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1268 Part IX: Lymphocytes and Plasma Cells Chapter 82: Mononucleosis Syndromes 1269

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including EBV and CMV, are negative in a small percentage of typical placebo group. Nevertheless, treatment with glucocorticoid is reason-
mononucleosis cases. able when the tonsils are touching in the midline when airway obstruc-
tion is imminent. Prednisone 40 to 60 mg/day is given for 7 to 10 days,
DIFFERENTIAL DIAGNOSIS OF then rapidly tapered once a clinical response is achieved. Urgent ton-
sillectomy and adenoidectomy may be required.
134,135
The same pred-
MONONUCLEOSIS SYNDROMES nisone regimen is used for severe immune hemolytic anemia, severe
symptomatic immune thrombocytopenia, neurologic complications,
At a very young age, EBV and CMV mimic each other. They present pancreatitis, and myocarditis.
as one of the many febrile illnesses in young children. The difference The same dose of glucocorticoid has been used for the hematologic
15
here is that the children with CMV present with abnormal liver func- or neurologic complications of CMV mononucleosis. Results of gan-
107
tion tests. The importance of documenting primary CMV is that with ciclovir 5 mg/kg/day given intravenously for 14 days for severe CMV
this information, one can develop a strategy to prevent transmission to a mononucleosis occasionally have been dramatic. However, ganciclovir
pregnant woman when she might not be immune. By so doing, a severe is seldom used because of the potential long-term risk to spermatogen-
110
congenital CMV infection may be avoided. The latter possibility is esis (aspermia) or potentially on female fertility. Thus, when the disease
much more likely in the developed world, because only 20 to 30 percent appears to be self-limited, many physicians do not treat it. Therapy that
of women have been infected with CMV before they reach reproduc- already was started is stopped after a few weeks. Antiretroviral therapy
tive age. In the older teenage child, both EBV and CMV may cause the has been suggested for severe HIV primary disease.
mononucleosis syndrome but EBV is far more common. If exudative Acyclovir use for other manifestations of EBV infection not result-
pharyngitis or lymphadenopathy is present then it is most likely to be ing from host response but from a high titer of EBV replication, such as
EBV. If the patient has intraoral ulcers tests for HIV should be done. oral hairy leukoplakia of AIDS, rapidly resolves lingual lesions. How-
136
In the sexually active teen, both EBV and HIV testing should be ever, treatment with acyclovir does not appear to be effective for the
108
done but CMV remains a possibility. Simultaneous infection with carrier state. 137
EBV and HIV has occurred, although this, too, is very uncommon.
Presence of heterophile antibody strongly supports EBV, although these
have been reported in HIV. In adults in their 30s or 40s, mononucle-
127
osis more likely results from infection with CMV than EBV because MONONUCLEOSIS IN PREGNANCY
almost all individuals have been infected with EBV by age 25 years. CYTOMEGALOVIRUS AND EPSTEIN-BARR
Furthermore, absence of exudative pharyngitis points to CMV, but HIV
also should be considered in this age group. Patients infected with either VIRUS INFECTION
CMV or HIV can present with blood neutrophilia with an increased For CMV, immunity does not necessarily protect against congenital
proportion of band neutrophils. Rash or aseptic meningitis is more infection. CMV viruria at birth occurs in babies of mothers known
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common in patients infected with HIV than CMV. In the middle-aged to be seropositive before they became pregnant. Some viruric children
patient, primary CMV infection is by far the most important possibility, whose mother is seropositive at conception go on to develop unilateral
although the unusual individual who has escaped infection with EBV or bilateral hearing loss. The reason for the susceptibility to this type
earlier in life may present with EBV with clinical manifestations similar of infection in the apparently immune mother is not clear. If primary
to patients with primary CMV infection at that age. 18,40,41 CMV infection occurs during gestation the baby can have very severe
disease. Microcephaly, mental retardation, cataracts, hepatosplenomeg-
110
THERAPY aly, and fetal loss or postnatal death have can occur. When EBV
mononucleosis occurs during pregnancy, severe abnormalities similar
For the majority of patients with primary CMV or EBV infection, treat- to those as described for CMV have occurred (see Table 82–4). 138,139
ment is supportive. Salicylates or other analgesics are appropriate for Ganciclovir for congenital CMV infection in a very young child is being
control of fever, headache, and sore throat. Contact sports should be studied for those who are viruric at birth. Antiviral therapy with fam-
avoided until the spleen has returned to normal size because splenic ciclovir or valacyclovir has been used for EBV primary infection dur-
rupture can occur in the first few weeks after diagnosis. The vast major- ing pregnancy, but the number of patients treated is too small to draw
ity of subjects improve and have resolution of most symptoms. Almost conclusions.
half of patients recovering from EBV mononucleosis still feel fatigued at
60 days and a small percent at 6 months. Severe fatigue can persist after
CMV mononucleosis as well. HIV INFECTION
Antiviral therapy may be considered in special settings for treat- Primary infection with HIV during pregnancy may not be recognized
ment of EBV mononucleosis. The nucleoside analogue acyclovir blocks because HIV antibody is absent early in infection and the antibody
EBV replication by inhibition of viral DNA polymerase and can prevent screening process is performed at the first prenatal visit. If suspicion of
viral shedding from the oropharynx. 131,132 However, acyclovir has little if HIV infection is raised during pregnancy and the antibody test for HIV
any effect on the course of mononucleosis, presumably because the dis- is negative, then viral load should be measured. If positive, antiretrovi-
ease at that point results from the immunopathologic process and not ral therapy for the mother to prevent HIV transmission to the fetus or
viral proliferation. Antiviral therapy may be useful in chronic aggressive newborn is indicated. 140
EBV infection and in EBV infection posttransplantation.
Glucocorticoids have been used for management of specific
complications. Their specific benefit is difficult to determine because TOXOPLASMA INFECTION
glucocorticoids often are started late in the clinical course, when immu- T. gondii producing primary infection during pregnancy can lead to
nologic reaction to infection is leading to improvement. One carefully congenital abnormalities. Although no controlled trials are available,
controlled trial showed little benefit from glucocorticoids in EBV treatment of the mother with pyrimethamine plus sulfonamides or spi-
mononucleosis, and the treated group did less well at 30 days than the ramycin may eradicate parasites from the infant and the placenta. 141,142

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