Infectious Mononucleosis: diagnosis and clinical interpretation

Active EBV infection in children: associations between DNA load, infection status, immune status, and disease severity

BACKGROUND

This study investigated active Epstein-Barr virus (EBV) infection in children and examined the associations among EBV deoxyribonucleic acid (DNA) load, infection types, disease severity, and immune characteristics.

METHODS

A total of 35,956 pediatric patients who underwent EBV DNA load testing were included. Patients were categorized based on their EBV DNA levels and infection status.

RESULTS

Spearman's rank correlation analysis revealed a positive association between EBV DNA levels and the mortality rate, as well as the incidence rates of acute kidney injury (AKI), respiratory failure, cardiovascular complications, coagulation abnormalities, and liver injury. Mortality risk significantly increased when EBV DNA exceeded 1 × 105 copies/mL (adjusted odds ratio: 10.53, 95% confidence interval: 2.38-46.59, P < 0.05). As EBV DNA levels increase, the rise in mortality rate during activation- immunoglobulin G (IgG+) was more pronounced than that observed during primary infections. Gaussian mixture model clustering identified two immune clusters. Cluster 0 exhibited elevated pro-inflammatory indicators (IFN-γ, IL-6) and anti-inflammatory indicator (IL-10) levels, along with reduced immune cell counts. This cluster showed higher activation-IgG+ and mortality rates compared with Cluster 1.

CONCLUSIONS

An elevated EBV DNA load (> 1 × 105 copies/mL) in children is associated with increased mortality risk. High pro-inflammatory and anti-inflammatory states, coupled with low immune cell numbers, indicate critical condition. Simultaneous examinations of EBV DNA, antibodies, and immune status are recommended, especially for children with EBV DNA > 1 × 105 copies/mL, emphasizing the need for caution in those with activation-IgG+ and immune dysregulation.

A rare case report of splenic infarction in a previously healthy teenager caused by acute infectious mononucleosis

RATIONALE

Splenic infarction usually occurs in patients with underlying illnesses such as thromboembolic disorders and infiltrative hematologic diseases. Herein, we report a rare case of splenic infarction in a previously healthy boy diagnosed with infectious mononucleosis (IM). Splenic infarction is a rare complication of IM and its incidence is unknown. This case report summarizes the clinical characteristics, treatment options, and anticipated time for recovery from splenic infarction in IM.

PATIENT CONCERN

A16-year-old boy presented to our clinic with complaints of fever, sore throat, and general sweakness for 7 days. The patient was diagnosed with IM due to an Epstein-Barr virus infection. Two days later, the patient developed severe abdominal pain in the left upper quadrant and returned to our ER for further evaluation.

DIAGNOSIS

IM complicated with splenic infarction.

INTERVENTIONS

Contrast-enhanced CT confirmed the diagnosis of splenic infarction. This patient was admitted for supportive treatment and close medical monitoring. Surgical.

OUTCOMES

The patient recovered well with conservative treatment.

LESSONS

IM is most often seen in adolescents and young adults. Splenic infarction is a rare complication of IM, particularly in patients who do not usually have any underlying predisposing medical conditions. Contrast-enhanced CT is the imaging modality of choice in suspected cases. Early recognition and treatment of splenic infarction in patients with IM can help prevent potentially life-threatening events. Patients should be advised to avoid sports that may precipitate splenic rupture. However it is still unknown when it is safe for patients to resume sports. In our case, 6 weeks after the splenic infarction, the patient generally felt well with complete resolution of objective symptoms and splenomegaly, and resumed sports without experiencing any adverse events.

Infectious mononucleosis: new concepts in clinical presentation, epidemiology, and host response

PURPOSE OF REVIEW

Infectious mononucleosis (IM) is an infectious disease that presents clinically in only a small percentage of individuals despite almost universal infection with the causative agent. Here, we review the latest concepts in the clinical presentation, epidemiology, and host response of this disease.

