Infectious mononucleosis combined with SARS-CoV-2 infection.

A clinical analysis of COVID-19 cases combined with acute respiratory diseases is presented. The aim of the study was to analyze clinical and laboratory data of patients with combined COVID-19 infection. In patient A. infected with SARS-CoV-2 without X-ray confirmation of lung damage, acute tonsillitis, polyadenopathy, hepatosplenomegaly, moderate leukocytosis, lymphomonocytosis and the presence of reactive lymphocytes were detected. Serological and molecular biological studies were carried out for the purpose of differential diagnosis. A positive test result for IgM antibodies to EBV was obtained. The method of polymerase chain reaction (PCR) revealed EBV DNA in blood plasma. The result of the determination of heterogeneous IgG antibodies to the EBV caspid antigen is negative. Clinical symptoms of the patient with coronavirus infection COVID-19, confirmed by radiological and serological screening, included: fever, sore throat, hyperemia and hypertrophy of the palatine tonsils, hepatomegaly, changes of the cellular composition of the blood. At the same time, the lymph nodes in the neck, chest and abdominal cavity were not enlarged;the presence of reactive lymphocytes and plasma cells was not detected. Serological markers of EBV were also not detected. A PCR test for Epstein-Barr virus DNA was negative.Copyright © 2022 Infectious Diseases: News, Opinions, Training.

Post-Infectious Acute Cerebellar Ataxia Treatment, a Case Report and Review of Literature.

BACKGROUND: infectious mononucleosis is very common during childhood and neurological manifestations are extremely rare. However, when they occur, an appropriate treatment must be undertaken to reduce morbidity and mortality as well as to ensure appropriate management. METHODS: we describe the clinical and neurological records of a female patient with post-EBV acute cerebellar ataxia, whose symptoms rapidly resolved with intravenous immunoglobulin therapy. Afterwards, we compared our results with published data. RESULTS: we reported the case of an adolescent female with a 5-day history of sudden asthenia, vomiting, dizziness, and dehydration, with a positive monospot test and hypertransaminasemia. In the following days, she developed acute ataxia, drowsiness, vertigo, and nystagmus with a positive EBV IgM titer, confirming acute infectious mononucleosis. The patient was clinically diagnosed with EBV-associated acute cerebellitis. A brain MRI showed no acute changes and a CT scan showed hepatosplenomegaly. She started therapy with acyclovir and dexamethasone. After a few days, because of her condition's deterioration, she received intravenous immunoglobulin and demonstrated a good clinical response. CONCLUSIONS: although there are no consensus guidelines for the treatment of post-infectious acute cerebellar ataxia, early intervention with intravenous immunoglobulin might prevent adverse outcomes, especially in cases that do not respond to high-dose steroid therapy.

It Takes Two to Make a Thing Go Wrong

Seventy-three-year-old diabetic male was a high-risk transfer from Alaska for respiratory decompensation in the setting of progressive bulbar and proximal weakness. He was diagnosed with COVID-19 two months prior and viral mononucleosis 1 month prior to presentation. While the patient had a fall 3 months prior to presentation, and decreased mobility at home, there was abrupt onset of progressive upper/lower extremity weakness, dysphagia, and difficulties managing secretions 2 weeks prior to presentation. Initial exam was notable for MRC 3-4/5 proximal upper/lower extremity weakness, areflexia, and negative inspiratory force of 224 to 230 cm H20. A subtle periorbital heliotrope rash was documented. Lumbar puncture demonstrated albumino-cytologic dissociation (protein 142 mg/dL, 6 WBCs) and CK remained elevated (1930 U/L) despite intravenous hydration. Outside electrodiagnostic testing demonstrated a sensorimotor axonal neuropathy with questionable myopathic features on needle electromyography. Given concern for an inflammatory neuropathy and concomitant inflammatory myopathy, intravenous immunoglobulin 2G/kg and IV methylprednisolone 1G/day over 5 days was started. He was transferred for further diagnostic workup and supportive care 6 days after presentation and required intubation within 24 hours of admission. Exam showed progressive proximal and distal weakness of the extremities and general areflexia/hyporeflexia. Repeat electromyography confirmed a severe sensorimotor axonal polyneuropathy without acquired demyelinating features and normal repetitive nerve stimulation. While the patient could no longer activate muscles voluntarily, proximal muscles had increased spontaneous activity with predominant myotonia. Neuroaxis imaging was notable only for enhancement of the lumbar nerve roots. Combined vastus lateralis muscle biopsy and serologic testing confirmed a second pathologic process contributing to the patient's weakness. This case highlights the cooccurrence of 2 distinct neuropathological entities, with potential relation to a prior viral infection, and the importance of ancillary testing to guide treatment for acute causes of neuromuscular respiratory failure.

