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A case is presented of a young adult with splenic hemorrhage secondary to infectious mononucleosis. The patient was managed successfully without surgery and has done well over the long term with progressive resolution of the hematoma on ultrasound. The implications of this case for the management of patients with this syndrome are discussed.
Lymphocytes were explanted from EBV-seropositive donors including peripheral blood of infectious mononucleosis patients, healthy donors and EBV-genome-carrying cells from Burkitt lymphoma (BL) biopsies or nude mouse-passaged, BL-biopsy-derived lines. The explanted cells were mixed with fresh cord-blood lymphocytes from mice of the opposite sex. In all categories of derived lines, cord-blood cell progeny was predominant, as judged by the sex marker and other associated markers. Only one BL biopsy line, serially passaged in nude mice, gave rise to a monoclonal lymphoma line.
Samples from the fur covering the palatine tonsils of 10 patients with infectious mononucleosis (IM) were subjected to fluorescence microscopy after staining with acridine orange. Standard aerobic cultures from swabs were set up simultaneously. The fur constituted a mass of variously sized cocci and rods intermingled with granulocytes and cellular detritus. Five patients had growth of beta-haemolytic Streptococci on the tonsils. Bacteria in abundance were found attached to the tonsillar epithelial cells. The B-lymphotrophic Epstein-Barr virus, responsible for the IM infection, causes an immense increase in the bacterial colonization of the tonsillar surfaces, probably due to an increased attachment of bacteria to the tonsillar epithelial cells.
Shedding of Epstein-Barr virus (EBV) into saliva was studied in 31 patients with verified acute infectious mononucleosis. The patients had been randomized for intravenous treatment with acyclovir (ACV) at 10 mg/kg body weight at 8 h intervals for 7 days, or placebo, in a double-blind trial. EBV in centrifuged throat washings was detected by transformation of umbilical cord lymphocytes and by immunofluorescence staining for EBV-associated nuclear antigen in fixed cell smears. Saliva samples were obtained before and during treatment, and after 4 weeks and 6 months, respectively. ACV effectively but transiently interrupted EBV production (P less than 0.001), but virus shedding resumed at the initial level within 3 weeks of cessation of the treatment. Initially, 93.5% of the patients had detectable EBV in the saliva compared with 83% in the 4th week and 58% after 6 months.
The presence of Epstein-Barr virus (EBV) in the blood and urine of 20 patients with infectious mononucleosis (IM) was investigated together with the clinical course of the disease, and in 9 patients up to 2-7 months after recovery. EBV DNA, analyzed by the polymerase chain reaction (PCR), was detected in the blood of all 20 patients from the first sample obtained and detected between 3 to 42 days from the beginning of symptoms and up to 2-3 months after recovery. In the urine, EBV DNA was detected in 15 out of 16 (93%) patients in the first sample obtained and detected between 3 to 50 days during the clinical course of the disease. In four patients EBV DNA was detected in the urine up to 3 months after full recovery. Seventeen out of 26 (65%) urine samples including 3 which were obtained 2-7 months after recovery infected B cells as assessed by PCR. Nine out of 12 (75%) urine samples tested induced Epstein-Barr nuclear antigen (EBNA) in the infected B-cell line. In addition to the persistence of EBV in the blood of IM patients, these studies show for the first time the presence of infective EBV in the urine during the clinical course of the disease and up to 7 months after full clinical recovery.
The antigen specificity of anti-phospholipid antibodies in infectious mononucleosis (IM) was studied using ELISA for the detection of anti-beta2-glycoprotein I (beta2-GPI), anti-annexin V, anti-protein S and anti-prothrombin antibodies and TLC immunostaining for the detection of anti-phospholipid antibodies. This technique enabled us to look at antibodies reacting to 'pure' phospholipid antigens in the absence of protein contamination. Sera from 46 patients with IM, 18 with systemic lupus erythematosus (SLE), 21 with primary anti-phospholipid antibody syndrome (PAPS), 50 with Helicobacter pylori infection and 30 healthy blood donors were tested. This study highlights anti-phospholipid antibodies in patients with IM as specific 'pure' anti-cardiolipin antibodies, while in PAPS and SLE patients anti-phosphatidylserine and anti-phosphatidylethanolamine antibodies were also found. This investigation also shows that the anti-cardiolipin antibodies found in IM can be present with anti-cofactor protein antibodies. The higher prevalence of anti-cofactor antibodies found in IM sera than in Helicobacter pylori sera may be due to the immunostimulatory effect and/or the polyclonal activation often observed in course of Epstein-Barr virus infection. However, anti-beta2-GPI and, to a lesser extent, anti-prothrombin antibodies occur with a significantly lower prevalence in IM than in PAPS patients. This finding suggests that these antibodies should be regarded as the expression of the broad autoimmune syndrome involving the phospholipid-binding plasma proteins.
