Mononucleosis lecture

1. DEPARTMENT of CHILDREN's
infectious diseases
Discipline: Children's infectious
diseases
Topic of the lecture: Infectious mononucleosis in children
4 course, level of development: DT, P
Lecturer: assistant Erzhigitova E. M.

2. Relevance of the topic
• high infection rate of the child population;
• increase in the incidence of infectious diseases
mononucleosis and chronic infection;
• lack of specific prevention and specific
etiotropic therapy;
• polymorphism of clinical manifestations;

3. Plan of the lecture
• Definition of " Infectious
mononucleosis»
• Etiology, epidemiology
• Pathogenesis
• Classification
• Clinical picture
• Differential diagnosis
• Laboratory diagnostics
• Treatment
• Prevention

4. Infectious mononucleosis in children
Infectious mononucleosis-
this is an acute viral disease (mainly
Epstein-Barr virus), which is
characterized by fever,
oropharyngeal lesions, lymph
nodes, liver, spleen, and peculiar
changes in the blood composition
(lymphomonocytosis, atypical
mononuclears).
https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcRPfyhtNjME-_E-
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5. Epidemiology
• infectious mononucleosis-anthroponosis;
• the source of infection is a sick person, a virus
carrier;
• the path of transmission is airborne (most often
with saliva - "kissing disease", "disease of
patched children"), with blood transfusions,
during childbirth;
• susceptibility-high;
• seasonality-spring-autumn;
• immunity is strong, but non-sterile;
• possible chronization and reactivation of the
infection.

6. Patients are contagious
• at the end of the incubation period (2 to 8 weeks);
• in the prodromal period;
• in the period of reconvalescence (from 1 to 18 months).

7. Infectious mononucleosis is
characterized by:
• Cyclicity with a duration epidemiological waves of
6-7 years.
• Development of the epidemic process mostly due to
erased and asymptomatic forms.
• Preemptive defeat of men's faces gender.
• The highest incidence among children of preschool age,
organized in children's groups.
• It is more common in the form of sporadic more cases
than epidemic outbreaks.
• Mortality is low, descriptions of the cases single
deaths.
• Cause of death-rupture of the liver, spleen, the defeat of
the cardiovascular system and Central nervous system.
• Prenatal protective antibodies saved for 3-6 months.

8. Etiology
•Epstein-Barr virus :
•contains DNA
•the diameter of 120-150 nm
Сontains antigens:
• capsid (VCA),
•nuclear(EBNA),
•early (EA)
• membrane (MA).
https://сдатьанализ74.рф/upload/iblock/7ef/Virus-epshteyn-barr-2.jpg

9. Pathogenesis
•replication of EB virus in the nasopharyngeal epithelium and
nasopharyngeal lymphatic formations;
• hematogenous and lymphogenous dissemination of the virus;
• infection of B-lymphocytes, activation of T-suppressors that
suppress proliferation of B-lymphocytes;
• young T-suppressor cells have the appearance of atypical
mononuclear cells;
•activation of the lymphatic system is manifested by an increase in
lymph nodes, tonsils, and other lymphoid formations of the spleen,
liver, pharynx.
Атипичные
мононуклеары
https://meduniver.com/Medical/gematologia/Img/mazok_krovi_pri_infekcionnom_mononukleo
ze.jpg

10. CLASSIFICATION of INFECTIOUS MONONUCLEOSIS
(N. I. Nisevich, 1990)
By type:
• typical;
• atypical (asymptomatic, erased, visceral).
According to the severity:
• • mild form;
• • medium-heavy form;
• • severe form.

11. CLASSIFICATION OF INFECTIOUS
MONONUCLEOSIS
Course of infectious mononucleosis
• On duration:Acute (up to 3 months);
• Prolonged (up to 6 months);
• Chronic (more than 6 months);
In character:
• Smooth;
• Wavy;
• Recurrent;
• Complicated;

12. COMPLICATIONS:
• EARLY COMPLICATIONS (1-3 weeks
of illness):
• ruptured spleen,
• asphyxia, (due to edema
pharyngotonsillitis),
• myocarditis,
• interstitial pneumonia, encephalitis,
• cranial nerve paralysis,
• including bell's paralysis,
• meningoencephalitis,
• polyneuritis,
• Guillain-Barre syndrome;
• LATE COMPLICATIONS (after 3 weeks
of illness):
• hemolytic anemia, thrombocytopenic
purpura,
• aplastic anemia,
• hepatitis,
• malabsorption syndrome, etc., as a
consequence of the autoimmune process.

