Cervical necrotising fasciitis: a rare complication of infectious mononucleosis.

Cervical necrotising fasciitis (NF) is an aggressive polymicrobial infection of the subcutaneous tissues in the head and neck. We present a case of a healthy 19-year-old man who developed cervical and upper mediastinal NF after an initial presentation of infectious mononucleosis (IM). He was treated with broad-spectrum antibiotics in addition to incision and drainage of an anterior neck and upper mediastinal abscess. He progressed favourably after ten days of hospitalisation and was discharged home on intravenous antibiotics. This is a unique case of cervical NF as a sequelae of IM in a previously healthy paediatric patient.

Detection and virulence potential of a phospholipase D-negative Corynebacterium ulcerans from a concurrent diphtheria and infectious mononucleosis case.

Diphtheria by Corynebacterium ulcerans is increasingly occurring in children, adolescents and adults. In addition to diphtheria toxin (DT), phospholipase D (PLD) is considered a virulence factor of C. ulcerans. In the present study, a first case of concurrent diphtheria by a PLD-negative C. ulcerans and infectious mononucleosis (IM) was verified. Clinical and microbiological profiles and binding properties to human Fibrinogen (Fbg), Fibronectin (Fn) and type I collagen (col I) biotinylated proteins and virulence to Caenorhabditis elegans were investigated for C. ulcerans strain 2590 (clinical isolate) and two control strains, including PLD-positive BR-AD22 wild type and PLD-negative ELHA-1 PLD mutant strains. MALDI-TOF assays and a multiplex PCR of genes coding for potentially toxigenic corynebacteria identified strain 2590 as non-DT producing. Interestingly, strain 2590 did not express PLD activity in the CAMP test although the presence of the pld gene was verified. PLD-negative 2590 and a PLD-positive 210932 strains showed similar affinity to Fbg, Fn and type I collagen. C. elegans were able to escape from C. ulcerans strains, independent of PLD and DT production. Higher mortality of nematodes was verified for PLD-negative strains. Additional studies concerning multifactorial virulence potential of C. ulcerans, including environmental conditions remain necessary.

An infant with concurrent serotype 6C invasive pneumococcal disease and infectious mononucleosis.

Streptococcus pneumoniae is a main causative agent of serious invasive bacterial infections. However, concurrent infection with invasive pneumococcal disease (IPD) and viral infectious mononucleosis (IM) is rare. We report an infant with serotype 6C infection causing IPD occurring simultaneously with IM. A previously healthy 11-month-old girl referred to our hospital because of fever, leukopenia, and elevated C-reactive protein presented to us with disturbance of consciousness, tachycardia, tachypnea and agranulocytosis. Other findings included tonsillitis with purulent exudates and white spots, bilateral cervical adenopathy, and hepatosplenomegaly. We diagnosed her illness as sepsis and administered a broad-spectrum antibiotic, an antiviral agent, and granulocyte transfusions. After treatment was initiated, fever gradually decreased and general condition improved. IPD was diagnosed based upon isolation of S. pneumoniae of serotype 6C from blood cultures obtained on admission. Concurrently the girl had IM, based upon quantitation of Epstein-Barr viral DNA copies in blood and fluctuating serum antibody titers. Although simultaneous IPD and IM is a rare occurrence, this possibility is important to keep in mind.

[THE DIAGNOSTIC APPROACHES TO VERIFICATION OF STREPTOCOCCUS INFECTION IN PATIENTS WITH INFECTIOUS MONONUCLEOSIS].