RECENT FINDINGS

Several recently published papers/reviews describe IM as a condition caused by one of several etiologic agents including, cytomegalovirus (HHV-5), Roseola virus (HHV-6) and Toxoplasmosis amongst others; this review focuses on IM as solely caused by the human herpes virus 4 (HHV-4). Since the initial discovery of the virus in the 1960s and its subsequent discovery as the primary etiologic agent for IM it has been associated with several human cancers and autoimmune disorders. Recent published findings show a correlation between HHV-4 and the autoimmune disorder, multiple sclerosis (MS), suggesting earlier IM could possibly act as a causative factor. Considering the important links being made with IM to so many cancers and autoimmune disorders it is surprising that a standard investigative procedure has yet to be determined for this disease. A standard approach to the investigation of IM would ensure more cases are diagnosed, particularly atypical cases, this would benefit epidemiological studies, and more immediately help practitioners distinguish viral from bacterial throat infections, enabling them to treat accordingly.

SUMMARY

The understanding of the latest concepts in clinical presentation, epidemiology and host response to IM would benefit greatly from the introduction of a standard procedure for its investigation and diagnosis.

Clinical analysis of infectious mononucleosis complicated with acute acalculous cholecystitis

Objective

This study aimed to investigate specific clinical diagnostic methods for children with infectious mononucleosis (IM) complicated by acute acalculous cholecystitis (AAC).

Methods

We conducted a retrospective analysis of 171 cases of IM diagnosed in the infectious disease ward of Children's Hospital of Nanjing Medical University between January 2020 and December 2020. All IM patients underwent abdominal ultrasound examinations to assess the liver, gallbladder, and spleen. Fourteen patients with symptoms of AAC underwent a follow-up assessment one week later.

Results

The estimated incidence of AAC in hospitalized IM children was 8.2%. Both groups of patients presented with fever, abdominal pain, and eyelid edema upon admission. Characteristic radiological findings of AAC were observed, including gallbladder (GB) distention, increased GB wall thickness and increased common bile duct diameter. Analysis of laboratory results revealed no statistically significant differences in leukocyte, absolute lymphocyte count, CD3+, CD3 + CD4+, CD3+ CD8+, Aspartate Aminotransferase (AST), Alanine Aminotransferase (ALT), or Gamma-Glutamyl Transferase (GGT) levels between the AAC(+) and AAC(-) groups on admission. However, these parameters were not significant risk factors for AAC. After discharge, relevant indicators in non-AAC patients gradually decreased to normal levels, while those in AAC(+) patients did not show a significant decrease.

Conclusion

While cases of IM complicated by AAC are relatively uncommon, the utilization of abdominal ultrasound offers a reliable tool for confirming this diagnosis. Routine abdominal ultrasound examinations are recommended for IM patients to improve early detection and treatment of associated conditions.

Insights into the interplay between Epstein-Barr virus (EBV) and multiple sclerosis (MS): A state-of-the-art review and implications for vaccine development

Background and Aims

Multiple sclerosis (MS) is a chronic autoimmune disease of the central nervous system (CNS). MS results from an inflammatory process leading to the loss of neural tissue and increased disability over time. The role of Epstein Barr Virus (EBV), as one of the most common global viruses, in MS development has been the subject of several studies. However, many related questions are still unanswered. This study aimed to review the connection between MS and EBV and provide a quick outline of MS prevention using EBV vaccination.

Methods

For this narrative review, an extensive literature search using specific terms was conducted across online databases, including PubMed/Medline, Scopus, Web of Science, and Google Scholar, to identify pertinent studies.

Results

Several studies proved that almost 100% of people with MS showed a history of EBV infection, and there was an association between high titers of EBV antibodies and an increased risk of MS development. Various hypotheses are proposed for how EBV may contribute to MS directly and indirectly: (1) Molecular Mimicry, (2) Mistaken Self, (3) Bystander Damage, and (4) Autoreactive B cells infected with EBV.

Conclusion

Given the infectious nature of EBV and its ability to elude the immune system, EBV emerges as a strong candidate for being the underlying cause of MS. The development of an EBV vaccine holds promise for preventing MS; however, overcoming the challenge of creating a safe and efficacious vaccine presents a significant obstacle.

