Infectious mononucleosis in patients aged 40 to 72 years: report of 27 cases, including 3 without heterophil-antibody responses

Fever with atypical lymphocytosis: pearls and pitfalls in Epstein-Barr virus serology

The heterophile antibody (also known as the Monospot) test is a useful screening tool for infectious mononucleosis (IM) resulting from primary Epstein-Barr virus (EBV) infection. However, up to 10% of patients with IM are heterophile negative. Heterophile-negative patients who have lymphocytosis or atypical lymphocytes on peripheral blood smear should be further tested for EBV serologies, which include testing for specific IgM and IgG antibodies against viral capsid antigens, early antigens and EBV nuclear antigen proteins. A diagnostic dilemma arises when the patient has clinical and laboratory features of IM, but is both heterophile negative and seronegative for IM, as illustrated in this case presentation. To avoid missed diagnoses of IM, misdiagnosis of mononucleosis-like illnesses and unnecessary testing, knowledge of test characteristics and the evolving course of EBV serologies is important to assure and inform both the physician and the patient.

Epstein-Barr Virus: An Infrequent Pathogen of Acute Undifferentiated Febrile Illness From a Tertiary Care Hospital in Southern India

Context: Acute undifferentiated febrile illness (AUFI) is characterized by a sudden onset of raised body temperature and is a common cause of hospital admission though not recognized as a disease state by the World Health Organization. Epstein-Barr virus (EBV) is reported to account for a significant occurrence of AUFI cases.

Aim: To know the role of EBV infection as a cause of acute undifferentiated febrile illness (AUFI).

Settings and design: We have used the combination of EBV serological assays to establish the role of the Epstein-Barr virus as the cause of acute undifferentiated febrile illness.

Methods and material: A total of 721 suspected cases of acute undifferentiated febrile illness which were tested negative for other common causes of acute febrile illness were selected for the study. Serum samples collected from these cases were tested for the presence of the EBV viral capsid antigen (VCA) IgM antibody. All positive serum samples were tested for the presence of EBV Epstein-Barr nuclear antigen (EBNA) IgG.

Statistical analysis used: Statistical analysis was performed with the help of Microsoft Excel software (Microsoft Corporation, Redmond, USA). 

Results: Out of 721 suspected AUFI cases tested for EBV VCA IgM antibodies, 117 samples were positive and 604 were negative. All these 117 samples were tested for EBV EBNA IgG antibodies in which 88 were positive and 29 were negative. In our study, we found that around 4% (positive for VCA IgM and negative for EBNA IgG) of AUFI cases can be attributed to primary acute EBV infection.

Conclusions: EBV infection should be considered particularly in AUFI cases of less than five years of age even in those who do not meet the typical presentation of fever, lymphadenopathy and sore throat. Our study should help to raise awareness regarding the possibility of EBV infection particularly in AUFI cases. A high index of suspicion and timely diagnosis will definitely help clinicians to avoid a battery of investigations and misuse of antibiotics in cases of AUFI.

Acute systemic viral infection masquerading as an infiltrating lymphoma in an elderly patient: a case report and review of the literature

Primary Epstein-Barr virus (EBV) infection occurs mainly in adolescents and young adults, with more than 90% of adults having serological evidence of past infection. Primary infection in those over the age of 40 is associated with an atypical and often more severe presentation that can lead to more extensive and invasive, and often unnecessary, diagnostic testing. The incidence of severe EBV-related illness in older adults has been observed to be increasing in industrialized nations. The characteristic presentation of infectious mononucleosis (IM) syndrome in elderly patients (age > 65) is not clearly defined in the literature. Here, we describe a case of primary EBV infection in an 80-year-old female and review the literature regarding primary seroconversion in elderly patients.