The Rostovskii state medical university of Minzdrav of Russia, 344022 Rostov-on-Don, Russia The analysis is applied concerning significance of laboratory techniques of verification of streptococcus infection (bacteriological analysis, detection of anti-streptolysin O in pair serums) in 148 patients with infectious mononucleosis aged from 3 to 15 years. The content of anti-streptolysin O exceeded standard in 41 ± 4.8% of patients with concomitant in acute period and in 49.5 ± 4.9% during period of re-convalescence. This data differed from analogous indicator in patients with negative result of examination on streptococcus infection independently of period of disease (9.3 ± 2.8%). The exceeding of standard of anti-streptolysin O was detected more frequently (t ≥ 2, P ≥ 95%) in patients with isolation of Streptococcus pyogenes (56.9 ± 5.8%) than in patients with Streptococcus viridans (31.2 ± 6.5%). The concentration of anti-streptolysin 0 in patients with concomitant streptococcus infection varied within limits 200-1800 IE/ml. The minimal level of anti-streptolysin O (C = 200 IE/mI) was detected independently of type of isolated Streptococcus and period of disease. The high levels of anti-streptolysin O were observed exclusively in patients with isolation of Streptococcus pyogenes. In blood serum ofpatient with concomitant streptococcus infection (Streptococcus pyogenes + Streptococcus viridans) increasing of level of anti-streptolysin O was detected in dynamics of diseases from minimal (C = 200 IE/ ml) to moderately high (200 < C < 400 IE/mI). It is demonstrated that to identify streptococcus infection in patients with infectious mononucleosis the anamnesis data is to be considered. The complex bacteriological and serological examination ofpatients is to be implemented This is necessary for early detection ofpatients with streptococcus infection and decreasing risk of formation of streptococcus carrier state.

Evaluación del sistema VIDAS para estudio de marcadores serológicos de infección por el virus Epstein Barr / Performance of the VIDAS automated immunoassay for the determination of Epstein-Barr virus serological status

Se han evaluado ensayos de fluorescencia ligada a enzima (VIDAS EBV VCA IgM, VIDAS EBV VCA/EA IgG y VIDAS EBV EBNA IgG (Biomérieux, Francia) para la determinación de marcadores de infección por el virus Epstein Barr, así como para el establecimiento de perfiles de anticuerpos, comparándolos con ensayos de inmunofluorescencia como referencia. Los ensayos evaluados han mostrado buenas características de sensibilidad, especificidad y coincidencia porcentual de resultados, lo que les hace adecuados para su aplicación en laboratorios de diagnóstico clínico (AU)

Enzyme linked fluorescent assays (VIDAS EBV VCA IgM, VIDAS EBV VCA/EA IgG and VIDAS EBV EBNA IgG (Biomérieux, France) were evaluated to determine markers for infection of Epstein Barr virus, as well as to establish antibody profiles, compared with immunofluorescence assays as reference. The assays evaluated showed good values for sensitivity, specificity and agreement, making them useful for their application in clinical laboratories (AU)

[A young man with mononucleosis and swelling of the right eye]. / En ung mann med mononukleose og hevelse over høyre øye.

Treatment of acute infections in the upper airways comprises a significant part of direct healthcare expenditure and is a challenge for healthcare professionals. In Norway, 11,495 hospitalized days were recorded for acute infections (influenza and pneumonia excluded) in the upper airways in 2008. Acute bacterial rhinosinusitis (ABRS) is defined as inflammation of the nose and the paranasal sinuses characterized by both 1): symptoms of nasal blockage/obstruction/congestion or nasal discharge, and/or facial pain/pressure and 2): endoscopic signs of mucopurulent discharge from middle meatus and/or CT changes within the osteomeatal complex/sinuses. After 12 weeks of symptoms the definition changes to chronic rhinosinusitis. With antibiotic treatment of complicated ABRS we see fewer severe complications, but they still occur. Due to anatomical proximity of the orbit and intracranial structures a localized spread of the infection is especially unfortunate and potentially dangerous. We present a case report (with pan sinusitis and grave local complications) from the ear, nose and throat department in St. Olav's University Hospital in Trondheim, Norway.

Lemierre's and Lemierre's-like syndromes in association with infectious mononucleosis.

