40. Fever and Chills (adult and paediatric)

Question 1

what is the EB virus?

Answer 1

glandular fever

Question 2

clinical manifestations of glandular fever?

Answer 2

sore throat- A history of sore throat is often accompanied by pharyngeal inflammation

swollen glands- neck most prominent, also check all other ones

flu like symptoms, malaise

1 in 5 become puffy around the eyes

tonsillar exudates-which may appear white, gray-green, or even necrotic.

splenomegaly- can cause mild pain- Splenomegaly occurs in as many as 50 percent of patients, but jaundice and hepatomegaly are uncommon.

mild hepatitis encountered in about 90 percent of infected individuals- this may cause some jaundice

NO symptoms- subclinical infection- common in children and adults over 40yrs

Question 3

describe the lymphadenopathy and appearance of tonsils in glandular fever?

Answer 3

The lymphadenopathy characteristically is symmetric and involves the posterior cervical chain more than the anterior chain.

Tonsillar exudate is a frequent component of the pharyngitis; the exudate can have a white, gray-green, or necrotic appearance.

Question 4

Other clinical manifestations of glandular fever?

Spleen?
rash?
neurological?

Answer 4

splenic rupture-Splenomegaly is seen in 50 to 60 percent of patients with IM and usually begins to recede by the third week of the illness

rash-10-20%….A generalized maculopapular, urticarial, or petechial rash is occasionally seen, while erythema nodosum is rare. A maculopapular rash almost always occurs following the administration of ampicillin or amoxicillin,

Neurologic syndromes include Guillain-Barré syndrome, facial and other cranial nerve palsies [62-64], meningoencephalitis [65], aseptic meningitis, transverse myelitis, peripheral neuritis, optic neuritis, and encephalomyelitis [66]. These manifestations tend to occur two to four weeks or more after initial symptom onset.

Question 5

discuss infection of EBV during pregnancy?

Answer 5

There is little evidence of a teratogenic risk to the fetus in women who develop infection during pregnancy

Question 6

what are the lab abnormalities in glandular fever—-

Hematological?

Answer 6

lymphocytosis (mostly CD8+) (atypical lymphocytes)

glandular fever antibodies (monospot test)

mild neutropenia, and thrombocytopenia

Question 7

what are the lab abnormalities in glandular fever—-

Liver FT’s?

Answer 7

Elevated aminotransferases are seen in the vast majority of patients, but are self-limited.

AST and ALT (in viral hepatitis AST is higher, alcoholic ALT is higher)

Abnormal liver function tests in a patient with pharyngitis strongly suggest the diagnostic possibility of IM.

Question 8

DDX of Glandular fever? and the symptoms differentiating them from each other.

Answer 8

—–Patients with fever, pharyngitis, and lymphadenopathy may have streptococcal, cytomegalovirus, acute HIV, or, rarely, toxoplasma infection.

——Streptococcal infection is not usually accompanied by significant fatigue or splenomegaly on examination.

——Pharyngitis associated with cytomegalovirus (CMV) tends to be extremely mild, if present at all, but may cause liver function test elevations, as does acute Epstein-Barr virus (EBV).

Question 9

Diagnosis of glandular fever?

Answer 9

Lymphocytosis, heterophile antibodies (monospot test)

EBV-specific antibodies — the vast majority of patients are heterophile positive. However, testing for EBV-specific antibodies may be warranted in patients with suspected IM who have a negative heterophile test

Epstein-Barr virus (EBV)-induced infectious mononucleosis (IM) should be suspected when an adolescent or young adult complains of sore throat, fever, and malaise and also has lymphadenopathy and pharyngitis on physical examination

The presence of palatal petechiae, splenomegaly, and posterior cervical adenopathy are highly suggestive of IM, while the absence of cervical lymphadenopathy and fatigue make the diagnosis much less likely

Question 10

what is the symptomatic treatment of glandular fever?

Answer 10

The mainstay of treatment for individuals with infectious mononucleosis (IM) is supportive care.

—-Acetaminophen or nonsteroidal anti-inflammatory drugs are recommended for the treatment of fever, throat discomfort, and malaise.

—-Provision of adequate fluids and nutrition is also important.

—-adequate rest, although complete bed rest is unnecessary.

Steroids- no evidence to support- not reccomended

Question 11

other advice to give to patients with EBV?

Answer 11

RETURN TO SPORTS — Since infectious mononucleosis (IM) mostly affects teenagers and young adults, many of whom participate in competitive sports and other forms of exercise, a common question is when to recommend resumption of athletic activities. More than 50 percent of patients with IM develop splenic enlargement within the first two weeks of symptoms; as a result, the central issue is avoiding activities that may precipitate splenic rupture, while a secondary consideration relates to resumption of training in an athlete complaining of fatigue.

Question 12

prognosis of EBV?

Answer 12

——most acute symptoms resolve in one to two weeks

——fatigue and poor functional status can persist for months

Question 13

associated diseases with IM?

Answer 13

EBV has been associated with a variety of malignancies, particularly lymphoma.

Many of these infections are subclinical, but Hodgkin lymphoma has been associated with a history of infectious mononucleosis

Question 14

transmission of EBV?

Answer 14

sexual contact
breastfeeding
person to person- saliva

Question 15

pathogenesis—-

incubation?
types of lymphocyctes are involved?

Answer 15

The incubation period prior to the development of symptoms averages four to eight weeks.

incubation 4-14 days

EBV-specific cytotoxic T-lymphocytes are considered essential in controlling acute and reactivation infection. T cell activation leads to a T helper 1-type profile with production of interleukin-2 and interferon-gamma cytokines

Question 16

what antibiotic must you avoid in glandular fever?

Answer 16

amoxicillin- as it causes a rash