Serological diagnosis of Epstein-Barr virus infection: Problems and solutions

Serological tests for antibodies specific for Epstein-Barr virus (EBV) antigens are frequently used to define infection status and for the differential diagnosis of other pathogens responsible for mononucleosis syndrome. Using only three parameters [viral capsid antigen (VCA) IgG, VCA IgM and EBV nuclear antigen (EBNA)-1 IgG],it is normally possible to distinguish acute from past infection: the presence of VCA IgM and VCA IgG without EBNA-1 IgG indicates acute infection, whereas the presence of VCA IgG and EBNA-1 IgG without VCA IgM is typical of past infection. However, serological findings may sometimes be difficult to interpret as VCA IgG can be present without VCA IgM or EBNA-1 IgG in cases of acute or past infection, or all the three parameters may be detected simultaneously in the case of recent infection or during the course of reactivation. A profile of isolated EBNA-1 IgG may also create some doubts. In order to interpret these patterns correctly, it is necessary to determine IgG avidity, identify anti-EBV IgG and IgM antibodies by immunoblotting, and look for heterophile antibodies, anti-EA (D) antibodies or viral genome using molecular biology methods. These tests make it possible to define the status of the infection and solve any problems that may arise in routine laboratory practice.

Progress and problems in understanding and managing primary Epstein-Barr virus infections

Epstein-Barr virus (EBV) is a gammaherpesvirus that infects a large fraction of the human population. Primary infection is often asymptomatic but results in lifelong infection, which is kept in check by the host immune system. In some cases, primary infection can result in infectious mononucleosis. Furthermore, when host-virus balance is not achieved, the virus can drive potentially lethal lymphoproliferation and lymphomagenesis. In this review, we describe the biology of EBV and the host immune response. We review the diagnosis of EBV infection and discuss the characteristics and pathogenesis of infectious mononucleosis. These topics are approached in the context of developing therapeutic and preventative strategies.

Viral Infections

Although influenza remains indisputably the most significant viral pathogen in adults, other viruses such as respiratory syncytial virus, parainfluenza viruses, and human metapneumovirus are now recognized as significant pathogens in older populations.

Oseltamivir and zanamivir are antiviral agents that are effective for the treatment and prophylaxis of influenza A and B. For treatment and for optimal effect, therapy should be initiated within 48 h of symptom onset.

Infection with hepatitis viruses may be more severe in older adults with more fulminate disease as observed with acute hepatitis A and a more rapid progression to cirrhosis with hepatitis C.

Outbreaks of viral gastroenteritis are common in long-term care facilities, and infection may lead to death due to dehydration and oliguria.

The incidence of herpes zoster increases with advancing age and carries with it a significant risk of post herpetic neuralgia. The use of antiviral medications and corticosteroids may reduce the incidence and severity of chronic pain.

Epstein-Barr Virus Gastritis

We describe an exceedingly rare case of severe gastritis that was temporally associated with primary Epstein-Barr virus (EBV) infection. The patient was a 59-year-old immunocompetent man who presented with intermittent fever of unknown origin and epigastric pain for 18 days. A computed tomographic scan of the abdomen showed diffuse thickening of the gastric wall and esophagogastroduodenoscopy revealed numerous ulcers in the stomach. Histologic examination of gastric biopsies showed a dense and diffuse atypical lymphoid infiltrate in the lamina propria with erosions and focal lymphoepithelial lesions. No lymphoid follicles or Helicobacter microorganisms were identified. Immunohistochemical studies demonstrated the lymphoid infiltrate to consist of mixed T and B cells. Immunoglobulin heavy chain gene arrangement analysis showed a polyclonal pattern. The plasma cells present in the biopsies exhibited no light chain restriction as determined by in situ hybridization. Concurrent clinical work-up revealed peripheral lymphocytosis with atypical lymphocytes and positive serum IgM antibody to EBV capsid antigen in the absence of IgG antibody. These findings indicated that the gastric abnormalities were related to primary EBV infection as the predominant manifestation of infectious mononucleosis. This was further confirmed by subsequent in situ hybridization showing numerous EBV-positive lymphocytes in the gastric mucosa. The patient's symptoms were spontaneously resolved with only supportive treatment. A follow-up endoscopy 2 months later showed completely normal gastric mucosa and he remained well with no gastrointestinal complaints for 2 and a half years. This case illustrates the importance of a high index of suspicion to avoid misdiagnosis of gastric lymphoma that requires more aggressive therapies.

