1. Infectious Mononucleosis Mary Ann Hudson, RN The Ohio State University College of Nursing

2. Overview of presentation Presentation of patient where infectious mononucleosis is part of differential An establishment of a few clinical pearls that assist the practitioner when infectious mono has entered the differential Epidemiology, patho, pediatric differential Dx (including labs), research, clinical Tx guidelines Dx of our mystery patient

3. 14-year-old Female 4 day Hx sore throat, extreme fatigue, headache, loss of appetite, fever, N/V Exam revealed cervical lymphadenopathy and tenderness, pharyngeal inflammation and erythema, fever (101 F), mild left-sided tenderness, nasal congestion, and otitis serous. Patient and caregiver reported no previous Hx of mononucleosis. Negative rapid Strep A.

4. Exudative pharyngitis

5. Cervical lymphadenopathy

6. Epidemiology Epstein-Barr infectious mononucleosis is caused by the Epstein-Barr virus, one type of herpes virus to which 90% of adults have been exposed. In developing countries, most of the population is exposed in early childhood. In developed countries, most of the population is exposed during adolescence. It is characterized by fever, sore throat, and fatigue.

7. Epidemiology—First World Consideration

8. Prognosis and Natural Hx 4-6 incubation period to appearance of Sx 2-7 week period of Sx, infectious at anytime from introduction of virus, and some remain viral reservoirs for life. Reemergence from dormancy with Sx is possible. Less than 5% of patients experience complications leading to mortality and morbidity. Lymphomas and carcinomas d/t EBV initiated changes on the lymphocytes are are in the United States.

9. Burkitt’s Lymphoma--EBV

10. Pathophysiology

12. Differential—14 y.o. Female EBV – Fever, malaise, pharyngitis, +N/V, cervical lymphadenopathy, left-sided tenderness, reports no Hx of IM – HOWEVER, progressive and additive Sx over 4 days, non-exudative pharyngitis, nasal congestion, otitis serous, lymphadenopathy limited to cervical chain, palpation of left-sided tenderness may be non-sensitive.

13. Differential—14 y.o. Female Strep A Pharyngitis – Inflammatory and painful pharyngitis, fever, cervical lymphadenopathy, possible exposure from younger siblings. – HOWEVER, nasal congestion, otitis serous, and negative rapid strep A

14. Differential—14 y.o. Female Adenovirus infection – Pharyngitis, nasal congestion, cervical lymphadenopathy, fever, progressive symptomology, +N/V (adenovirus), otitis serous, negative rapid strep A. – HOWEVER, left-sided tenderness, extreme fatigue, report of negative EBV Hx.

15. General Differential Group A Strep Adenovirus Cytomegalovirus (few clinical correlates, serology r/o) HIV (clinically and historically correlate) Viral Hepatitis A, B, C (clinically correlate with hepatomegaly, jaundice, Hx) Leukemia, Lymphomas (will r/o with CBC)

16. Laboratory Orders CBC with differential Liver Enzymes Mononucleosis Rapid Slide Agglutination Test (MonoSpot. Detects 90% of cases in teens and adults by identifying heterophile antibodies) EBC Serology detects past and present EBV infection Optional: CMV serology, HIV serology, Hepatitis panel serology

17. Laboratory Results CBC will show leukocyte count up to 20,000/mm3 and >10% atypical (Downey’s) lymphocytes. If this is result and clinically correlates to patient Sx, this is early positive IM result. Serology should confirm CBC. If not, may need to add differentials.

18. Laboratory Results—14 y.o. Female CBC WDL EBV Serology revealed previous, but not current EBV infection Dx—Adenovirus. Clinically correlates with symptomology as adenovirus accounts for all UR and GI symptoms. Remember that left-sided tenderness can be non-sensitive and that patient had GI Sx.

19. Infectious Mononucleosis Treatment Acetaminophen or Ibuprofen for fever reduction and analgesia Prednisone 1mg/kg divided into 2 doses BID for severe lymphatic inflammation

20. Our 14 y.o. Female Adenovirus is also self-limiting and requires self-care that supports the symptomology (fluids, rest, analgesics or NSAIDs) Patient presented in the context of IM because she was an excellent example of correct differential for her age and symptoms and importance of understanding and ruling out IM. Her exposure to IM is an important part of her medical Hx.

21. Complications of IM Meningitis, Guillain-Barre, transverse myelitis Ctyo and thrombo penias Jaundice UA restriction Myocarditis Splenic rupture (surgical emergency and a point of education for families)

22. Splenic Rupture Sudden, acute, exquisite left-sided pain, LOC, rigid abdomen. Avoid contact activities during all phases of IM.

23. Research—Safe Return to Play After Infectious Mononucleosis Waninger, K.,, & Harcke, H. (2005). Determination of safe return to play for athletes recovering from infectious mononucleosis: a review of the literature. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine, 15(6), 410-6. Important clinical consideration!

24. Research—Sensitivity of CBC as initial IM diagnostic tool Lennon, P., O' Neill, J., Fenton, J.,, & O' Dwyer, T. (2010). Challenging the use of the lymphocyte to white cell count ratio in the diagnosis of infectious mononucleosis by analysis of a large cohort of Monospot test results. Clinical otolaryngology : official journal of ENT-UK ; official journal of Netherlands Society for Oto- Rhino-Laryngology & Cervico-Facial Surgery, 35(5), 397-401. doi:10.1111/j.1749- 4486.2010.02187.x

25. Research—Adenovirus vs IM Mel, ón, S., M, éndez, S., Iglesias, B., Boga. (2005). Involvement of adenovirus in clinical mononucleosis-like syndromes in young children. European Journal of Clinical Microbiology & Infectious Diseases, 24(5), 314-8. doi:10.1007/s10096-005-1333-7 Good overview of why labs are important and establish medical history (important in future differentials of EBV complications).

26. American Family Physician Clinical Guidelines for the Management of Infectious Mononucleosis Complete guidelines include a grade B for clinical findings that include generalized lymphadenopathy, fatigue, and exudative pharyngitis. Grade Cs are given for CBC correlation, use of prednisone, and avoidance of contact sports until patient is completely asymptomatic Guidelines include complete EBV serology, other serologies as clinically indicated, and Strep A rapid testing. Symptomatic and supportive treatment of symptoms including rest, fluids, and monitoring are also recommended.

27. Complete AFP Guidelines Available via Free PDF http://www.aafp.org/afp/2004/1001 /p1279.pdf http://www.aafp.org/afp/2004/1001 /p1279.pdf

28. 14 y.o. Female—Critique of Care This patient received a complete physical that included IM in the differential. The patient was swabbed for Strep A and it was a negative rapid strep. The patient was sent for lab work that included a CBC and complete EBV serology. Lab results were correlated with clinical picture. This patient’s management was an exemplar case according to AFP clinical guidelines.