Infectious Mononucleosis Presenting with Loss of Taste and Smell During the SARS-CoV-2 Pandemic?

A 53-year-old woman presented during the SARS-CoV-2 pandemic with an 18-day history of pyrexia, myalgia, progressive dyspnoea and loss of taste and smell after a close contact had tested positive for SARS-CoV-2. In this period two swabs had been negative for SARS-CoV-2. Clinical examination was normal. During this admission a third SARS-CoV-2 swab was negative, and investigations showed mildly elevated inflammatory markers, mildly deranged liver function, atypical lymphocytes on a blood film and a normal chest x-ray. Her Epstein-Barr virus serology was positive and thus the diagnosis was infectious mononucleosis. LEARNING POINTS: SARS-CoV-2 is not the only virus to cause loss of taste/smell and so other differential diagnoses should be considered.Loss of taste/smell is a subjective symptom, and therefore caution should be exercised in the context of an upper respiratory tract infection.

An Unusual case of epstein-barr virus hepatitis mistaken for multisystem inflammatory syndrome in children

Case Report: As COVID-19 infections became more common, children began presenting with multisystem inflammatory syndrome (MIS-C). It can be difficult to distinguish rare presentations of common diseases from MIS-C, especially when there has been a close contact with COVID-19. Epstein-Barr virus (EBV) is a universally common infection with 90% of individuals showing serological signs of past infection. Both MIS-C and EBV can present with similar signs and symptoms. Our case aims to remind the reader to keep in mind uncommon presentations of common viral infections which may mimic MIS-C. Case Presentation: A previously healthy 5-year-old girl presented with persistent fevers for 12 days, associated with stomatitis, vomiting, and diarrhea. Physical exam was significant for a moderately ill-appearance, small (<1 cm) left posterior cervical lymphadenopathy, and soft palate and buccal oral ulcers. Initial labs (see Table) revealed leukocytosis with reactive lymphocytes and cholestatic hepatitis with mild coagulopathy. Although she had no respiratory symptoms, CT chest revealed left upper lobe pneumonia. Abdominal ultrasound showed diffuse hepatosplenomegaly, gallbladder wall thickening, and enlarged epigastric lymph nodes. Echocardiogram showed normal systolic function and coronary arteries without dilation. Extensive viral and bacterial nasal swab and serologic testing, including for SARS-CoV-2 antibodies, was negative. On Day 2, her Monospot was positive, along with EBV viral capsid antigen IgM and IgG with the absence of EBV nuclear antigen IgG. In addition, serum PCR was positive for EBV. Management and Outcome: Due to persistent fevers on Day 3 of broad-spectrum antibiotics, coupled with a close contact with active COVID infection, she was treated with the MIS-C protocol of intravenous immunoglobulin G (IVIG), prednisone, and aspirin. Within a day of IVIG, she improved clinically and fever resolved. By discharge on Day 8, her lab values had begun to normalize. Discussion(s): EBV is known to present in children with typical infective mononucleosis symptoms such as fever, sore throat, and lymphadenopathy. However, these can be lacking which makes the diagnosis challenging. Although hepatitis is a common sequalae of EBV, EBV induced pneumonitis and stomatitis are rare, especially in immunocompetent individuals. While our patient improved after treatment with IVIG, suggesting MIS-C, we still attribute her illness to EBV, as IVIG has been shown to provide antiviral and anti-inflammatory benefit in EBV infections. This case highlights the challenge of recognizing and overtreating rare presentations of common viral infections in the face of an emerging disease such as MIS-C. Significant Laboratory Values [Table presented] Copyright © 2023 Southern Society for Clinical Investigation.

