The Kissing Disease

Acute Infectious Mononucleosis with Epstein-Barr Virus (EBV)
Short Summary

Patient with clinical and laboratory picture compatible with acute infectious mononucleosis with Epstein-Barr Virus (EBV) receives from the expert wide information regarding the virus, the symptoms and clinical course, the needed follow-up tests etc.

Patient's Questions

1. When should follow-on tests be run and what kind? - Is intense articular pain related to the condition?

2. What can you infer causes the skin rash that comes in the shape of pinkish spots which at times take on a more intense coloring?

3. Fever has been persistent for 10 days. Is the clinical course within the norm?

4. Does abundant perspiration relate to the condition?

5. Is there any general advice you can share?

6. Any recommendations to avoid infection (apart from oral transmission)?

7. Until when is the virus to be considered potentially contagious?

 

Medical Background

Patient with clinical and laboratory picture compatible with acute infectious mononucleosis with Epstein-Barr Virus (EBV).

Expert's Opinion

Epstein-Barr virus infects more than 95% of the world's population. The most common manifestation of primary infection with this organism is acute infectious mononucleosis, a self-limited clinical syndrome that most frequently affects adolescents and young adults.

Humans are the only known reservoir of Epstein-Barr virus. Epstein-Barr virus is present in oropharyngeal secretions and is most commonly transmitted through saliva.

EBV infection is characterized by pharyngitis, enlarged lymph nodes, liver and spleen. Weakness, fatigue, night-sweats may last several weeks.

More than 90% of patients develop fever, which is most severe in the afternoon, typically peaking at 38-39°C, but it may reach 40°C. Fever usually resolves after two or three weeks. Despite fever, the pulse is usually normal or relatively low, and tachycardia is unusual.

A rash, usually faint, widely scattered, and occurs in 3-15% of patients. Treatment with antibiotics such as amoxicillin or ampicillin is associated with rash in approximately 80% of patients. This is often encountered when primary Epstein-Barr virus (EBV) infection is initially misdiagnosed as strep throat and is treated as such. Eyelid edema: This may be present, especially in the first week of illness. Arthritis may be present.

The laboratory abnormalities usually consist of elevated liver enzymes (GOT, GPT and sometimes LDH, Alk Phos and GGT).

Complete blood count is usually remarkable for atypical lymphocytes (characterized as LUC's). Mild reduction in thrombocyte count occurs in 25-50% of patients.

EBV-IgM levels are usually measurable at symptom onset, peak at 2-3 weeks, and then decline and become unmeasurable within 3-4 months. IgG levels rise shortly after symptom onset, peak at 2-3 months, then drop slightly but persist for life.

The good news is that the disease is disturbing, but not dangerous (to patients with a healthy immune system). The bad news is that the clinical course may take up to several months.

Regarding the specific questions:

- When should follow-on tests be run and what kind? - Is intense articular pain related to the condition?

o Blood smear should be analyzed to confirm that the LUC's in the complete blood count are in fact atypical lymphocytes (as expected in EBV infection)
o Liver enzymes tests to see that their levels don't exceed the expected in EBV
o Abdominal ultrasound to see that the liver and spleen are not congested (as sometimes seen in EBV)
o If the articular pain does not improve within a week or two - consult with a Rheumatologist, as some arthritis diseases may be aggrevated by EBV infection
o Re-evaluate EBV IgM + IgG levels in a month or two, to validate that the infection moved from acute to the chronic phase

- What can you infer causes the skin rash that comes in the shape of pinkish spots which at times take on a more intense coloring?
o Skin rash is common in EBV infection especially with concominant use of antibiotics (especially Penicillins)
o Consult with a Dermatologist if rash does not improve within a week (without antibiotics)

- Fever has been persistent for 10 days. Is the clinical course within the norm?
o Yes, unfortunately it may take up to several months

- Does abundant perspiration relate to the condition?
o Yes, unfortunately it may take up to several months.

- Is there any general advice you can share?
o Avoid physical activity until symptoms resolve.
o Do not share drinks, glasses or plates until symptoms resolve is over.

- Any recommendations to avoid infection (apart from oral transmission)?
o Do not share drinks, glasses or plates until symptoms resolve
o Avoid close contact with people with immune deficiency until symptoms resolve.

- Until when is the virus to be considered potentially contagious?
o The virus is considered not infective, when the IgG levels rise and the IgM levels fall. Right now, the IgM levels are high and the IgG levels are low - so he is still highly infectious
o It may take several months for the patient to become not infective.
 

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