Virus infection participates in the occurrence and development of human diseases through monoamine oxidase

Monoamine oxidase (MAO) is a membrane-bound mitochondrial enzyme that maintains the steady state of neurotransmitters and other biogenic amines in biological systems through catalytic oxidation and deamination. MAO dysfunction is closely related to human neurological and psychiatric diseases and cancers. However, little is known about the relationship between MAO and viral infections in humans. This review summarises current research on how viral infections participate in the occurrence and development of human diseases through MAO. The viruses discussed in this review include hepatitis C virus, dengue virus, severe acute respiratory syndrome coronavirus 2, human immunodeficiency virus, Japanese encephalitis virus, Epstein-Barr virus, and human papillomavirus. This review also describes the effects of MAO inhibitors such as phenelzine, clorgyline, selegiline, M-30, and isatin on viral infectious diseases. This information will not only help us to better understand the role of MAO in the pathogenesis of viruses but will also provide new insights into the treatment and diagnosis of these viral diseases.

Autoimmune Heart Disease: A Comprehensive Summary for Forensic Practice

Autoimmune heart disease is a non-random condition characterised by immune system-mediated aggression against cardiac tissue. Cardiac changes often exhibit nonspecific features and, if unrecognised, can result in fatal outcomes even among seemingly healthy young individuals. In the absence of reliable medical history, the primary challenge lies in differentiating between the various cardiopathies. Numerous immunohistochemical and genetic studies have endeavoured to characterise distinct types of cardiopathies, facilitating their differentiation during autopsy examinations. However, the presence of a standardised protocol that forensic pathologists can employ to guide their investigations would be beneficial. Hence, this summary aims to present the spectrum of autoimmune cardiopathies, including emerging insights such as SARS-CoV-2-induced cardiopathies, and proposes the utilisation of practical tools, such as blood markers, to aid forensic pathologists in their routine practice.

EBV and Lymphomagenesis

The clinical significance of Epstein–Barr virus (EBV) cannot be understated. Not only does it infect approximately 90% of the world’s population, but it is also associated with numerous pathologies. Diseases linked to this virus include hematologic malignancies such as diffuse large B-cell lymphoma, Hodgkin lymphoma, Burkitt lymphoma, primary CNS lymphoma, and NK/T-cell lymphoma, epithelial malignancies such as nasopharyngeal carcinoma and gastric cancer, autoimmune diseases such as multiple sclerosis, Graves’ disease, and lupus. While treatment for these disease states is ever evolving, much work remains to more fully elucidate the relationship between EBV, its associated disease states, and their treatments. This paper begins with an overview of EBV latency and latency-associated proteins. It will then review EBV’s contributions to select hematologic malignancies with a focus on the contribution of latent proteins as well as their associated management.

Diagnostic Value of Whole-Blood and Plasma Samples in Epstein-Barr Virus Infections

Epstein-Barr virus (EBV) is an oncogenic virus classified by the World Health Organization as a class 1 carcinogen. Post-transplant lymphoproliferative disorders are believed to be strongly related to an EBV infection. Monitoring of EBV DNAemia is recommended to assess the risk of reactivation of latent infection and to assess the effectiveness of therapy. Currently, various types of clinical specimens are used for this purpose. The aim of the study was to assess a reliable method of EBV viral load investigation depending on the clinical material used: whole blood or plasma samples. We found that of 134 EBV-DNA-positive whole-blood samples derived from 51 patients (mostly hemato-oncology or post-transplantation), only 43 (32.1%) were plasma-positive. Of these, 37 (86.0%) had lower plasma DNAemia compared to the corresponding whole-blood samples. We conclude that whole-blood samples have a higher sensitivity than plasma samples in EBV DNA detection. The clinical utility of the tests is unclear, but our results suggest that either whole blood or plasma should be used consistently for EBV viral load monitoring.

Infectious mononucleosis in children and differences in biomarker levels and other features between disease caused by Epstein-Barr virus and other pathogens: a single-center retrospective study in China

Background

Infectious mononucleosis (IM) is a common viral infection that typically presents with fever, pharyngitis and cervical lymphadenopathy. Our aim was to identify the different pathogens causing IM in children admitted to our hospital and to analyze the differences in features of infection with different organisms.

Methods

We retrospectively analyzed the data of children aged 0-17 years admitted to Wuhan Children's Hospital during 2013-2022 with IM. We compared symptoms, physical findings, blood counts, and serum biomarkers between patients with IM due to Epstein-Barr virus (EBV) and IM due to other pathogens.

