This document discusses infectious mononucleosis (IM) and Epstein-Barr virus (EBV). EBV is a herpes virus that causes IM. IM presents as fever, pharyngitis, lymphadenopathy, and lymphocytosis. While most cases resolve in 2 weeks, complications can occasionally occur. Diagnosis involves detecting heterophile antibodies or EBV serology. Treatment is symptomatic and management focuses on rest. Shingles is also discussed, caused by reactivation of varicella zoster virus. It presents as a rash in dermatomal distributions, and postherpetic neuralgia can occur. Antiviral treatment can reduce symptoms and the vaccine prevents shingles.

1. Infectious mononucleosis
(IM) and Epstein-Barr virus
(EBV)
For Third- Year Medical Students
Dr: Hussein Mohammed Jumaah
CABM
Mosul Medical College
31/3/2014

2. EBV is a gamma herpes virus.
In developing countries, subclinical infection
in childhood is virtually universal.
In developed countries, primary infection may
be delayed until early adult life.
The virus is acquired from asymptomatic
excreters via saliva, by droplet infection, or by
kissing.
EBV is not highly contagious ,isolation is
unnecessary.
Infectious mononucleosis (IM) and
Epstein-Barr virus (EBV)

3. Infectious mononucleosis (IM) and
Epstein-Barr virus (EBV)
IM is an acute viral illness characterised by
fever , pharyngitis, cervical
lymphadenopathy, and lymphocytosis.
Whereas ~90% of cases of IM are due to EBV,
5–10% of cases are due to Cytomegalovirus
(CMV).
CMV is the most common cause of
heterophile-negative mononucleosis.
Less common causes rubella ,Toxoplasma,
HIV, herpesvirus 6, hepatitis viruses and drug
reactions.

4. Clinical features
IM has a prolonged and undetermined
incubation period, followed by a prodrome of
fever, headache and malaise, succeeded by
IM
with severe pharyngitis, which may include
tonsillar exudates, and non-tender cervical
lymphadenopathy.
Palatal petechiae, periorbital oedema,
splenomegaly, macular, petechial or
erythema multiforme rashes may occur.

5. In most cases fever resolves over 2 weeks,
and other abnormalities settle over a further
few weeks.
EBV may present with jaundice, PUO* or
with a complication.
Death is rare but can occur due to
1. Respiratory obstruction.
2. Haemorrhage (splenic rupture or
thrombocytopenia).
3. Encephalitis
*pyrexia of unknown origin
Clinical features

6. Complications of Epstein–Barr virusn
infection

7. In children under 10 years the
illness is
mild and short-lived, but in adults
over
30 years of age it can be severe
and
prolonged.
Investigations
Atypical lymphocytes are
common in
EBVinfection but also occur in
other
causes of IM, HIV infection, viral
Atypical lymphocytes.
enlarged lymphocytes
that have abundant
cytoplasm, vacuoles,
and indentations of the
cell membrane .
Diagnosis

8. A 'heterophile' antibody is present during
the acute illness and convalescence,
agglutinates erythrocytes of other species,
e.g. sheep and horse.
detected by the classical
Paul-Bunnell titration or
a more convenient slide test such as the
'Monospot'.
Investigations

9. Specific EBV serology
(immunofluorescence) can be used to confirm
the diagnosis if necessary.
Acute infection is characterised by IgM
antibodies against the viral capsid, antibodies
to EBV early antigen and the initial absence
of antibodies to EBV nuclear antigen (anti-
EBNA).
Seroconversion of anti-EBNA at
approximately1 month after the initial illness
may confirm the diagnosis in retrospect.
CNS infections may be diagnosed by
Investigations

10. Management
largely symptomatic. If a throat culture yields
aβ-haemolytic streptococcus, a course of
penicillin should be prescribed. ampicillin or
amoxicillin in this condition commonly causes
an itchy macular rash, and should be
avoided
When pharyngeal oedema is severe, a
short course of corticosteroids, e.g.
prednisolone 30 mg daily for 5 days, may
help.
Antivirals are not sufficiently active against
EBV

