Meningoencephalopathy secondary to infectious mononucleosis. Unusual presentation with stupor and chorea

Pediatric Epstein-Barr virus-associated encephalitis: 10-year review

Many neurologic manifestations of Epstein-Barr virus (EBV) infection have been documented, including encephalitis, aseptic meningitis, transverse myelitis, and Guillain-Barré syndrome. These manifestations can occur alone or coincidentally with the clinical picture of infectious mononucleosis. Since 1994, The Hospital for Sick Children has maintained a prospective registry of all children admitted with acute encephalitis. This report summarizes all cases of Epstein-Barr virus-associated encephalitis compiled from 1994 to 2003. Twenty-one (6%) of 216 children, median age 13 years (range 3-17 years), in the Encephalitis Registry were identified as having evidence of Epstein-Barr virus infection. This evidence consisted of convincing Epstein-Barr virus serology and/or positive cerebrospinal fluid polymerase chain reaction (PCR). One patient had symptoms of classic infectious mononucleosis; all others had a nonspecific prodrome, including fever (n = 17; 81%) and headache (n = 14; 66%). Slightly less than half (n = 10; 48%) had seizures and often had electroencephalograms showing a slow background (n = 12; 57%). Many demonstrated cerebrospinal fluid pleocytosis (n = 17; 81%), and 71% (n = 15) had abnormal magnetic resonance imaging findings. Two patients died, 2 suffered mild deficits, and 16 were neurologically normal at follow-up. Most patients with Epstein-Barr virus encephalitis do not show typical symptoms of infectious mononucleosis. Establishing a diagnosis of Epstein-Barr virus encephalitis can be difficult, and, consequently, a combination of serologic and molecular techniques should be used when investigating a child with acute encephalitis. Most children make full recoveries, but residual neurologic sequelae and even death can and do occur.

Neurologic complications of infectious mononucleosis

A review of the neurologic complications of Epstein-Barr viral (EBV) infections is presented. EBV has been associated with a wide range of acute neurologic diseases in children. Encephalitis, meningitis, cranial nerve palsies, mononeuropathies, and many other neurologic ailments have been described since the confirmation of EBV as the etiology of infectious mononucleosis. It is important to recognize that EBV can cause a myriad of neurologic illnesses with or without the stigmata of infectious mononucleosis.

Epstein-Barr virus genomic sequences and specific antibodies in cerebrospinal fluid in children with neurologic complications of acute and reactivated EBV infections

Four children with infectious mononucleosis (IM) and one with reactivated Epstein-Barr virus (EBV) infection had concomitant central nervous system disorders. Cerebrospinal fluid (CSF) samples from all five patients contained EBV genomic sequences and EBV-specific antibodies in the neurologic stage, but not during convalescence. Cerebrospinal fluid from two non-neurologic IM patients had neither EBV DNA nor EBV antibodies. The EBV-positive CSF of the five with neurological disorders were aseptic in culture and all negative for other human herpesvirus DNAs and antibodies: herpes simplex virus types 1 and 2, cytomegalovirus, varicella-zoster virus, and human herpesvirus 6. Epstein-Barr virus DNA and EBV antibodies were not detected in the CSF of 17 EBV-seropositive patients with mumps meningitis, rubella encephalitis, unknown febrile convulsion, or partial epilepsy. It is suggested that EBV plays a causal role in neurologic manifestations in patients with acute and reactivated EBV infections, through direct viral invasion and immunopathological reactions.

Infectious mononucleosis encephalitis. Possible therapeutic response to vidarabine

A comatose patient with seizures and focal neurological signs was given vidarabine because herpes simplex encephalitis was a likely diagnosis. Investigations showed that the illness was due to infectious mononucleosis. Although recovery is usual in infectious mononucleosis encephalitis, the complete clinical and neuropsychological recovery documented in this severe case raises the possibility that vidarabine may have exerted a therapeutic effect.

Periodic EEG complexes in infectious mononucleosis encephalitis

The presence of periodic EEG complexes in patients with an acute viral encephalitis is generally held to suggest that infection is due to herpes simplex. We now report a patient with clinical and laboratory findings of infectious mononucleosis, and neurologic involvement manifested by lymphocyte meningitis, coma, seizures, aphasia, hemiparesis and hemianopsia. Serial EEGs showed periodic, predominantly left-sided slow wave complexes occurring every 4 to 5 seconds, which disappeared with clinical resolution of the illness. In view of our findings and the similar findings reported previously by others in another case of infectious mononucleosis encephalitis, an EEG showing periodic complexes in the clinical setting of acute viral encephalitis should not be considered pathognomonic of herpes encephalitis, and infectious mononucleosis should be included in the differential diagnosis.

Head Trauma in Football Players with Infectious Mononucleosis

Are football players who have infectious mononucleosis more susceptible to cerebral disorders from minor head trauma? The authors discuss three case reports.

Bilateral sixth cranial nerve palsy in infectious mononucleosis

A 15-year-old girl who presented with a bilateral sixth nerve palsy caused by infectious mononucleosis is described. The neurological presentation of infectious mononucleosis is discussed.