Results

Among 1480 enrolled children, 1253 (84.66%) had EBV infection, 806 (54.46%) had M. pneumoniae infection, 796 (53.78%) had cytomegalovirus infection, 159 (10.74%) had parvovirus infection, 38 (2.57%) had influenza virus infection, and 25 (1.69%) had adenovirus infection. Receiver operating characteristic curves were used to determine the area under the curve for alanine transaminase (ALT), aspartate transaminase (AST), Alkaline phosphatase (ALP), total bilirubin (TBil), indirect bilirubin (IBil) levels to assess liver damage, and for creatine kinase (CK), CK-MB, and lactate dehydrogenase (LDH) levels to assess myocardial damage. The optimal cutoff values of these biomarkers were then determined. In multivariate analysis, elevated ALT, AST, ALP, TBil, and IBil were independently associated with liver damage, and age <3 years, CK, CK-MB, and LDH with myocardial damage.

Conclusion

Evaluation of biomarkers and pathogen detection may help physicians to take preventive actions to avoid serious complications in children with infectious mononucleosis.

Is there a role for herpes simplex virus type 1 in multiple sclerosis?

Numerous studies relate the onset and severity of multiple sclerosis (MS) with viral infections. Herpes simplex virus type 1 (HSV-1), which is neurotropic and highly prevalent in the brain of healthy individuals, has been proposed to relate to MS. Here, we review and discuss the reported connections between HSV-1 and MS.

Molecular Mechanisms of Flavonoids against Tumor Gamma-Herpesviruses and Their Correlated Cancers-A Focus on EBV and KSHV Life Cycles and Carcinogenesis

Epstein-Barr virus (EBV) and Kaposi sarcoma-associated herpesvirus (KSHV) are cancer-causing viruses that belong to human gamma-herpesviruses. They are DNA viruses known to establish lifelong infections in humans, with the ability to develop various types of cancer. Drug resistance remains the main barrier to achieving effective therapies for viral infections and cancer. Thus, new medications with dual antiviral and anticancer actions are highly needed. Flavonoids are secondary metabolites biosynthesized by plants with diverse therapeutic effects on human health. In this review, we feature the potential role of flavonoids (flavones, protoflavones, isoflavones, flavanones, flavonols, dihydroflavonols, catechins, chalcones, anthocyanins, and other flavonoid-type compounds) in controlling gamma-herpesvirus-associated cancers by blocking EBV and KSHV infections and inhibiting the formation and growth of the correlated tumors, such as nasopharyngeal carcinoma, Burkitt's lymphoma, gastric cancer, extranodal NK/T-cell lymphoma, squamous cell carcinoma, Kaposi sarcoma, and primary effusion lymphoma. The underlying mechanisms via targeting EBV and KSHV life cycles and carcinogenesis are highlighted. Moreover, the effective concentrations or doses are emphasized.

A Protracted Course of Periorbital Oedema in Infectious Mononucleosis Caused by Epstein-Barr Virus

Infectious mononucleosis (IM) is a viral disease most commonly caused by the Epstein-Barr virus (EBV). The triad of fever, pharyngitis, and cervical chain lymphadenopathy classically describe this benign condition. Ocular association is also possible, although less commonly reported, and manifests as bilateral periorbital oedema presenting early in the disease process. A case of a fit and well 18-year-old female patient who developed periorbital oedema before the classic triad is presented. Furthermore, her case describes a significantly longer duration of periorbital tissue involvement, contrary to what is described in the current literature. Clinicians should not only recognise periorbital oedema as an initial manifestation of IM but also be alerted of its possible protracted course.