Review of Epstein–Barr virus and post-transplant lymphoproliferative disorder post-solid organ transplantation (Review Article)

Post-transplant lymphoproliferative disorder (PTLD) following solid organ transplantation is an important form of post-transplant malignancy. PTLD is typically associated with Epstein-Barr virus (EBV) and occurs in the setting of profound immunosuppression resulting in a deficiency of EBV-specific cytotoxic T lymphocytes (CTL). Predisposing factors include EBV mismatch between donor and recipient, use of immunosuppression especially T-cell depletive therapies and genetic predisposition of recipients. The standard approach has been to reduce immunosuppression but is often insufficient to induce tumour regression. Further understanding of the immunobiology of PTLD has resulted in improved monitoring techniques (including EBV viral load determined by polymerase chain reaction) and newer treatment options. Recent work has highlighted a potential role for dendritic cells in both the pathogenesis and treatment of PTLD. Current treatment modalities include adoptive immunotherapy using ex vivo generated autologous EBV-specific CTL or allogeneic CTL, cytokine therapies, antiviral agents, and more recently, rituximab and dendritic-cell based therapies. This review focuses on the developments and progress in the pathogenesis, diagnosis and treatment of PTLD.

Acute Epstein-Barr virus infection in two elderly individuals

Most individuals acquire Epstein-Barr virus (EBV) infection in young age. Because of uncommon presentation and misdiagnosis, clinical manifestations are less well described in older age. We present two cases of elderly patients with predominant symptoms attributed to cold agglutinin haemolytic anaemia due to acute EBV infection without fever, lymphadenopathy, pharyngitis or splenomegaly. We conclude that misleading clinical manifestations are frequent in older individuals and may lead to inappropriate diagnostic invasive procedures.

Serum Epstein-Barr virus DNA load in primary Epstein-Barr virus infection

Specific viral laboratory diagnosis of primary Epstein-Barr Virus (EBV) infection is usually based on antibody-detection assays. During acute, lytic phase of infection, viral DNA can also be detected in serum. In the present study, the diagnostic utility of EBV DNA detection and quantitation in serum in primary EBV infection was investigated. The level of EBV DNA in the serum of 98 immunocompetent patients aged 1-47 years with symptomatic, antibody-confirmed EBV primary infection was assessed using a quantitative real-time PCR assay. The association between viral load and time after onset of disease, age and clinical and laboratory data was investigated. Quantitative PCR detected EBV DNA in 93 of 98 samples (94.9%), and the measured viral loads ranged from 3.8 x 10(1) to 6.6 x 10(4) copies/ml. EBV DNA detection exhibited a sensitivity of 94.9% and a specificity of 97.4% for primary EBV infection. EBV DNA was always detectable until day 12 after onset of symptoms, whereas no further positive PCR results were found after a period of 22 days after onset of disease. Detection of EBV DNA also showed a clearer association with the clinical manifestation of disease than the presence of EBV specific VCA IgG antibodies of low avidity. EBV DNA load was found to correlate inversely with the time after onset of disease (P < 0.001), and higher viral load levels were detected in younger (P = 0.009) and in hospitalized patients (P = 0.038). The results indicate that real-time PCR is a reliable tool for diagnosis of primary EBV infection early in the course of disease. In addition, EBV DNA detection may serve as a useful diagnostic supplement in serologically indeterminate EBV infections.

Gallbladder wall thickening associated with infectious mononucleosis

Acute infectious mononucleosis is a typical self-limited lymphoproliferative illness characterized by fever, tonsillar pharyngitis, and lymphadenopathy in adolescents and young adults. Thickening of the gallbladder wall is rarely observed. We report a case of infectious mononucleosis in which marked thickening of the gallbladder wall was detected by ultrasonography and computed tomography.

Significant liver injury with dual positive IgM antibody to Epstein-Barr virus and cytomegalovirus as a puzzling initial manifestation of infectious mononucleosis

A 35-year-old man was admitted because of significant hepatic dysfunction with mild splenomegaly and intra-abdominal lymphadenopathy of unknown cause. Infectious mononucleosis was suggested by subsequently detected high fever, pharyngotonsillitis and cervical lymphadenopathy, but IgM to Epstein-Barr virus (EBV) and cytomegalovirus (CMV) showed dual positivity. A definite diagnosis of EBV-induced infectious mononucleosis was established 3 months later on the basis of seroconversion to Epstein-Barr nuclear antigen (EBNA)-IgG positivity and reduced CMV-IgM titer with persistently negative CMV-IgG. This case highlights the initial diagnostic difficulties of EBV-induced infectious mononucleosis particularly in older patients, due to concomitant abnormal humoral immunity and unusual initial manifestations such as significant liver injury and extensive intra-abdominal lymphadenopathy.