Aplastic Anemia with Epstein-Barr Virus Reactivation after Anti-thymocyte Globulin Therapy.

Lymphoproliferative disorders and Epstein-Barr virus reactivation (EBV-LPDs) have various forms of onset, ranging from infectious mononucleosis-like syndrome (IM-like) to lymphoma, although whether or not IM-like progresses to lymphoma remains unclear. A 61-year-old man was diagnosed with aplastic anemia (AA). Polyclonal atypical B-lymphocytes were observed in the peripheral blood, and IM-like was diagnosed. Atypical lymphocytes disappeared, but a gastrointestinal examination revealed diffuse large B-cell lymphoma (DLBCL). Rituximab was initiated but later discontinued because of severe acute respiratory syndrome coronavirus 2 infection. Pancytopenia due to AA exacerbation recurred. The patient ultimately died of multiple organ failure due to bacterial infection.

Infectious mononucleosis combined with SARS-CoV-2 infection

A clinical analysis of COVID-19 cases combined with acute respiratory diseases is presented. The aim of the study was to analyze clinical and laboratory data of patients with combined COVID–19 infection. In patient A. infected with SARS-CoV-2 without X-ray confirmation of lung damage, acute tonsillitis, polyadenopathy, hepatosplenomegaly, moderate leukocytosis, lymphomonocytosis and the presence of reactive lymphocytes were detected. Serological and molecular biological studies were carried out for the purpose of differential diagnosis. A positive test result for IgM antibodies to EBV was obtained. The method of polymerase chain reaction (PCR) revealed EBV DNA in blood plasma. The result of the determination of heterogeneous IgG antibodies to the EBV caspid antigen is negative. Clinical symptoms of the patient with coronavirus infection COVID-19, confirmed by radiological and serological screening, included: fever, sore throat, hyperemia and hypertrophy of the palatine tonsils, hepatomegaly, changes of the cellular composition of the blood. At the same time, the lymph nodes in the neck, chest and abdominal cavity were not enlarged;the presence of reactive lymphocytes and plasma cells was not detected. Serological markers of EBV were also not detected. A PCR test for Epstein–Barr virus DNA was negative. © 2022 Infectious Diseases: News, Opinions, Training.

CLINICAL CASE OF CORONAVIRUS DISEASE COMBINED WITH INFECTIOUS MONONUCLEOSIS IN CHILDREN

The article presents a clinical case of coronavirus disease in a child, combined in time with infectious mononucleosis. Today there is a growing tendency in the prevalence of diseases caused by herpes viruses. At the same time there is an increase in the incidence of infectious mononucleosis. The level of Epstein-Barr virus infection among the adult population of Ukraine has reached almost 100%, and more than 50% among the children. The number of children confirmed by COVID-19 is growing with each passing wave, and coronavirus disease is dangerous for young children with a high probability of complications and hospitalizations. The first manifestations of the disease were not typical: fever, nausea, periorbital edema. A week later, typical mononucleosis complaints of sore throat, "nasality", raids on the tonsils and enlargement of the tonsils appeared. Additional examinations revealed an increase in ALT and AST, an increase in the liver. The diagnosis was made on the basis of detecting an increase in the level of specific immunoglobulins to SARS-Cov-2 and EBV. The coronavirus disease can initiate the manifestation of persistent viruses, in particular EBV. © L. V. Melnichuk, 2022.

High Monocyte Count Associated with Human Cytomegalovirus Replication In Vivo and Glucocorticoid Therapy May Be a Hallmark of Disease.

