[Epstein-Barr virus and cytomegalovirus primary infections: a comparative study in 52 immunocompetent adults]

Challenges of Primary Care Medicine in a Tertiary Care Setting—The Case of Primary CMV Infection Compared to Primary EBV Infection: A Retrospective Cohort Study

Background

In the immunocompetent adult primary cytomegalovirus (CMV) infection may present as prolonged febrile illness or may resemble infectious mononucleosis. Hence, establishing a diagnosis of primary CMV infection may be challenging, in particular in the hospital setting.

Methods

We performed a retrospective analysis of all immunocompetent patients treated at a tertiary care center in Switzerland over a 5-year period in whom a diagnosis of primary CMV infection was established. We assessed their demographic, clinical, and laboratory characteristics and compared them to patients with a diagnosis of primary Epstein-Barr virus (EBV) infection during the same period.

Results

We identified 16 and 125 patients with primary CMV and EBV infection, respectively (rates of 3.1 and 23.8 cases/year, respectively). Patients in the CMV group were older (median 34 vs. 22 years), had a longer illness duration before presentation (median 14 vs. 7 days) and more frequently systemic symptoms compared to patients in the EBV group. Increased lymphocyte count and presence of atypical lymphocytes were observed in both groups, yet less frequently and less pronounced in the CMV group. The overall number of performed tests (including laboratory and radiology tests) was significantly higher in the CMV group (median 11.5 vs. 3.0) before arriving at the final diagnosis. Antibiotic treatment was more frequently prescribed in patients with primary EBV infections (40 vs. 25%).

Conclusions

Given its low incidence and non-specific symptoms, establishing a diagnosis of primary CMV infection can be challenging. Knowledge about clinical features of primary CMV infection in the immunocompetent host might help to adopt a stepwise approach to diagnosis avoiding over-testing.

Clinical differentiation of infectious mononucleosis that is caused by Epstein-Barr virus or cytomegalovirus: A single-center case-control study in Japan

Introduction

Infectious mononucleosis (IM) is a common viral infection that typically causes fever, pharyngitis, and lymphadenopathy in young patients. The Epstein-Barr virus (EBV) is the most common cause of IM, followed by cytomegalovirus (CMV). Given that serological testing is associated with limitations regarding its accuracy, availability, and time to receive results, clinical differentiation based on symptoms, signs, and basic tests would be useful. We evaluated whether clinical findings could be used to differentiate EBV-IM from CMV-IM.

Methods

In this single-center retrospective case-control study, we evaluated >14-year-old patients with serologically confirmed EBV-IM or CMV-IM during 2006–2017. We compared the patients’ symptoms, physical findings, blood counts, and serum biomarkers to create three regression models: model 1 (symptoms and signs), model 2 (model 1 plus sonographic hepatosplenomegaly and blood counts), and model 3 (model 2 plus hepatobiliary biomarkers).

Results

Among the 122 patients (72.6%) with EBV-IM and 46 patients (27.4%) with CMV-IM, the median age was 25 years and 82 patients (48.8%) were male. The median age was 10 years older in the CMV-IM group (p < 0.001) and the median interval from onset to visit was 5 days longer in the CMV-IM group (p < 0.001). Logistic regression revealed that EBV-IM was predicted by younger age, short onset-to-visit interval, lymphadenopathy, tonsillar white coat, hepatosplenomegaly, atypical lymphocytosis, and elevations of lactate dehydrogenase and gamma-glutamyl transferase. All regression models had areas under the curve of >0.9.

Conclusion

History and physical findings, especially when used with atypical lymphocytosis and sonographic hepatosplenomegaly, can help physicians differentiate EBV-IM from CMV-IM.

Severe infectious mononucleosis in immunocompetent adults

OBJECTIVES

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

METHODS

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%.

RESULTS

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).

CONCLUSION

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.

[Cytomegalovirus ileitis in a non-immunocompromised old patient: a case report]

INTRODUCTION

Cytomegalovirus ileitis occurs rarely in immunocompetent subjects.

CASE REPORT

An 88-year-old woman presented with severe pain located in right iliac fossa. Biological tests showed an increase in C-reactive protein and neutrophils. Colonoscopy revealed a severely ulcerated and inflamed terminal ileal mucosa. Histopathological analysis of biopsies showed a typical cytopathic effect with ballooned cells and intranuclear inclusions, confirmed by positive immunological marking with anti-cytomegalovirus antibodies. Cytomegalovirus polymerase chain reaction in the plasma showed positive activity. The patient was successfully treated with valganciclovir.

CONCLUSION

The predominant or isolated ileal location of cytomegalovirus infection should be known, especially in the elderly because aging could be a risk factor.

Infectious mononucleosis-like syndrome probably attributable to Coxsackie A virus infection

Infectious mononucleosis (IM) is a clinical syndrome most often attributable to Epstein-Barr virus (EBV). Characteristic clinical features of EBV IM include bilateral upper lid edema, exudative or nonexudative pharyngitis, bilateral posterior cervical adenopathy, and splenomegaly ± maculopapular rash. Laboratory features of EBV IM include atypical lymphocytes and elevated levels of serum transaminases. Leukopenia and thrombocytopenia are not uncommon. The syndrome of IM may also be attributable to other infectious diseases, eg, cytomegalovirus (CMV), human herpes virus-6 (HHV-6), or Toxoplasma gondii. Less commonly, viral hepatitis, leptospirosis, brucellosis, or parvovirus B(19) may present as an IM-like infection. To the best of our knowledge, only 2 cases of IM-like infections attributable to Coxsackie B viruses (B(3) and B(4)) have been reported. We present the first reported case of an IM-like syndrome with sore throat, fatigue, atypical lymphocytes, and elevated levels of serum transaminases likely due to Coxsackie A in an immunocompetent adult.