13. CLINIC OF INFECTIOUS
MONONUCLEOSIS
INTOXICATION SYNDROME (priority) :
• pallor, lethargy, weakness, headache,
• fever (high, persistent, prolonged):
• - light severity: up to 38.0 ° C, no more than 38.5
° C;
• - average severity: up to 39.0 ° C, no more than
39.5 ° C;
• - severe severity: more than 39.0 ° C;

14. CLINIC OF INFECTIOUS
MONONUCLEOSIS
Catarrhal respiratory syndrome (primary):
• Nasal congestion;
• Lack of nasal breathing;
• Breathing with an open mouth;
• Catarrh of the nasopharyngeal mucosa: Palatine
arches, tonsils, posterior pharyngeal wall;
• Snoring breath;
• Puffiness of the eyelids, face;

15. CLINIC OF INFECTIOUS MONONUCLEOSIS
Lymphadenopathy
syndrome-100%
(priority)
• Reaction and enlargement of
lymph nodes:
• Anterior and / or posterior neck
• Submandibular;
• Occipital;
• Parotid
• Axillary;
• Inguinal;
• Intra-abdominal lymph nodes;
• Most often at the gate of the
liver and spleen,
• Hypertrophy of the Palatine and
pharyngeal tonsils
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16. ENLARGEMENT OF CERVICALAND
SUBMANDIBULAR LYMPH NODES IN
INFECTIOUS MONONUCLEOSIS
http://womanclub.site/wp-
content/uploads/2019/08/dce64d2c5a7c6abc4e1a34fe487e7e00.png

17. CLINIC OF INFECTIOUS
MONONUCLEOSIS
THE SYNDROME OF ANGINA:
• Very often (up to 85% of cases) in children, various
overlays appear on the Palatine and nasopharyngeal
tonsils in the form of Islands and stripes; they completely
cover the Palatine tonsils.
• Overlays of a whitish-yellowish or dirty-gray color,
loose, bumpy, rough, easily removed, the tonsillar tissue
after removing the plaque usually does not bleed.
• Overlays are sometimes partially fibrinous, dense, not
completely rubbed between slides.
• Possible and follicular angina, and very rarely-necrotic.
• Overlays on the tonsils may appear in the first days of the
disease, sometimes after 3-4 days.

18. ANGINA IN INFECTIOUS MONONUCLEOSIS
http://diagnoster.ru/wp-content/uploads/2013/02/Infektsionnyiy-mononukleoz-gorlo.jpg
https://s.zakon.kz/Cache/041269/041269868.JPG

19. CLINIC OF INFECTIOUS
MONONUCLEOSIS
HEPATOLIENAL SYNDROME (in 97-98% of
cases):
• The liver begins to grow from the first
days of illness, and its size reaches a
maximum of 4-10 days from the
beginning of the disease. The edge of
the liver becomes dense, sharp, and
slightly painful on palpation.
Sometimes there is a slight jaundice of
the skin and sclera.
• All patients who came under
observation in the first 3 days from the
onset of the disease, it is possible to
palpate the enlarged spleen. The
maximum increase in the spleen is
observed on day 4-10.
http://simptomed.ru/upload/content/infe
kcionniy-mononukleoz-u-detey.jpg

20. Liver cell cytolysis syndrome and disorders of liver pigment
(bilirubin) metabolism
• Increasing alanine aminotransferase, aspartate
aminotransferase.
• Disorder of pigment metabolism of the liver manifested by
jaundice and increased bilirubin

21. CLINIC OF INFECTIOUS
MONONUCLEOSIS
Rash syndrome:
• The rash is spotty-papular, less often
hemorrhagic with localization on the face, trunk,
limbs, more often proximal parts, bright,
abundant, sometimes draining.
• Possible skin itching, swelling of the face.
• Appears on 5-10 days of illness.

22. Rash with mononucleosis
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23. Differential diagnosis
• Adenovirus infection:fever, polyadenopatiya,
enlargement of the spleen and liver, pharyngitis,
tonsillitis.
• Measles: fever, polyadenopatiya, puffy face, rash.
• Cmvi (mononucleosis-like form): Fever,
polyadenopathy, hepatolienal syndrome, increased
activity of liver enzymes, adenoiditis, tonsillitis.
• HIV (mononucleosis-like syndrome): Fever,
polyadenopathy, rash, hepatolienal syndrome.
• Acute tonsillitis: tonsillitis, lymphadenitis.

