Mononucleosis

 

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Definition/Description

typical gland presentation
Mononucleosis, also known as the "kissing disease," is a viral infection spread through the passing of saliva that causes fever, sore throat, and swollen lymph glands. Since the virus that causes Mono is transmitted through the sharing of saliva you can get it through kissing, but people are also if not more likely to contract Mono through the sharing of utensils, drinking glasses, or interaction through someone with Mono who coughs or sneezes. [1] However, mononucleosis isn't as contagious as some infections, such as the common cold.


(Photo available at http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001617/figure/A000591.B2936/?report=objectonly)

Prevalence

Current statistics on mononucleosis are only as recent as 2002, as non could be found from the CDC. The following are the latest reportings:

  • In the research conducted in 2005, it was found that Epstein-Barr Virus (EBV) infects more than 98 percent of the world's population.
  • Epstein-Barr Virus (EBV) causes infectious mononucleosis in 90 percent of the cases." [2]


According to the latest statistics in 2005 95% of people in the United States over the age 30 have been infected with EBV at some point, but may not have known. People in the 20's who have been infection will only present with symptoms 35-50% of the time. For those in their 20's that have lived in dorms or other close quarter housing the chance of infection increases.[3] Mono occurs most commonly between the ages of 15 to 17, however you many develop mono at any age.[1]


Characteristics/Clinical Presentation

 

Typical Patient Presentation http://www.healthcentral.com/sleep-disorders/000548.html [4]

Common Symptoms - these symptoms usually resolve in a few days[5][6] 

  • Drowsiness
  • Fever
  • General discomfort
  • Loss of appetite
  • Muscle aches/stiffness
  • Rash
  • Sore Throat
  • Swollen lymph nodes
  • Swollen spleen Fatigue

Less Uncommon - may be signs of rare but serious condition. Patient's should be instructed to contact physician immediately.

  • Chest pain
  • Cough
  • Headache
  • Hives
  • Jaundice
  • Neck stiffness
  • Nosebleed
  • Rapid heart rate
  • Sensitivity to light
  • Shortness of Breath

Associated Co-morbidities

While there are very few co-morbidities associated with mono, a select group of studies as shown a correlation between Chronic Fatigue Syndrome (CFS) and Mononucleosis. According to research the Epstein Barr Virus has many similar clinical features. It has yet to be determined whether or not the conditions are synonymous or just present with similar symptoms due to their viral nature of transmision. [7]

Medications

Since Mono is not a bacterial infection, anti-biotics are not typically prescribed to help fight off the infection. Viral infections, such as mono are more typically managed with over the counter medications such as Tylenol and Ibuprofen (Advile). In more complex cases patients may be prescribed corticosteriods to help control any systemic effects occuring from the virus. [5]

 

Diagnostic Tests/Lab Tests/Lab Values

A combination of clinical examination, lab tests, and positive Monospot test are used to diagnosis Mononucleosis. Antibodies in the serum are elevated during the acute phase of the illness and can last for 3-4 weeks. This must be differentiated from Chronic Fatigue because these same antibody levels were at one time shown to be increased with CFS as well.[3] In the initial clinical evaluation a strep test should also be performed to rule that out as a possible cause for the fever and swollen glands. Elevated white blood cell count will be noted during lab work and may remain this way for up to 4 months. [8]                                                                                                      

Etiology/Causes

Mono is caused by the Epstein-Barr virus, a form of herpesvirus. EBV is one of the most common virus in the United States and does not disappear once symptoms supposide like some viruses. Some of the EBV cells remain dormant in their host for the rest of the patient's life. The virus is passed through saliva and close contact. It has also been shown that mono can be caused from other viral organisms such as cytomegalovirus. Mononucleosis is spread sharing beverages, utensils, lip balm, and most commonly known is kissing.[1] Infectious mononucleosis can be caused from Acute Cytomegalovirus (CMV) infection, condition caused by a member of the herpes virus family. Once symptoms have subsided the individual is still caring the virus, it has just become dormant. A few of the viral cells will remain permanently and the person may have an acute flare up years down the road.[8]

Systemic Involvement

Enlargement of the spleen is the most serious systemic complication that can arise from Mono. In very rare, extreme cases the spleen may rupture if not treated properly. This would be evident by sudden, sharp, stabbing pain in the left side of the upper abdomen.