A 10-month-old girl with glycogen storage disease type III developed recurrent severe hypoglycaemia induced by infectious mononucleosis. Severe metabolic damage probably reflected a rapid breakdown of liver cells induced by the viral infection.
A four-year-old boy developed oliguria, proteinuria and hypocomplementemia, without hematuria, in the course of proven infectious mononucleosis. A chest radiograph revealed a mild cardiomegaly, prominent pulmonary vasculature and pleural fluid. These abnormalities were compatible with acute glomerulonephritis and were in support of this clinical diagnosis in spite of the absence of hematuria.
A young man developed infectious mononucleosis complicated by profound anaemia due to haemolysis. The Donath Landsteiner antibody was found in his serum. He was treated successfully by blood transfusion but subsequently developed severe neutropenia. Both complications have been reported previously but not in the same individual. No underlying immune deficiency could be identified.
A ten-year-old boy presented with an illness resembling infectious mononucleosis associated with an unusual skin rash and marked cholestatic hepatitis. This combination represents a rare reaction to diphenylhydantoin. Few reported cases have been published. The illness commences from three to seven weeks after starting therapy. Although one death has been reported, other cases have shown complete recovery. Early recognition of the combination of symptoms and cessation of drug therapy is essential.
Reports on the incidence of beta-hemolytic group A streptococci (BHGAS) in the pharynx of patients with infectious mononucleosis (IM) have varied from 3% to 33%. To ascertain the rate of infection, we prospectively performed serial throat cultures and determined anti-streptococcal antibody titers on 45 students with confirmed IM by Epstein-Barr virus-specific serology. One hundred healthy control students had throat cultures for comparison. The rate of recovery of BHGAS was similar in patients with IM (4%) and controls (3%). No students with IM had a fourfold rise of anti-streptococcal antibodies. We conclude that routine culture for BHGAS and/or treatment with antibiotic agents is not indicated in all patients with IM.
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We report a 45-year-old lady with infectious mononucleosis due to Epstein-Barr virus. The unusual features of this case included a negative heterophil antibody test, marked leukocytosis, renal involvement and jaundice.
We compared the results obtained with six different test kits for infectious mononucleosis with those obtained with the Paul-Bunnell test. The investigation was carried out in one laboratory using 149 selected pools of patient sera. Each pool was tested three times with the Paul-Bunnell test and once with each kit. The results obtained with the kits were grouped according to the titre found with the Paul-Bunnell test. The percentage of positive results within each group was calculated for each kit. The Paul-Bunnell titre, which would have classified 50% of the specimens as positive, was estimated for each kit and this was designated the 50% cut off value. In general, there was good agreement. However, false positive test results were found rather frequently with one kit (19%) and the 50% cut off values differed. One kit showed a 50% cut off value at about 8, another at about 16, and the rest at between 16 and 32. We suggest the introduction of improved internal quality control combined with external quality assessment.
The aim of the present study was to provide preliminary information on the acute and chronic effects of infectious mononucleosis (IM) on memory, attention, psychomotor performance and mood. These issues were examined by comparing individuals with acute IM, those who had the initial illness some months before, and matched healthy controls. Objective measures of memory, attention, motor skills and visual functions were obtained, as were subjective reports of mood. The results showed selective effects of acute IM on performance and mood, with the profile of impairments being very similar to those observed in previous studies of influenza. Different impairments were observed in subjects who had the primary illness several months before, and the effects observed in this group were similar to those observed in recent studies of chronic fatigue syndrome patients. Both acute and chronic IM subjects reported similar levels of symptoms and psychopathology, with both groups having greater scores than the controls. However, the performance impairments did not reflect symptoms or psychopathology. One may conclude that the study of IM will provide important data on both the acute and longer lasting effects of viral infections on the brain and behaviour.