24. Laboratory research
• CBC: leukopenia / moderate leukocytosis (12-25x109/l);
lymphomonocytosis up to 70-80%; neutropenia; increase in
ESR up to 20-30 mm / h; atypical mononuclears (absence or
increase from 10 to 50%).
• Serological (ELISA with determination of the avidity index):
determination of the avidity index) detection of specific
antibodies IgM VCA to EBV and IgG VCA, IgG EA, IgG-
EBNA to EBV with determination of the avidity index index

25. Additional laboratory tests:
• Molecular genetic method (PCR): detection of Epstein-Barr
virus DNA in the blood.
• Biochemical blood analysis (for hepatomegaly and jaundice):
determination of the concentration of bilirubin and ALAT in the
blood: moderate hyperfermentemia, hyperbilirubinemia.
• Bacteriological examination of mucus from the tonsils and
the back wall of the pharynx for aerobic and optionally
anaerobic microorganisms: to identify the bacterial etiology of
acute tonsillitis.

26. TREATMENT TACTICS AT THE
HOSPITAL LEVEL:
Non-drug treatment :
• Mode: bed rest (during the fever period) semi-flat; patient
hygiene: hygienic care of the mucous membranes of the mouth,
nose toilet.
• Diet: table №13, №5 (with liver damage) fractional warm
drink, dairy plant diet;

27. Principles of therapy at the hospital level
• for the relief of hyperthermic syndrome over 38.5 o C,
paracetamol is prescribed 10-15 mg / kg at intervals of at
least 4 hours, no more than three days through the mouth
or per rectum or ibuprofen at a dose of 5-10 mg/kg no
more than 3 times a day through the mouth;
• infusion therapy is indicated for patients with severe
disease (infusion volume from 30 to 50 ml/kg of body
weight per day) with the inclusion of solutions: 5% or
10% dextrose (10-15 ml / kg), 0.9% sodium chloride (10-
15 ml/kg);

28. • hormone therapy is used for complications such as
encephalitis and thrombocytopenic purpura;
• for convulsions-diazepam 0.5% solution (0.2-0.5 mg/kg) in /
m; or in / in; or rectally;
• antibacterial therapy for purulent tonsillitis of
staphylococcal or streptococcal etiology (Staphylococcus
aureus, Streptococcus pyogenes) - cefuroxime 50-100 mg/kg
per day in / m 2-3 times a day for 5-7 days or Ceftriaxone 50-80
mg/kg per day in / m 1-2 times a day for 5-7 days. NB

29. NB!
In infectious mononucleosis, the following antibiotics are
contraindicated: ampicillin-due to the frequent appearance of a
rash and the development of a drug disease; chloramphenicol, as
well as sulfonamides – due to the oppression of hematopoiesis.

30. • Further management: discharge of patients with
infectious mononucleosis from the hospital is carried out
after the disappearance of clinical symptoms, but earlier
than 7 days from the moment of the disease;
• dispensary observation by a child infectious disease
doctor/GP for 1 year;
• doctor's examination once a quarter to determine the
severity of lymphadenopathy, hepatosplenomegaly, the
presence of atypical mononuclears in the blood and the
concentration of Alat and ASAT.
• compliance with diet №5 (if hepatitis is detected) for 6
months after infectious mononucleosis;
• medical withdrawal from physical education for 3
months;
• recommendations for the patient-limit insolation for 1
year;

31. • reconvalescents who have undergone viral-bacterial
pneumonia-medical examination within 1 year (with control
clinical and laboratory examinations in 3 (mild form), 6
(moderate form) and 12 months (severe form) after the disease;
convalescents who have suffered damage to the nervous system
(meningitis, encephalitis, meningoencephalitis) – at least 2
years, with control clinical laboratory examinations 1 time in 3
months during the first year, then 1 time in 6 months. in
subsequent years.

32. Prevention
• specific prevention measures have not been developed
(there is no vaccine) ;
• General prevention measures are similar to those for SARS;
• compliance with personal hygiene rules;
• non-specific prevention-increasing the overall and
immunological resistance of the body.

33. Sources
• Clinical Protocol of diagnosis and treatment
"Infectious mononucleosis in children", 2017
(Efendiev I. M. with co-authors)
• V. F. Uchaykin, N. I. Nisevich, O. V. Shamsheva.
Infectious diseases in children; textbook-Moscow:
GEOTAR-Media, 2010. – 688 p.: Il.

34. Thank you for
your attention!!!