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Mononucleosis

Matthew DeLaney, MD and Solomon Behar, MD
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25:02

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Matt and Sol take us through how to diagnose and manage EBV infection in children and adolescents.

Pearls:

  • Typical symptoms of Epstein Barr virus (EBV) infection are pharyngitis, cervical lymphadenopathy, and fevers in a teenager

  • When testing for EBV,  Monospot is good in older kids, especially after illness has been around >5-7 days. Younger kids don’t make heterophile Ab as often so you should  send EBV titers in this population to make the diagnosis

  • Rash after antibiotic administration is a common side effect in kids with EBV infection, especially if it is ampicillin, less so with PCN’s. It is NOT an allergic reaction

 

  • Mononucleosis is caused by Epstein Barr virus

  • Peak age of incidence is 10-19 years.

  • Symptoms include:

    • sore throat

    • lymphadenopathy (posterior)

    • palatal petechiae

    • tonsillar swelling

    • sometimes splenomegaly (which we are not great at detecting)

    • younger kids may have Fever of Unknown Origin as only presenting symptom

  • EBV is spread through saliva and has a long incubation period (weeks)

  • EBV infection must be differentiated from strep throat, as there are many overlapping symptoms.  Patients can test (+) for both- the question becomes: are you colonized with strep or is it a true infection?

    • Adults have ~30% rate of colonization with strep, while younger children have a lower incidence of ~10%

    • If fevers persist for more than 48 hrs while on antibiotics in  child (+) for both EBV and strep, this probably reflects the body responding to EBV

    •  

  • Testing:

    • Monospot- tests for presence of Heterophile antibody.  It is a good test in older kids, esp after illness has been present for at least 5-7 days .

    • Younger kids don’t make heterophile antibody  as often as older ones. Use EBV titers to make the diagnosis in this age group. EBV VCA IgM is elevated in kids with recent new EBV infection.

    • EBV PCR is a very sensitive test, but values are not standardized.  Therefore it is mostly used in research settings or for screening purposes in those with rare malignancies, or in children s/p transplant  .

    • CBC: shows atypical lymphocytosis, low/normal platelets counts.

    • LDH and transaminases (AST/ALT) can be elevated.

 

  • Complications:

    • Splenomegaly and rupture is a rare complication (0.05-0.1%) but a concern for those in contact sports.

      • Keep out of sports for 3 weeks-1 month

      • Can present with left sided abdominal pain or life-threatening hemorrhagic shock

      • Delaney uses ultrasound to determine absence or presence of splenomegaly in a child who wants to return to sports in less than 1 month   

    • Rash after antibiotic  administration is a common side effect, esp if it is ampicillin (95-100% incidence), less so with PCN’s (~50%)- NOT an allergy!

    • Airways obstruction (the most common cause of pediatric hospitalization in EBV).

    • Rarely, aseptic meningitis or autoimmune hemolytic anemia can occur.

    • EBV plays a role in development of lymphoproliferative disorder in immunosuppressed children or kids with transplants.

  • Treatments:

    • Steroids may help with short term pain at 12 hours, some clinicians will use it in setting of upper airway obstruction .

    • There is no evidence to support longer courses of steroids in EBV infection.

    • Antivirals play no role in the otherwise healthy patient with EBV infection.

David R. -

Hi,
Thanks for covering this interesting topic. However after recently doing a literature search on the rates of strep colonization, I think the rates you cite in this topic are incorrect. Although data seems limited, from everything I read rates of strep colonization in adults is quite low, typically less than 5% (rates of 2-3% seemed most commonly reported). On the other hand, I found rates of colonization in school age children as high as 30% (with rates of 20% most commonly reported). So I don't think you can presume that a positive strep test in an adolescent with mono indicates strep infection. I think there is up to a 30% chance that it is simply demonstrating strep colonization. On the other hand, if you do see an older teenager (>16 yrs) or young adult that tests positive for strep, that is much more likely to indicate true infection and not colonization. This is opposite what was said I understood to be said in this podcast. Here is one study (https://www.ncbi.nlm.nih.gov/pubmed?term=9323783 ) to support the low rates of colonization in adults. Although studies vary somewhat, I didn't find anything to support the rate of 30% colonization in adults that was mentioned in this chapter. Thanks.

Solomon B., MD -

Hi David- I reached out to Dr Delaney and he agreed the colonization rates in adults might be lower when you look at the larger body of literature in adults. As we discussed in the segment, knowing what to do with those who test (+) for strep and EBV is tricky business, with no clear answer on how to manage them. Thank you for your comments and the link to that study!

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The Beautiful Podcast Full episode audio for MD edition 189:42 min - 89 MB - M4AHippo Peds RAP May 2018 Written Summary 385 KB - PDF

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