Case Reports

The Changing Epidemiology of Infectious Mononucleosis?

The use of systemic corticosteroids during Epstein-Barr virus (EBV)-induced infectious mononucleosis is a controversial but widespread practice. We aimed to investigate the frequency of complications in adolescents and adults with infectious mononucleosis in relation to the use of corticosteroids.

We reviewed the clinical records of 396 patients admitted to the hospital with infectious mononucleosis (52.0% male; median age, 19 years; range, 15–87 years), with a focus on both short-term (infectious and non-infectious) and long-term (hematological malignancies) complications in relation to corticosteroid use.

A total of 155 (38.6%) patients received corticosteroids at some point during infectious mononucleosis. Corticosteroid use was significantly (P ≤ 0.002) associated with sore throat, lymphadenopathy, leukocytosis, and with antibiotics use (mainly indicated after suspicion of tonsillar bacterial superinfection). Overall, 139/155 (89.7%) patients who were treated with corticosteroids also received antibiotics either before or during hospitalization, compared with 168/241 (69.7%) patients who did not. The frequency of short-term severe complications, either infectious (peritonsillar–parapharyngeal abscess or bacteremia) or non-infectious (splenic rupture, severe thrombocytopenia, myopericarditis, or lymphocytic meningitis) were similar in patients receiving and not receiving corticosteroids. After a median of 15 years of follow-up, only one Hodgkin's lymphoma was diagnosed, in a patient who was not treated with corticosteroids during infectious mononucleosis.

The use of systemic corticosteroids during EBV-induced infectious mononucleosis is generally safe, at least with concomitant antibiotic therapy. However, this should not encourage the use of corticosteroids in this context, given that their efficacy has yet to be demonstrated.

El uso de corticoides durante la mononucleosis infecciosa es una práctica controvertida, pero habitual. El objetivo del estudio fue investigar la frecuencia de complicaciones del empleo de corticoides en adolescentes y adultos con mononucleosis.

Se revisaron las historias de 396 pacientes ingresados en el hospital por mononucleosis (52,0% varones; edad 15-87 años), las complicaciones a corto plazo (infecciosas y no infecciosas) y a largo plazo (neoplasias hematológicas) y su posible relación con el uso de corticoides.

Un total de 155 (38,6%) pacientes recibieron corticoides en algún momento de la enfermedad. El uso de corticoides se asoció (p ≤ 0,002) con la presencia de odinofagia, adenopatías, leucocitosis y con el empleo de antibióticos por sospecha de sobreinfección bacteriana. En conjunto, 139/155 (89,7%) pacientes tratados con corticoides recibieron también antibióticos antes o durante el ingreso, comparado con 168/241 (69,7%) pacientes que no fueron tratados con corticoides. La frecuencia de complicaciones graves a corto plazo, fueran infecciosas (absceso periamigdalino/parafaríngeo o bacteriemia) o no infecciosas (rotura esplénica, trombopenia grave, miopericarditis o meningitis linfocitaria) fue similar en los pacientes que recibieron corticoides y en los que no los recibieron. Tras una mediana de 15 años solo se diagnosticó un linfoma de Hodgkin en un paciente no tratado con corticoides durante la mononucleosis.

El uso de corticoides sistémicos durante la mononucleosis infecciosa es seguro, al menos con el uso concomitante de antibióticos. Sin embargo, esto no debe ser una justificación para su uso en la mononucleosis, pues su eficacia está por demostrar.