11. Return to work or school is governed
by the patient's physical fitness. contact
sports should be avoided until
splenomegaly has completely resolved
because of the danger of splenic
rupture.
10% of patients with IM suffer a chronic
relapsing syndrome

12. Shingles (herpes zoster)

13. After initial infection ,Varicella
zoster virus ,(VZV) persists in
latent form in the dorsal root
ganglion of sensory nerves and can
reactivate in later life as a localised
rash or with other clinical
manifestations.
Commonly seen in the elderly,
shingles
may also present in younger
patients
with immune deficiency.
Chickenpox may be contracted
Shingles (herpes zoster)

14. Clinical features
Burning discomfort occurs in the affected
dermatome, where discrete vesicles
appear
3-4 days later, associated with a brief
viraemia and can produce distant satellite
'chickenpox' lesions.
Severe disease, a prolonged duration of
rash, multiple dermatomal involvement or
recurrence suggests underlying immune
deficiency.
Clinical features

15. Thoracic dermatomes are most
Commonly involved .
Ophthalmic division of the
trigeminal nerve is also
frequently
affected;vesicles may appear on
the
cornea and lead to
ulceration,and
can lead to blindness.
Bowel and bladder
dysfunction
occur with sacral nerve root
Clinical features

16. Ramsay Hunt syndrome
Involvement of the Geniculate ganglion
causes facial palsy, ipsilateral loss of
taste and buccal ulceration, plus a rash
in the external auditory canal. This may
be mistaken for Bell's palsy.
Post-herpetic neuralgia
Postherpetic neuralgia arises in
approximately 20% of patients .
Troublesome persistence of pain for 1-6
months or longer, following healing of the
rash. It is more common with advanced
age.
Clinical features

17. Management and preventionAciclovir has been shown to
reduce both early- and late-onset
pain. new drugs valaciclovir and
famciclovir . demonstrate similar or
superior efficacy and good safety
and tolerability.
Post-herpetic neuralgia requires
aggressive analgesia, along with
agents such as amitriptyline or
gabapentin. Capsaicin cream may
be helpful. Although controversial,
corticosteroids have not been
demonstrated to reduce post-
herpetic neuralgia to date.

18. Acyclovir for chickenpox/shingles
Aciclovir shortens symptoms in chickenpox
by an average of 1 day. In shingles aciclovir
reduces pain by 10 days and the risk of
post-herpetic neuralgia by 8%. Aciclovir is
therefore cost-effective in shingles but not
chickenpox.'

19. Human VZ immunoglobulin (VZIG) is used to
attenuate infection in people who have had
significant contact with VZV, are susceptible to
infection (i.e. have no history of chickenpox or
shingles and are negative for serum VZV IgG) and
are at risk of severe disease (e.g.
immunocompromised, steroid-treated or
pregnant).
Newborn whose mother develops chickenpox no
more than 5 days before delivery or 2 days after
delivery.
Ideally, VZIG should be given within 7 days of
exposure, but it may attenuate disease even if
given up to 10 days afterwards.
Susceptible contacts who develop severe

20. A zoster vaccine (Zostavax) ,VZV vaccine ,.
Is a live, attenuated . Is exceedingly safe ,On
March 24, 2011, the Food and Drug
Administration (FDA) approved its use for the
prevention of shingles in individuals 50 to 59
years of age, including persons who have
already had an episode of shingles.
should not be given to individuals who have
a. A weakened immune system
b. Individuals with active, untreated
tuberculosis.
c. Pregnant women should not receive this

21. UK ,its use has been restricted to non-immune
healthcare workers and household contacts of
immunocompromised individuals.
Children receive one dose after 1 year of age
and a second dose at 4–6 years of age;
seronegative adults receive two doses at least
1 month apart.
The vaccine may also be used prior to planned
iatrogenic immunosuppression, e.g. before
transplant.