of patients who report failure to recover. Department of Medicine, University of Washington, Seattle, Washington, USA. Am J Med. 2000 Nov;109(7):531-7.

Resources

Center for Disease Control

WebMD

MayoClinic

Merck Manual