Case 3

1. How is the virus transmitted? 

EBV is transmitted by close contact with respiratory secretions; it is frequently referred to as "the kissing disease."

2. What is a monospot test and what other laboratory tests may be useful in confirming your preliminary diagnosis? 

The monospot test detects the presence of heterophile antibody (human serum which will agglutinate sheep red blood cells). This is IgM antibody, and appears during the first or second week of illness, persisting for several months. Many conditions can produce heterophile antibodies, but specific absorption studies allow for specificity of the test for infectious mononucleosis (ie the reaction occurs if the serum is absorbed first with guinea pig kidney antigens, but not if the serum is absorbed first with beef red blood cells-other illnesses will be associated with other absorption patterns). The monospot is an insensitive test in young children. Some false-positive reactions may occur in adolescents and adults. If a more specific test is desired, serum can be tested for IgM and IgG antibodies to EBV viral capsid antigen (VCA).

3. What are the long-term consequences of infection? 

Most individuals have no long-term consequences following EBV infection. Many infections in normal hosts are asymptomatic. Immunocompromised patients may develop long-term sequelae. Transplant patients may develop an EBV-associated lymphoproliferative disease. Individuals with X-linked lymphoproliferative syndrome cannot mount a normal immune response to EBV, and EBV infection in these individuals may be fatal. Patients with AIDS may develop several EBV-associated disorders: non-Hodgkin lymphoma, lymphocytic interstitial pneumonitis, and oral "hairy" leukoplakia. Several malignancies have been associated with EBV infection: Burkitt lymphoma, nasopharyngeal carcinoma, and possibly Hodgkin disease. EBV has not been proved to be associated with "chronic fatigue syndrome."

4. Are there any effective anti-viral agents that act against this virus? 

Acyclovir and ganciclovir act on the lytic phase of EBV replication, but not the latent phase, inhibiting EBV DNA polymerase and subsequent viral production. These drugs share no effect on the clinical course of infectious mononucleosis and therefore should not be prescribed for this condition. Acyclovir therapy has been reported to result in regression of oral "hairy" leukoplakia lesions.

5. Is your patient likely to be re-infected? Are family members at risk for infection? What other contacts are likely to be infected? 

Recurrent infection has not been well-documented, if it occurs at all. Family members are at risk of infection if they share oral secretions. Other individuals who may become infected are the patient’s boyfriend, due to sharing the oral secretions during kissing.

6. Why did the patient have a rash after Ampicillin? Should you tell her that she is allergic to the drug?

Ampicillin and other penicillin derivatives frequently are associated with rash when given to patients with infectious mononucleosis. This is a classic association which may provide a clue to the diagnosis. The exact basis for this reaction is unclear, but it is known that it does not represent a hypersensitivity reaction to the drug, which can be safely given to the patient after the infectious mononucleosis illness has resolved.

7. What other pathogens besides EBV can result in an infectious mononucleosis illness?

Cytomegalovirus, Toxoplasma gondii, and acute HIV infection can also cause infectious mononucleosis-type illnesses. Also mention Acute EBV hepatitis followed by the appearance of local and humoral antibody along with an evolving, more durable cellular immunity. Finally, there is repair of tissue damage.