Peripheral Neuropathy

This chapter focuses on peripheral neuropathy, which is the third or fourth most common neurologic disorder, even among the elderly. It begins with a description of the classification system for peripheral neuropathies. Because the underlying etiology or precipitating events of peripheral neuropathy are identifiable for the majority of affected individuals, epidemiologic research has largely focused on descriptive studies of disease frequency or on identifying the factors that modify the influence of the already existing risk factors. Three of the most common neuropathies are covered in detail: diabetic neuropathy, carpal tunnel syndrome, and Guillain–Barré syndrome. Each of these conditions is discussed in terms of distribution and risk factors, and is concluded with a discussion of future research directions to address unanswered questions. The chapter emphasizes methodologic approaches that that could be employed to improve the rigor of studies of these conditions.

Infectious mononucleosis, diffuse pneumonia and acute respiratory failure in an elderly woman

Infectious mononucleosis (IM) is a benign disease and is frequently associated with mild respiratory symptoms. The pulmonary manifestations rarely dominate the clinical picture. We report a case of an older adult patient with IM who developed diffuse pneumonia and acute respiratory failure. The diagnosis of IM was confirmed serologically, whereas other possible causes of pneumonia were excluded in this study. Pulmonary manifestations of IM are discussed, and the atypical features that may be seen in older adults are simultaneously reviewed.

Measurement of EBV-IgG anti-VCA avidity aids the early and reliable diagnosis of primary EBV infection

Current serological methods for the diagnosis of Epstein-Barr virus (EBV) infection still differentiate poorly between primary infection and reactivation. This is particularly true when IgG and IgM antibodies are present simultaneously and only a single serum sample is provided for analysis. The demonstration of the IgG avidity state has the potential to distinguish recent from past or reactivated infection. An analysis of the kinetics of avidity maturation of anti-VCA antibodies in primary EBV infection was undertaken with longitudinally collected sets of sera from 28 well-characterised EBV cases and in sera from 35 cases with previous EBV infection and recent primary infection due to HIV, CMV, or hepatitis A. Antibodies directed against the viral capsid antigen (VCA) and Epstein-Barr nuclear antigen (EBNA-1) were sought, using a commercial enzyme immunoassay (EIA). In parallel with standard IgG anti-VCA detection, serum was incubated with 8 M urea to disrupt low-avidity complexes to allow calculation of the percentage avidity. In cases with primary EBV infection, the mean avidity rose from 54% at 6 weeks to 82% by 28 weeks after the onset of symptoms, but remained lower than that of the control sera (96%). The addition of the avidity measurement improved the sensitivity of IgG and IgM anti-VCA testing in diagnosis of primary EBV infection from 93% to 100%. The specificity of IgM anti-VCA testing alone was poor, with 14 of 35 cases (49%) demonstrating false-positive results, but it improved to 97% by the demonstration of high-avidity IgG anti-VCA. The combination of negative IgG anti-EBNA and low-avidity IgG anti-VCA had a sensitivity and specificity of 100%. The routine addition of IgG anti-VCA avidity estimation to diagnostic EBV serology is recommended.

Hepatic fibrin-ring granulomas in granulomatous hepatitis: report of four cases and review of the literature

BACKGROUND

The differential diagnosis of hepatic fibrin-ring granulomas includes infective agents (Coxiella burneti, CMV, EBV,....), hypersensitivity to medication (allopurinol) and malignancy.

METHODS

During a period of 6 months, four patients presented at our university hospital with a similar clinical picture of fever and abnormal liver tests, and fibrin-ring granulomas on liver biopsy. Clinical course, laboratory and imaging findings, and histopathological features were compared.

RESULTS

Clinical manifestations, and laboratory and imaging findings were similar. Histopathological assessment of the hepatic fibrin-ring granulomas appeared not to be helpful in identifying the causative agent. Other histopathological features (e.g. sinusoidal rows of lymphocytes, eosinophilic polymorphonuclear infiltrate) were suggestive for the causative agent, yet conclusive identification was obtained by either serology (Q fever, CMV, EBV), or by exclusion with concomitant stop of medication (allopurinol).

CONCLUSIONS

In the differential diagnosis of hepatic fibrin-ring granulomas, serologic titers remain the determining factor, since an infective agent is the most common cause. When hepatic fibrin-ring granulomas are present, other histopathological features may be helpful in making the differential diagnosis.

