Plt=45. Her paul brunnel test +ve. What is the most likely dx?
a. Glandular fever
b. ITP
c. Trauma
d. NAI
e. Septicemia
answer: A.... infectious mononucleosis
Definition
• systemic viral infection caused by EBV with
multivisceral involvement; often called “the great
imitator”
Epidemiology
• peak incidence between 15-19 yr old
• ~50% of children in developed countries have a primary
EBV infection by 5 yr old, but <10% of
children develop clinical infection
Etiology
• EBV: a member of herpesviridae
• transmission is mainly through infected saliva
(“kissing disease”) and sexual activity (less
commonly); incubation period of 1-2 mo
Risk Factors
• infectious contacts, sexually active, multiple sexual
partners in the past
History
• prodrome: 2-3 d of malaise, anorexia
• infants and young children: often asymptomatic or mild
disease
• older children and adolescents: malaise, fatigue,
fever, sore throat, abdominal pain (often LUQ),
headache, myalgia
Physical Exam
• classic triad: febrile, generalized non-tender
lymphadenopathy, pharyngitis/tonsillitis (exudative)
• ± hepatosplenomegaly
• ± periorbital edema, ± rash (urticarial, maculopapular,
or petechial) – more common after
inappropriate treatment with β-lactam antibiotics
• any “-itis” (including arthritis, hepatitis, nephritis,
myocarditis, meningitis, encephalitis, etc.)
Investigations
• heterophil antibody test (Monospot® test) (horse rbc) …Paul
bunnel test (sheep rbc)
ƒ 85% sensitive in adults and
older children, but only 50% sensitive if <4 yr of age
ƒ false positive results with HIV,
SLE, lymphoma, rubella, parvovirus
• EBV titers
• CBC and differential, blood smear: atypical
lymphocytes, lymphocytosis, Downey cells ±
anemia ± thrombocytopenia
• throat culture to rule out streptococcal pharyngitis
Management
• supportive: adequate rest, hydration, saline gargles,
and analgesics for sore throat
• splenic enlargement is often not clinically apparent so
all patients should avoid contact sports
for 6-8 wk
• if airway obstruction secondary to nodal and/or tonsillar
enlargement is present (especially
younger children), admit for steroid therapy
• acyclovir does NOT reduce duration of symptoms or
result in earlier return to school/work
Prognosis
• most acute symptoms resolve in 1-2 wk, though fatigue
may last for months
• short-term complications: splenic rupture,
Guillain-Barré syndrome
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