OBJECTIVE: This study aimed to review cases of Lemierre's and Lemierre's-like syndromes in paediatric patients, to examine a possible association with Epstein-Barr virus as a predisposing factor, and to assess the impact of this virus on the severity of illness. METHODS: We performed a retrospective analysis of data from the in-patient database at Winthrop University Hospital, from January 2001 to October 2007. We reviewed clinical and laboratory findings as well as the outcome of infection in patients aged 21 years or less with a diagnosis of Lemierre's syndrome. An additional case of Lemierre's-like syndrome was also included. The illness severity and duration of in-patient management of those testing positive for heterophile antibody were then compared with the same parameters in patients who tested negative. RESULTS: Of the five patients diagnosed with Lemierre's syndrome, two had concomitant acute infection with Epstein-Barr virus. Additionally, a 19-year-old adolescent was admitted during this period with acute infectious mononucleosis, Fusobacterium necrophorum sepsis, sinusitis, frontal lobe abscess and ophthalmic vein thrombosis. The clinical presentation of all patients included fever, sore throat, and ear or neck pain. The duration of symptoms ranged from two days to three weeks prior to admission. The patients with acute Epstein-Barr virus infection had been diagnosed with infectious mononucleosis prior to admission, and tested positive for heterophile antibody. These patients subsequently underwent more extensive in-patient treatment, including intensive care management and ventilator support. The patients who tested negative for heterophile antibody experienced a milder course of illness, with a shorter duration of in-patient management. CONCLUSION: Two patients diagnosed with Lemierre's syndrome, and a third with Fusobacterium necrophorum sepsis, had coexisting acute Epstein-Barr virus infection. Patients who tested positive for heterophile antibody experienced a more severe course of illness. These observations suggest a possible association between Epstein-Barr virus infection and the severity of concomitant Lemierre's syndrome.

The uptake and use of the Monospot test in patients with tonsillitis.

The objective of the study was to ascertain the uptake of the Monospot test in St. James's hospital in Dublin over the five years 2002-2006 and to determine the percentage of Monospot tests which had a positive result. Using the HIPE, Electronic Patient Record (EPR) and Patient Access System (PAS) databases in St. James's Hospital, a cohort of 593 patients with a diagnosis of tonsillitis or infectious mononucleosis was identified. Fourteen patients met the exclusion criteria as outlined below leaving a valid pool of 579 patients. It was ascertained whether each patient had a Monospot performed and if so, whether the result was positive or negative. In total, 249 (43.0%) of the included patients had a Monospot test. Of these, 197 (79.1%) were negative and 29 (11.6%) were positive. In 23 (9.2%) cases, no result was available. The uptake of the Monospot increased over the five years studied. A positive Monospot impacts on treatment and follow up. We therefore recommend that one is carried out in all patients presenting with acute tonsillitis.

Pharyngitis of infectious mononucleosis: computed tomography findings.

Two women presented with sore throat and fever. Their symptoms were not alleviated by antibiotics. Cervical computed tomography (CT) with contrast enhancement demonstrated enlargement of predominant posterior cervical lymph nodes and streaky heterogeneous tonsils with interspersed low attenuation. They were diagnosed as having infectious mononucleosis by their laboratory data. Thus, when radiologists encounter these CT findings of pharyngitis that is not alleviated by antibiotic therapy, infectious mononucleosis should be considered in the differential diagnosis.

Screening for glandular fever in patients with Quinsy: is it necessary?

Quinsy (peritonsillar abscess) is a common emergency seen in otolaryngology practice. These patients are often screened for glandular fever in addition to routine haematological tests. In our unit, we have screened 66 patients with quinsy for glandular fever over a period of 12 months. All these patients were screened for glandular fever by rapid immunoassay. Only one out of 66 patients was tested positive for glandular fever. Due to the extremely low incidence of glandular fever in quinsy patients, we do not see any relevance in screening for glandular fever in quinsy patients. Hence we recommend that routine screening for glandular fever in quinsy patients is an unnecessary invasive investigation for the patients and not cost effective for the hospital.