Acute infectious mononucleosis: characteristics of patients who report failure to recover

PURPOSE

We sought to determine how often acute mononucleosis precipitates chronic illness, and to describe the demographic, clinical, and psychosocial features that characterize patients who report failure to recover.

SUBJECTS AND METHODS

We enrolled 150 patients with infectious mononucleosis during the acute illness and asked them to assess their recovery at 2 and 6 months. At baseline, we performed physical and laboratory examinations; obtained measures of psychological and somatic functioning, social support, and life events; and administered a structured psychiatric interview.

RESULTS

Self-assessed failure to recover was reported by 38% of patients (55 of 144) at 2 months and by 12% (17 of 142) at 6 months. Those who had not recovered reported a persistent illness characterized by fatigue and poor functional status. No objective measures of disease, including physical examination findings or serologic or laboratory markers, distinguished patients who failed to recover from those who reported recovery. Baseline predictors for failure to recover at 2 months were older age (odds ratio [OR] = 1.4, 95% confidence interval [CI]: 1.1 to 1.8, per 5-year increase), higher temperature (OR = 1.5, 95% CI: 1.1 to 2.2, per 0.5 degrees C increase), and greater role limitation due to physical functioning (OR = 1.5, 95% CI: 1.2 to 1.9, per 20-point decrease in Short Form-36 score). At 6 months, baseline predictors for failure to recover included female sex (OR = 3.3, 95% CI: 1.0 to 12), a greater number of life events more than 6 months before the disease began (OR = 1.7, 95% CI: 1.1 to 2.5, per each additional life event), and greater family support (OR = 1.9, 95% CI: 1.1 to 4.2, per 7-point increase in social support score).

CONCLUSIONS

We were not able to identify objective measures that characterized self-reported failure to recover from acute infectious mononucleosis. The baseline factors associated with self-reported failure to recover at 2 months differed from those associated with failure to recover at 6 months. Future studies should assess the generalizability of these findings and determine whether interventions can hasten recovery.

Clinical features and costs of care for hospitalized adults with primary Epstein-Barr virus infection

PURPOSE

To study the clinical and laboratory features of primary infection with the Epstein-Barr virus in adults who required hospitalization and to assess the difficulty in its diagnosis, the use of diagnostic procedures, and the associated costs of care.

PATIENTS AND METHODS

We retrospectively identified all adult patients who were diagnosed with primary Epstein-Barr virus infection in our region between 1988 and 1997 using strict serologic criteria. The added costs of unnecessary diagnostic tests and treatment were estimated.

RESULTS

The analysis included 47 patients (60% men) with a mean (+/-SD) age of 30 +/- 14 years. The prime cause of admission was fever (83%). Compared with patients 35 years of age and older, those younger than 35 years were more likely to have pharyngitis (45% vs 10%) and lymphadenopathy (66% vs 17%). Younger patients also had a greater mean atypical lymphocyte count (17% +/- 14% vs 8% +/- 6%) and more abnormal hepatic enzyme levels. Inpatient work-ups resulted in 309 days of hospitalization, many diagnostic tests, and unnecessary empiric treatments (total 203 days of antibiotic therapy). Overall, unnecessary diagnostic procedures and medical treatments contributed an average of approximately $12,000 in health-care costs per patient.

CONCLUSIONS

Testing for primary Epstein-Barr virus infection should be a routine step in the investigation of fever in adults of all ages. A higher index of suspicion might prevent unnecessary, sometimes hazardous inpatient work-ups from being performed, thereby reducing health-care expenses.

Severe cholestatic jaundice induced by Epstein-Barr virus infection in the elderly

Infectious mononucleosis due to Epstein-Barr virus (EBV) is almost always a self-limited disease, most commonly seen in young adults. Hepatitis is a well-recognized complication of EBV infection that usually resolves spontaneously. Jaundice occasionally results from the unusual complication of autoimmune haemolytic anaemia rather than hepatitis. We report a 60-year-old man with severe cholestatic jaundice whose history, liver histology and laboratory findings suggested EBV infection. He also developed significant jaundice related to his hepatitis, but not to autoimmune haemolysis, a situation that led to diagnostic delay. Costly diagnostic laboratory tests and invasive procedures were performed to rule out a malignant extrahepatic biliary obstruction. Physicians need to be aware of this complication and EBV infection should be included in the differential diagnosis of cholestatic jaundice in the elderly.