Interleukin-35 has a Protective Role in Infectious Mononucleosis-Induced Liver Inflammation Probably by Inhibiting CD8+ T Cell Function

Interleukin (IL)-35 plays an immunosuppressive role in infectious diseases, autoimmune disorders, and cancers. However, IL-35 expression and its regulation of CD8⁺ T cells in infectious mononucleosis (IM) are not fully understood. In this study, three groups of participants were compared, including twenty-three patients of IM without liver inflammation, twenty-eight patients of IM with liver inflammation, and twenty-one controls. Plasma and peripheral blood mononuclear cells (PBMCs) were isolated. CD8⁺ T cells were purified. Plasma IL-35 was measured by ELISA. PBMCs and CD8⁺ T cells were stimulated with recombinant human IL-35 in vitro. Perforin and granzyme B secretion was assessed by ELISPOT. Immune checkpoint molecule expression was investigated by flow cytometry. CD8⁺ T cells were co-cultured with HepG2 cells in direct contact and indirect contact manner. The cytotoxicity of CD8⁺ T cells was calculated by measuring lactate dehydrogenase release and proinflammatory cytokine expression. There was no significant difference in plasma IL-35 levels between patients with IM without liver inflammation and the controls, but the IL-35 level was notably increased in patients with IM who presented with liver inflammation and negatively correlated with aminotransferase. CD8⁺ T cells in patients with IM with liver inflammation showed stronger cytotoxicity. IL-35 stimulation inhibited CD8⁺ T cell-induced target cell death in patients with IM, mainly through suppression of IFN-γ/TNF-α secretion and elevation of immune checkpoint molecule expression, but did not affect perforin or granzyme B secretion. The current data indicated that IL-35 dampened the cytotoxicity of CD8⁺ T cells in patients with IM probably via repression of cytokine secretion. Elevated IL-35 may protect against CD8⁺ T cell-induced liver inflammation in patients with IM.

Epidemiological characteristics and disease burden of infectious mononucleosis in hospitalized children in the mainland of China: a nationwide retrospective study

Epstein-Barr virus (EBV) is very common, with the infection rate in adults over 90% worldwide. Infectious mononucleosis (IM) is caused by primary infection with EBV. Most IM patients are generally considered to have a favorable prognosis, but a few patients will also develop complications. Children with severe symptoms will require hospitalization. However, the disease burden of children hospitalized with IM in China has been rarely described. In this study, we included the Face sheets of discharge medical records from 27 member children's hospitals of Futang Research Center of Pediatric Development from Jan 1^st, 2016 to Dec 31^st, 2020, and medical information such as gender, age, region, time of admission, length of stay and expenditure were extracted. There are 24,120 IM cases, which accounted for 0.42% (24,120/5,693,262) of all hospitalized cases during this period. The ratio of male to female was 1.48:1. Hospitalization for IM in the 4-6 y age group was the highest among inpatients of all age groups. Case numbers increased year by year between 2016 to 2020, and the monthly hospitalization was generally high from Jul to Sep but reduced from Jan to Feb per year. Bronchitis/pneumonia and hepatic dysfunction are two common complications in hospitalized IM patients. The median length of stay was 8 days, and the median cost of hospitalization was 970.59 US dollars. This study will help understand the epidemiological characteristics and disease burden of hospitalized children with IM in China.

Is post-COVID syndrome an autoimmune disease?

INTRODUCTION

: Coronavirus disease 2019 (COVID-19) causes a long-term and persistent condition with clinical features similar to previous virulent outbreaks and other epidemics. Currently, post-COVID syndrome (PCS) is recognized as a new entity in the context of SARS-CoV-2 infection. Though its pathogenesis is not completely understood, persistent inflammation from acute illness and the development of autoimmunity play a critical role in its development. As the pandemic develops, the increasing latent and overt autoimmunity cases indicate that PCS is at the intersection of autoimmunity.

AREAS COVERED

The mechanisms involved in the emergence of PCS, their similarities with post-viral and post-care syndromes, its inclusion in the spectrum of autoimmunity and possible targets for its treatment.

EXPERT OPINION

An autoimmune phenomenon plays a major role in most causative theories explaining PCS. Due to the wide scope of symptoms and pathophysiology associated with PCS, there is a need for both PCS definition and classification criteria (including severity scores). Longitudinal and controlled studies are necessary to better understand this new entity, and to confirm that PCS is the chronic phase of COVID-19 as well as to find what additional factors participate into its development. With the high prevalence of COVID-19 cases worldwide, together with the current evidence on latent autoimmunity in PCS, we may observe an increase of autoimmune diseases (ADs) in the coming years. Vaccination's effect on the development of PCS and ADs will also receive attention in the future. Health and social care services need to develop a new framework to deal with PCS.