Cytomegalovirus (CMV) syndrome and infectious disease are defined as pathogen detection with appropriate clinical symptoms, but there are not pathognomonic signs of CMV disease. Although the prodrome of acute minor viral infections leukopenia (lymphopenia and neutropenia) is noted with onset of fever, followed by monocytosis, the role of monocytosis in CMV disease has not been described. Furthermore, under influence of corticosteroid therapy, CMV reactivation and monocytosis are described, but without a strict relationship with steroids dose. In the study, the monocyte level was investigated during the CMV infectious process. Regrettably, a non-selected group of 160 patients with high CMV viremia showed high dispersion of monocyte level and comparable with the median value for healthy subjects. Therefore, we investigated monocyte level in CMV-infected patients in relation to the logarithmic phase of the infectious process. Samples from patients with active CMV replication (exponential growth of CMV viremia) were tested. Significant monocytosis (above 1200/µL) during the logarithmic phase of CMV infection (with exponent between 3.23 and 5.77) was observed. Increased count and percentage of monocytes correlated with viral replication in several clinical situations except when there was a rapid recovery without relapse. Furthermore, glucocorticoids equivalent to 10 and 20 mg of dexamethasone during a 2-3-week period caused monocytosis-significant increase (to 1604 and 2214/µL, respectively). Conclusion: In light of the logarithmic increase of viral load, high monocytosis is a hallmark of CMV replication. In the COVID-19 era, presence of high virus level, especially part of virome (CMV) in the molecular technique, is not sufficient for the definition of either proven or probable CMV replication at any site. These preliminary observations merit additional studies to establish whether this clinical response is mediated by monocyte production or by decrease of differentiation to macrophages.

Two cases of COVID vaccine-induced immune thrombotic thrombocytopenia in Luxembourg

Introduction: In March 2021, a signal for embolic and thrombotic events with Vaxzevria (COVID-19 Vaccine AstraZeneca) was raised in Austria and Germany, and on 7 April 2021, the European Pharmacovigilance Risk Assessment Committee (PRAC) concluded that a causal relationship between Vaxzevria and thrombosis combined to thrombocytopenia (TTS) was at least a reasonable possibility [1]. TTS mechanism is close to heparin-induced thrombocytopenia [2,3]. We report two Luxembourg cases of TTS that occurred one before and one after this confirmed signal. Results: The first case is a 74-year-old woman, with no medical history, who received her first dose of Vaxzevria in March 2021. Fourteen days later, she was hospitalised for sudden loss of consciousness. On admission she had thrombocytopenia (18 G/L), D-Dimers >20 000 ng/mL, antithrombin III 79%, fibrinogen 0.69 g/dL. Brain CT scan showed cerebral and meningeal haemorrhages. She died three days later. Autopsy confirmed multiple intracranial haemorrhages and showed right transverse sinus organised thrombosis. Post-mortem analysis revealed positive heparin-Platelet Factor 4 (PF4) antibodies (HIPA and PIPA). The second case is a 31-year-old man with medical history of splenic infarction in 2017 during mononucleosis. He received his first dose of Vaxzevria in June 2021, and 12 days later was admitted for right lower limb and lumbar pain with severe thrombocytopenia (28 G/L), low fibrinogen and elevated D-Dimers. Angiography showed sub-occlusive cruoric impactions of the left carotid bifurcation, the sub-renal abdominal aorta and the right common femoral artery. PF4 antibody initially negative (Zymutest Hyphen) were positive with IMMUCOR technique. Management included clots removal, intravenous immunoglobulins started for 3 days and anticoagulation with sodium danaparoid. The patient recovered within one month without sequelae. Discussion/Conclusion: The quick communication about TTS signal and the rapid identification of its mechanism both allowed, as reported here for the second patient, adapted management (prohibiting heparin), with full recovery.

[Fatigue Doesn't Always have to be caused by SARS-CoV-2: Case Report]. / Fatigue muss nicht immer SARS-CoV-2-bedingt sein ­ eine Kasuistik.