Protein study of T and B acute lymphoblastic leukemia cell lines

Two-dimensional polyacrylamide gel electrophoresis (2-D PAGE) was used to identify cellular proteins in T and B acute lymphoblastic leukemia (ALL) cell lines. Five lines, REH and BALL-1 of B-cell lineage, CCRF-CEM and HPB-ALL of T-cell lineage, and a normal Epstein-Barr virus (EBV)-transformed line of B-origin (SKLN1) were studied. The lines were immunophenotyped using flow cytometry and lineage associated monoclonal antibodies. Whole cell lysates of the cell lines were subjected to 2-D PAGE analyses. 2-D gels were analyzed with an image scanning computer and the qualitative as well as quantitative differences of the protein patterns were studied. Despite the great similarities in the patterns of the B- and T-gels, three proteins were unique to B-cell lines, while eight were unique to T-cell lines. Using cell lines is the first step toward identifying potential markers in ALL and can provide important information regarding the human ALL databases. Whether these proteins are definite markers for B- or T-ALL or are unique to the cell lines studied needs further exploration.

Diffuse pneumonia and acute respiratory failure due to infectious mononucleosis in a middle-aged adult

This report describes a 48-yr-old patient who developed bilateral hilar adenopathy, diffuse pulmonary infiltrates, and respiratory failure in association with infectious mononucleosis. Lung and paratracheal lymph node biopsies suggested the diagnosis, and an acute Epstein-Barr virus infection was confirmed serologically. Pulmonary involvement in infectious mononucleosis is reviewed, and atypical features, which may lead to diagnostic difficulty, particularly in the older adult, are discussed.

Fine-needle aspiration of lymph nodes in patients with acute infectious mononucleosis

We studied lymph node fine-needle aspirations from 10 patients with primary Epstein-Barr virus (EBV) infections (infectious mononucleosis). There were five males and five females, aged 15-54 yr. The diagnoses were confirmed by blood morphology and heterophil antibody (HA) and EBV-specific serologic studies. Nine patients were HA-positive, nine were viral capsid antigen (VCA)-IgM-positive, and all 10 were VCA-IgG-positive and anti-EBV nuclear antigen (EBNA)-negative. Five patients were referred for fine-needle aspiration biopsies for clinically suspected malignant lymphoma (ML). Four of these patients had been tested for HA prior to fine-needle aspiration, with negative results in three cases. The heterophil-positive patient was referred for fine-needle aspiration due to very impressive unilateral cervical adenopathy. Cytologically, all cases showed atypia consisting of greater numbers of large immunoblastic lymphocytes than are usually seen in the reactive lymph node. Two cases were cytologically suspicious for malignant lymphoma but included a considerable background of polymorphic immunoblasts. We suggest that polymorphic immunoblastic proliferations in lymph node cytology are suggestive of infectious mononucleosis. Since several reactive and neoplastic processes mimic this pattern, cases not followed by both confirmatory serologic studies and resolution of adenopathy should be pursued by excisional lymph node biopsy.

Seroepidemiological study of infectious mononucleosis in older patients

In southern Tasmania, Australia, primary Epstein-Barr virus infection occurs in adults greater than 30 years of age at a higher frequency (approximately 13% of all cases) than is generally reported for other parts of the world, and approximately 7% of the general population of the region have no antibodies to the virus. Epstein-Barr virus should not be overlooked as a possible cause of disease in older patients in similar populations elsewhere.

Severe optic neuritis in infectious mononucleosis

Because the presentation and clinical features of infectious mononucleosis can be misleading in the elderly, a significant number of infections may go unrecognized. We report an unusual case of infectious mononucleosis in a 61-year-old man in whom marked visual impairment was the presenting complaint and severe optic neuritis was the only prominent finding. Confirmation of the diagnosis was made by serologic testing for Epstein-Barr virus antibody. Recovery of visual function was near complete, but optic atrophy persisted. We reviewed the English literature and collected seven cases of well-documented optic neuritis associated with infectious mononucleosis. A clinical profile of parainfectious optic neuritis is discussed along with the likely pathogenesis for this complication.

