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The Informed Parent

Different Presentations of Infectious Mononucleosis

by Louis P. Theriot, M.D., F.A.A.P.
Published on Jul. 06, 2009
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Infectious mononucleosis is a fairly common disease that is caused by the Epstein-Barr virus. While many think of it as the “kissing disease” that affects teenagers, it actually can affect young children as well as young adults. It can present in many different ways.

While making teaching rounds at USC this month, the residents presented a 17-month-old who had a two week history of swollen lymph nodes in the neck region. The baby appeared pale and looked “ill”. In addition to a large, firm 1 ½ inch lymph node below the jaw, he also had matted nodes in the right and left neck. A pea sized lymph node was found above the right collarbone and another smaller node was above the right elbow. Most concerning was the feel of the node below the jaw. It was firm and not freely moveable…seemingly adherent to the overlying skin. The fact that there was a node above the collarbone was also disquieting since this is usually associated with a malignancy of some sort. The chest x-ray revealed enlarged lymph nodes near the heart. With this the concern for a cancer such as Hodgkin’s disease or a lymphoma was high on the list.

We consulted the Oncologist without delay to see if a biopsy was warranted. She stated that she wanted to wait until the Epstein -Barr titers came back to be sure this wasn’t just a case of infectious mononucleosis (mono). Sure enough, two days later the EBV titers came back positive for an early case of mono. The baby was discharged home and we expect a full and uneventful recovery.

Sam is a sophomore in college who just came home for the summer. A week ago he was seen in the student health clinic at his college for a bad sore throat, fever and fatigue. They did a test that ruled out strep throat and a mono test that was negative. He was told it was viral and in a couple of days he should be better. He did seem to get better for a day or two. But when he came to our office he had fever, a bad sore throat, difficulty swallowing because the throat was so sore, fatigue and sweats. On examination he had a beefy red throat with copious amounts of pus on the tonsils. His voice was garbled and he had large, tender lymph nodes in the neck. He also had a pea-sized node above the elbow and was tender on the right upper abdomen, just below the rib case. There was absolutely no desire to eat. I repeated the mono test in the office, and it was positive. Additional specific tests were warranted and I wanted him to stay at home to rest until the results of the tests would be in.

In two days I would recheck him as the EBV titers showed that he was early in the course of the disease. The labs also showed that he had hepatitis which is not uncommon with mono. At the recheck he actually looked and felt worse. I put him on a five-day course of steroids. Within 36 hours he felt much better. I told him he was essentially under house arrest for the next week. When next I saw him he felt nearly back to normal. The repeat labs showed that the hepatitis had resolved. This is a common presentation of mono in a young adult.

EBV is a virus that typically causes an illness manifested by fever, sore throat, swollen glands and fatigue. The clinical presentation depends on the age of infection. In Central Africa almost all of the children have been infected by three years of age. Most of these cases go unnoticed, or are thought to be typical childhood illnesses. In industrialized countries most cases of mono are in older children or adolescents. The cases can present a broad spectrum of illness.

Diagnosing this disease in the office, we use a mono spot test. This is a quick screening test that is very helpful when it is positive. A negative test does not completely rule out mono as it may be too early in the course of the disease. The test can be done within ten minutes and is not very costly.

The definitive test for mono is the EBV titers that measure the specific antibodies in the blood stream against the virus. When one gets infected with EBV there is a rise in the lgM immunoglobulin. It peaks at one-to-two weeks before it falls to zero by about a month. After a week or so, there is a slow and steady rise in the lgG immunoglobulin. This will remain positive forever. It is the immunoglobulin that confers life-long protection, thus preventing one from getting EBV again. These antibodies can be measured in the blood. They can tell you exactly where in the course of a mono infection one is.

Most cases of mono are self-resolving, and the patient will recover completely within a couple of weeks. There are the extreme cases however. We have all heard about the teenager who missed an entire semester of school because of the severe fatigue due to mono. But this is the exception.

In addition to fatigue, sore throat and swollen glands, 50 percent of mono patients get an enlarged spleen and 10 percent get an enlarged liver. The most serious complication from mono has to do with the enlarged spleen. It can become up to 6-7 times the normal size. With trauma the spleen can rupture causing life-threatening complications. The hepatitis seen in mono is not usually very serious and resolves in due time.

When most patients are diagnosed in the office with mono they are in the early stages of the illness and there is no predicting how bad it will actually get. I tell them to go home, take plenty of fluids and rest. There should be absolutely no rough housing, nothing with wheels, (bikes, roller blades or skateboards) and no contact activities for fear of rupturing the spleen. I want them under “house arrest” until I recheck them in a few days. Most are feeling better by that time. If so, they can try to do a bit more activities, but I stress that they are NOT to push it. If they feel a bit fatigued, then they over did it. Quite often I will have them go to school for half days to see how they feel. If they do OK, they can then try whole days. As for sports, they are not allowed to return to contact sports for a month from the onset of the illness. This is to insure that the spleen has returned to its normal size. This one-month requirement is the rule that is followed by the NCAA for college athletes.

In a small number of patients the symptoms are quite severe. This may be manifested by a hepatitis or enlarged tonsils and adenoids that compromise the airway and cause trouble breathing. These are the patients that benefit from a short course of steroids.

The take home message about mono is that it can affect young children as well as young adults. The presentation can be very mild, or it can be quite severe. Most cases resolve without any treatment within a few weeks. The biggest concern is for a ruptured spleen which can happen with even mild abdominal trauma. After becoming infected with the EBV one should be given lifelong immunity. Therefore, you only get it once.




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