We report on a 17-year-old female adolescent who presented with marked fatigue. The cause of this was found to be Epstein-Barr virus (EBV) infection. Even during the COVID-19 pandemic, fatigue doesn't always have to be caused by SARS-CoV­2 but can also be induced by other adolescent-onset diseases (EBV), Up to 13.5 % of EBV sufferers develop chronic fatigue syndrome, which is why it makes sense to determine the exact cause. Diagnosis, therapy and prognosis of infectious mononucleosis are addressed.

"Fuzheng Quxie" and antiviral effect of Ganoderma (Lingzhi)

"Fuzheng Quxie" is an important theory of TCM related to prevention and cure of diseases. By enhancing the body immunity, Ganoderma (Lingzhi) indirectly inhibits the virus invasion, proliferation and destruction in the human body ("Fuzheng" means strengthening and consolidating body resistance). It can also directly inhibit and kill viruses ("Quxie" means dispelling evil). Lingzhi and its active components have antiviral effects on influenza virus, herpes virus, hepatitis B virus, human immunodeficiency virus, Newcastle disease virus, dengue virus and enterovirus. Lingzhi preparations alone or with antiviral drugs can treat hepatitis B, herpes zoster, recurrent genital herpes, condyloma acuminatum, infectious mononucleosis of children, cervical papillomavirus infection and AIDS. In addition, the possibility of preventing and treating COVID-19 (corona virus disease 2019) with Lingzhi was discussed.

Diagnostic value of FDG-PET/CT in fever of unknown origin

Background: Fever of unknown origin (FUO) is a challenging clinical problem in medicine that needs collaboration of various diagnostic techniques to establish the accurate diagnosis. We evaluated the diagnostic performance of 18F-FDG PET/CT in patients who presented themselves with FUO. Our study included 40 patients with FUO who underwent PET/CT examination and their results were compared to the results of laboratory, histopathological, microbiological investigations and/or response to therapy. Results: The final diagnosis included malignancy in 20 patients (50%), infectious causes in 7 patients (17.5%) and non-infectious inflammatory causes in 6 patients (15%). Fever resolved without diagnosis in 4 patients (10%), while no definite diagnosis was reached in 3 patients (7%). PET/CT successfully contributed to diagnosis of 35 out of 40 patients with diagnostic accuracy of 87.5%. The sensitivity, specificity, positive predictive value and negative predictive value of PET/CT in our study were 93.5%, 66.7%, 90.6% and 75%, respectively. Conclusion: PET/CT is a useful tool to investigate and diagnose the cause of FUO. It provides information that can guide the treatment strategy of the patients.

Transient hypertriglyceridemia: a common finding during Epstein-Barr virus-induced infectious mononucleosis.

BACKGROUND: Hypertriglyceridemia can occur in lymphoproliferative disorders. Infectious mononucleosis is a self-limiting, benign lymphoproliferative disorder. This study aimed to investigate the serum triglyceride concentrations and their change over time in patients with infectious mononucleosis. METHODS: We evaluated an adult patient with severe hypertriglyceridemia (>1000 mg/dL) during infectious mononucleosis and reviewed the records of 360 patients admitted to our hospital because of infectious mononucleosis (median age, 19 years; range, 15-87 years; 51.4% male). We compared the serum triglyceride concentrations with those of a control sample from the general population (n=75). A second triglyceride measurement, obtained during convalescence (median of 30 days after the initial determination), was available for 160 patients. RESULTS: The triglyceride concentrations in the acute phase (median: 156 mg/dL) were significantly higher than those of the controls (median, 76 mg/dL; P<0.001). A total of 194 (53.9%) patients presented with hypertriglyceridemia (>150 mg/dL), which was more common in the patients older than 30 years than in the younger patients (78.6% vs. 50.6%; P<0.001). A significant correlation (P<0.005) was observed between the triglyceride levels and white blood cell counts, total cholesterol levels, and liver damage markers. The triglyceride concentrations decreased during convalescence (P<0.001) and were lower than the initial measurement in 83.7% of the cases. Conversely, the total cholesterol concentrations during the acute phase were lower than those of the controls and increased during convalescence (P<0.001). CONCLUSIONS: Patients with severe infectious mononucleosis frequently show mild, transient hypertriglyceridemia. Further studies are needed to elucidate the mechanisms underlying this finding.