Infectious mononucleosis in hospitalized patients over forty years of age

Clinical and laboratory features of 17 patients over 40 years of age (mean age: 55 years) admitted with infectious mononucleosis were compared with those of 17 adolescents (mean age: 13 years) hospitalized with this illness. Elderly patients with infectious mononucleosis were found to run a longer febrile course (13 vs. 7 days, p less than 0.01) and to have a lower peak total white blood cell count (6,600/mm3 vs. 11,000/mm3, p less than 0.001) and a lower incidence of splenomegaly (50% vs. 76%, p less than 0.05), lymphadenopathy (25% vs. 94%, p less than 0.001), and pharyngitis (25% vs. 47%, p less than 0.05), compared with young patients with infectious mononucleosis. Patients in both groups had a high prevalence of abnormal liver function tests. It is concluded that infectious mononucleosis in patients over 40 years of age is not as uncommon as previously reported, and that clinical and laboratory features differ between young and older patients suffering from this disease.

Serological and demographic survey of Epstein-Barr virus infection in Ethiopia

A demographic and serological survey of Epstein-Barr virus infection was carried out in 5 geographically representative regions of Ethiopia. 80% of the 500 people studied were under 15 years of age. 82% of children under 5 years of age and 94% under 10 years of age were positive for IgG anti-viral capsid antigen (VCA) antibody. 51 of 100 children under 12 months of age and from 5 different provinces were positive for anti-VCA antibody. Of these, 23 were under 6 months. The distribution of anti-VCA antibody positivity was comparable in both sexes, in each age group and in the different provinces at different altitudes. Economic status, expressed in terms of estimated income, type of water supply, mode of excreta disposal and family size, did not significantly influence the distribution of anti-VCA antibody. Thus, early exposure to Epstein-Barr virus, with asymptomatic or subclinical presentation, probably accounts for the rarity of typical infectious mononucleosis in young adult Ethiopians. The lack of a relationship between Epstein-Barr virus infection and Burkitt's lymphoma, nasopharyngeal carcinoma, malaria as well as liver diseases is briefly discussed.

Changes in protoporphyrin distribution dynamics during liver failure and recovery in a patient with protoporphyria and Epstein-Barr viral hepatitis

Acute liver failure with cholestasis, histologic and serologic evidence of Epstein-Barr viral infection, and associated autoimmune hemolytic anemia occurred in a patient with lifelong protoporphyria. Changes in previously established baseline protoporphyrin distribution dynamics in erythrocyte, plasma, and fecal excretion compartments were observed during the period of severe hepatic dysfunction and recovery. These changes were consistent with predictions of a previously described conceptual model for human protoporphyria.

Infectious mononucleosis mimicking a B cell immunoblastic lymphoma associated with an abnormality in regulatory T cells

An elderly woman is described with infectious mononucleosis in whom cervical node biopsy was interpreted as showing immunoblastic lymphoma. Concomitant reactive lymphocytosis, Epstein-Barr virus serologic results consistent with an acute infection, and demonstration of polyclonal B cell infiltration of other tissues argued against intervention. Defective in vitro T cell responses were demonstrated during the acute phase of Epstein-Barr virus infection. Infectious mononucleosis has rarely been reported as mimicking a non-Hodgkin's lymphoma. At 18 months, our patient's course has been typical for infectious mononucleosis with no evidence of disseminated malignancy.

Cryptogenic fibrosing alveolitis and Epstein-Barr virus: an association?

13 patients with cryptogenic fibrosing alveolitis (CFA) and 12 with interstitial lung disease (ILD) of known cause were studied for their humoral response to herpes simplex virus (HSV), cytomegalovirus (CMV), and Epstein-Barr virus (EBV). Serum antibodies to HSV and CMV were within the normal range in all patients. 10 patients with CFA had raised serum antibodies to EBV, and IgA against viral-capsid antigen (VCA) was detectable in all 13. In the other 12 patients EBV serological profiles were normal and IgA against VCA was detectable in only 1 patient. The EBV antibody levels did not correlate with the level of circulating immune complexes, the presence of rheumatoid factors, or the cytological findings of the alveolitis. The presence of IgG against VCA in 5 CFA patients suggests local production of EBV-specific immunoglobulins. Elevated IgG and IgA against EBV in CFA may indicate non-specific depression of cell-mediated immunity or that EBV plays a part in the aetiology of CFA.