Epstein-Barr virus (EBV) infects about 90% of adults worldwide. It is the main cause of infectious mononucleosis, which is observed most frequently in adolescents. The disease can last several weeks and is characterized by lymphocytosis, sore throat, lymphadenopathy, and fatigue. Exposure to oral secretions during deep kissing has been identified as the major source for primary EBV infection in adolescents. Oral secretions are also thought to be the source for younger children through intimate intact or sharing food and eating utensils, although this has not been confirmed. Unlike most acute viral illnesses such as influenza, the incubation period of symptomatic primary EBV infection is unusually long, lasting about six weeks. Diagnosis is typically made by heterophile antibody tests and/or EBV-specific antibody tests. Long-term consequences may result from acquisition of the virus, including nasopharyngeal carcinoma and lymphomas. Nevertheless, there remains a surprising dearth of knowledge regarding the establishment of an immune response to persistent EBV infection, especially during the incubation period. This lack of knowledge has impaired our ability to develop an effective prophylactic EBV vaccine, despite various attempts. Our greatest challenges in EBV research are to develop a prophylactic vaccine and devise treatment strategies for persons already infected with EBV.

Pharyngitis is a common disease in the emergency department (ED). Despite a relatively low incidence of complications, there are many dangerous conditions that can mimic this disease and are essential for the emergency physician to consider.

This article provides a review of the evaluation and management of group A β-hemolytic Streptococcal (GABHS) pharyngitis, as well as important medical conditions that can mimic this disease.

GABHS pharyngitis often presents with fever, sore throat, tonsillar exudates, and anterior cervical lymphadenopathy. History and physical examination are insufficient for the diagnosis. The Centor criteria or McIsaac score can help risk stratify patients for subsequent testing or treatment. Antibiotics may reduce symptom duration and suppurative complications, but the effect is small. Rheumatic fever is uncommon in developed countries, and shared decision making is recommended if antibiotics are used for this indication. Oral analgesics and topical anesthetics are important for symptom management. Physicians should consider alternate diagnoses that may mimic GABHS pharyngitis, which can include epiglottitis, infectious mononucleosis, Kawasaki disease, acute retroviral syndrome, Lemierre's syndrome, Ludwig's angina, peritonsillar abscess, retropharyngeal abscess, and viral pharyngitis. A focused history and physical examination can help differentiate these conditions.

GABHS may present similarly to other benign and potentially deadly diseases. Diagnosis and treatment of pharyngitis should be based on clinical evaluation. Consideration of pharyngitis mimics is important in the evaluation and management of ED patients.

To determine the risk factors for severe infectious mononucleosis (IM) occurrence in immunocompetent adults.

We performed a multicenter, retrospective case series including immunocompetent adults presenting with confirmed IM between 2001 and 2011. Severe presentations were compared with uncomplicated presentations using Stata^® 9 software. The significance level was set at 5%.

In univariate analysis, age over 30 years (n = 13 or 41.9% vs. n = 5 or 12.8%; P = 0.006), prior use of non-steroidal anti-inflammatory drugs (NSAIDs) (n = 7 or 87.5% vs. n = 1 or 12.5%; P = 0.009), and smoking (n = 13 or 68.4% vs. n = 6 or 31.6%; P = 0.013) were associated with severe IM onset. In multivariate analysis, only age over 30 years (OR = 3.55; P = 0.05) and prior use of NSAIDs (OR = 15; P = 0.05) remained associated with severe IM onset, without reaching significance level (P = 0.05).

Our study confirmed that age over 30 years is a risk factor for severe IM onset. Prior use of NSAIDs also seems to be correlated with severe presentations. This new data needs to be confirmed in a prospective study.

L’objectif de notre étude était de déterminer les facteurs de risque de survenue de mononucléose infectieuse (MNI) grave chez l’immunocompétent.

Étude rétrospective cas-témoins multicentrique incluant les adultes immunocompétents ayant présenté une MNI prouvée par sérologie entre 2001 et 2011. Les formes graves ont été comparées aux formes simples à l’aide du logiciel Stata^® version 9. Le seuil de significativité a été fixé à 5 %.