The liver may also become involved in some cases. Hepatitis, or inflammation can occur in some cases or the patient may experience jaundice which is characterized by yellowing of the skin and whites of the eyes. If any abdominal pain or yellowing of the skin occurs medical attention should be sought immediately.[6]



 


Medical Management (current best evidence)

Usually the medical management for mononucleosis is self-treatment. Normally, all symptoms are resp;ved within a month but can last for up to four months.[1] Your doctor will advise you to get plenty of rest, gargle with salt water to sooth sore throat, take Tylenol or Ibuprofen for any present fever or headache, and avoid sports or heavy lifting in the event of an enlarged spleen. In more severe cases corticosteroids maybe prescribed to reduce swelling of throat, tonsils, or spleen. Patients with mono should avoid contact with other individuals if running a fever to reduce the risk of contamination. If in contact with others while the virus is active, avoid sharing utensils or drinking after others to minimize the risk of spreading the virus. [5]

Physical Therapy Management (current best evidence) [3]

Infectious Mononucleosis
PREFERRED PRACTICE PATTERNS 6B:
Impaired Aerobic Capacity/Endurance Associated with Deconditioning
Infectious mononucleosis is probably contagious before symptoms develop until the fever subsides and the oral and pharyngeal lesions disappear. Although infectious mononucleosis appears to be only mildly contagious, adherence to standard precautions, especially good handwashing and avoidance of shared dishware or food items with other people, is essential in preventing the HCW from contracting this condition.
The person with infectious mononucleosis should be cautioned against engaging in excessive activity, especially contact sports, which could result in splenic rupture or lowered resistance to infection. Usually this guideline is appropriate for a period of at least 1 month.
Any sign of splenic rupture (e.g., abdominal or upper quadrant pain, Kehr's sign, sudden left shoulder pain, or shock) requires immediate medical evaluation. Any soft tissue mobilization or myofascial techniques necessary in the left upper quadrant, especially up and under the rib cage, must take into consideration the enlarged liver and/or spleen; indirect techniques away from the spleen are indicated.
In rare cases mononucleosis impairs the CNS. Any change in neurologic status must be evaluated and reported to the physician. Changes in respiration or signs and symptoms of airway obstruction may require emergency intervention.


With permission from Elsevier

Differential Diagnosis

Since Mono is caused by a strand of herpevirus there are other conditions that may present with similar symptoms. It is always important for patient to consult with M.D. to rule out possibilty of any of the following: [9]


Also, there are several complications that can occur if patient's are not taking care of themselves once sypmtoms are present. Many of these condition are rare but dangerous: [1]

Case Reports/ Case Studies

Resources

Center for Disease Control

WebMD

MayoClinic

Merck Manual

Recent Related Research (from Pubmed)

 

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References

see adding references tutorial.

  1. 1.0 1.1 1.2 1.3 1.4 http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001617/
  2. http://www.tarunaoils.com/articles/mononucleosis-causes-mononucleosis-statistics.asp
  3. 3.0 3.1 3.2 Goodman C, Fuller K. Pathology. Implications for the Physical Therapist. St. Louis, MO: Saunders Elseveir: 2009
  4. http://www.healthcentral.com/sleep-disorders/000548.html
  5. 5.0 5.1 5.2 http://www.webmd.com/a-to-z-guides/infectious-mononucleosis-topic-overview
  6. 6.0 6.1 http://www.mayoclinic.com/health/mononucleosis/DS00352/METHOD
  7. Straus, S., The Chronic Mononucleosis Syndrome. The Journal of Infectious Diseases, Vol. 157, No. 3 (Mar., 1988) pp. 405-412. Oxford University Press. http://www.jstor.org/stable/30136640
  8. 8.0 8.1 http://www.cdc.gov/ncidod/diseases/ebv.htm
  9. http://emedicine.medscape.com/article/784513-differential