Atraumatic splenic rupture as a rare complication of acute myeloid leukemia: a case report and literature review

Introduction: Atraumatic Splenic Rupture (ASR) is a rare but life-threatening clinicopathological phenomenon with limited information on patient features, occurrence, or etiology. ASR is an uncommon and lethal complication that is observed in infectious (mainly mononucleosis) and hematological diseases (mainly malignant homeopathies) in more than half of cases. Mortality is approximately around 20%, and some deaths occur before the diagnosis is confirmed, while others occur after surgery due to delayed management and poor patient status. Case Presentation: A 48-year-old man with no history of the underlying disease presented to the Emergency Department with abdominal pain. He was admitted with leukocytosis 145..103/l, hemoglobin 6.4 g/dl, platelets 15..103/l, erythrocyte sedimentation rate 89 mm/h, and D-Dimer 1043 ng/FEU ml. Sputum test through PCR ruled out severe acute respiratory syndrome coronavirus 2 infections. Due to peripheral blood smear and bone marrow aspiration/biopsy, acute myeloid leukemia was diagnosed for the patient. On the third day of hospitalization, the patient's abdominal pain intensifies. Ultrasound revealed medium free fluid inside the abdomen and pelvis. The patient was transferred to the operating room to undergo an emergency laparotomy. There was a large hematoma in the spleen with a rupture in its posterior surface. Splenectomy was performed, and the histopathological study of the spleen showed leukemic involvement, capsular ruptures, and subcapsular hematomas.

A Case Found to Be Severe Acute Respiratory Syndrome Coronavirus 2 Positive Immediately Before Hospitalization for Infectious Mononucleosis.

The cases of coronavirus disease 2019 (COVID-19) mainly present with symptoms such as persistent fever, cough, and general malaise, which may become severe or fatal; while young people do not show these typical symptoms and are asymptomatic, some cases are infected with minor symptoms or none. Herein, we report a case of a 20-year-old woman who was hospitalized for infectious mononucleosis (IM). Initially, fever and sore throat were observed without typical COVID-19 symptoms, but polymerase chain reaction (PCR) tests performed before admission confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positivity. Fortunately, she was discharged without any serious symptoms as IM and COVID-19. Virological examination suggested a primary infection with the Epstein-Barr virus. In the COVID-19 pandemic, we should also pay attention to the possibility of SARS-CoV-2 coinfection in mild and asymptomatic young cases, even if the symptoms suggesting IM are preceded.

Development of infectious mononucleosis as an unusual manifestation of COVID-19.

It has generally been reported that patients with COVID-19 show a fever, cough, and/or respiratory failure as the most common clinical symptoms but some have unusual symptoms, such as anosmia, diarrhea, and throat pain. We herein report a 26-year-old woman with chief complaints of lymphadenopathy and a fever. First, she underwent a laboratory examination, which showed a high proportion of atypical lymphocytes (19%) and an increase in hepatic enzyme activities, and was then hospitalized with a diagnosis of infectious mononucleosis (IM). However, the blood examination did not show any increase in anti-Epstein-Barr virus VCM-IgM. Subsequently, she developed tonsillar hypertrophy with purulent plugs. An additional examination for infection of other pathogens revealed positivity only for SARS-CoV-2 in a loop-mediated isothermal amplification (LAMP) test. The patient was transferred to the COVID-19-specific isolation ward, and none of the ward staff, patients, or either of the two otolaryngologists who had directly examined this patient showed positive signs for SARS-CoV-2 in a LAMP test. Consequently, this case suggests that even if patients show clinical symptoms and signs of common diseases for otolaryngologists, such as IM, we should keep in mind the possibility of COVID-19 without arbitrarily assuming that IM is caused by Epstein-Barr virus.