En analyse univariée, l’âge supérieur à 30 ans (n = 13, soit 41,9 % vs. n = 5, soit 12,8 % ; p = 0,006), la prise d’anti-inflammatoires non stéroïdiens (AINS) (n = 7, soit 87,5 % vs. n = 1, soit 12,5 % ; p = 0,009) et le tabagisme (n = 13, soit 68,4 % vs. n = 6, soit 31,6 % ; p = 0,013) étaient des facteurs associés à la survenue d’une MNI grave. En analyse multivariée, seuls l’âge supérieur à 30 ans (OR = 3,55 ; p = 0,05) et la prise initiale d’AINS (OR = 15 ; p = 0,05) restaient associés à la survenue d’une MNI grave, avec des résultats à la limite de la significativité.

Cette étude souligne, à l’instar des données de la littérature, que l’âge supérieur à 30 ans est un facteur de risque de survenue de MNI grave. La prise initiale d’AINS semble être également associée aux formes graves, donnée inédite méritant d’être confirmée par une étude prospective.

Infectious encephalitis is a relatively common cause of morbidity and mortality. Treatment of infectious encephalitis with antiviral medication can be highly effective when administered promptly. Clinical mimics of encephalitis arise from a broad range of pathologic processes, including toxic, metabolic, neoplastic, autoimmune, and cardiovascular etiologies. These mimics need to be rapidly differentiated from infectious encephalitis to appropriately manage the correct etiology; however, the many overlapping signs of these various entities present a challenge to accurate diagnosis. A systematic approach that considers both the clinical manifestations and the imaging findings of infectious encephalitis and its mimics can contribute to more accurate and timely diagnosis.

Following an institutional review board approval, a health insurance portability and accountability act (HIPAA)-compliant search of our institutional imaging database (teaching files) was conducted to generate a list of adult and pediatric patients who presented between January 1, 1995 and October 10, 2013 for imaging to evaluate possible cases of encephalitis. Pertinent medical records, including clinical notes as well as surgical and pathology reports, were reviewed and correlated with imaging findings. Clinical and imaging findings were combined to generate useful flowcharts designed to assist in distinguishing infectious encephalitis from its mimics. Key imaging features were reviewed and were placed in the context of the provided flowcharts.

Four flowcharts were presented based on the primary anatomic site of imaging abnormality: group 1: temporal lobe; group 2: cerebral cortex; group 3: deep gray matter; and group 4: white matter. An approach that combines features on clinical presentation was then detailed. Imaging examples were used to demonstrate similarities and key differences.

Early recognition of infectious encephalitis is critical, but can be quite complex due to diverse pathologies and overlapping features. Synthesis of both the clinical and imaging features of infectious encephalitis and its mimics is critical to a timely and accurate diagnosis. The use of the flowcharts presented in this article can further enable both clinicians and radiologists to more confidently differentiate encephalitis from its mimics and improve patient care.

Primary Epstein-Barr virus infection (PEI) is acquired increasingly later in life in developed countries, involving a growing number of adults. No studies have examined the effect of age on PEI. We conducted a prospective, single-centre, noninterventional survey to assess the clinical and economic effects of PEI care according to age. We included all serology-confirmed cases observed in all departments of a large regional hospital. Clinical and biologic data, therapeutics and costs of care were examined. Over a 6-year period, we included 292 subjects (148 children and 144 adults) with a median age of 15.4 years (range 9 months to 79 years). Adults were hospitalized more often (83% vs. 60%) and for longer periods of time (median 4 days vs. 2 days) than children (p ≤ 0.0001 for both). Two adults required a secondary transfer into the intensive care unit, although no children did. Typically, adults showed higher levels of activated lymphocytes and liver abnormalities. They also required the use of systemic corticosteroids more often (45% vs. 23%, p < 0.0001) and for longer periods of time (median 7 days vs. 3 days, p 0.02) than children. Overall, the costs were significantly higher for adults than for children (median, €1940 vs. €1130, p < 0.0001), mainly because of the frequency and duration of hospitalizations. Age increases the immune response and clinical severity of PEI, resulting in substantial additional costs for the community. Better recognition of the disease in adults could shorten the average length of hospital stay.