Chlamydophila pneumoniae, un posible agente causal del síndrome mononucleósico / Chlamydophila pneumoniae, a possible cause of mononucleosis syndrome

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Mononucleosis infecciosa de evolución tórpida / Indolent infectious mononucleosis

Se presenta el caso de una paciente de 14 años, diagnosticada de mononucleosis infecciosa, con una importante hipertrofia del sistema reticuloendotelial, con hepatosplenomegalia de más de 16 cm, una importante afectación de las enzimas hepáticas e hipertrofia de los ganglios cervicales. A pesar de estas manifestaciones, prácticamente no presentó ningún tipo de sintomatología clínica. La paciente evolucionó clínica yanalíticamente a la normalidad en cuatro semanas; sin embargo, persistió la afectación del sistema reticuloendotelial con hipertrofia adenoidea y hepatomegalia durante 10 meses

The authors report the case of a 14-year-old girl. diagnosed as having infectious mononucleosis. She presented severe hypertrophy of the reticuloendothelial system, with hepatosplenomegaly of more than 16 cm, marked changes in liver enzymes and hypertrophy of the cervical Iymph nodes. Despite these signs, she presented practically no clinical symptomatology. Four weeks later, the clinical and analytical findings were normal; however, the reticuloendothelial system involvement persisted, with adenoid hypertrophy and hepatomegaly that lasted for 10 months

Ultrasonografía doppler color en el diagnostico de mononucleosis infecciosa en el niño / Color doppler ultrasonography in the diagnosis of the infectious monucleosis in children

La mononucleosis infecciosa (MNI) es una enfermedad frecuente que afecta a niños y adolescentes y es causada por el virus Epstein-Barr. En la mayor parte de los casos (80 por ciento) se presenta como un cuadro agudo, caracterizado por fiebre, faringoamigdalitis y linfoadenopatías (forma anginosa). Con menor frecuencia, puede presentarse con poliadenopatías asociadas a fiebre baja y faringitis leve. La ultrasonografía (US) Doppler color ha demostrado ser de utilidad en el estudio de adenopatías en el niño y puede ser de utilidad en el diagnóstico de MNI. Objetivos: Describir los hallazgos de la US Doppler color en la MNI. Pacientes y Método: Se revisó en forma retrospectiva los antecedentes clínicos y estudios por imágenes de 10 niños con diagnóstico confirmado de MNI y en quienes se efectuó US como parte de su estudio. Resultados: El estudio US Doppler color de las adenopatías cervicales mostró hallazgos relativa-mente constantes en todos los pacientes: adenopatías bilaterales múltiples, ovaladas o semi-rredondeadas, con una razón largo-ancho < 2, hiper o isoecogénicas con respecto al músculo, sin necrosis o alteración de estructuras vecinas. Mostró además aumento de flujo vascular en todas las adenopatías. En los cuatro pacientes con US abdominal, se encontró hepatoesplenomegalia (3 pacientes) o esplenomegalia (1 paciente). En dos pacientes, el bazo mostraba un aspecto reticular y nodular fino, que podría ser secundario a la hiperplasia linfática reactiva, con compromiso fundamentalmente de la pulpa blanca, que ha sido descrita en el estudio histológico del bazo en pacientes con esta patología(9). Conclusiones: La MNI es una enferme-dad frecuente en el niño y en la mayoría de los casos el diagnóstico se sospecha clínicamente y se confirma con el estudio serológico específico. La US Doppler color muestra un aspecto relativamente constante en el estudio de las adenopatías periféricas en esta enfermedad y puede ser de utilidad en el diagnóstico.

Subpopulation composition of peripheral blood lymphocytes in children with infectious mononucleosis.

In patients with viral and bacterial infectious mononucleosis during the acute period of disease and clinical convalescence blood content of CD72(+)and CD16(+)lymphocytes increased compared to normal. The count of CD8(+)cells increased in viral mononucleosis during convalescence and these changes persist in delayed periods after convalescence. In bacterial mononucleosis the content of CD72(+)lymphocytes return normal 18 months after convalescence.

Florid infectious mononucleosis: clinicopathological correlation in acute tonsillectomy.

In patients with infectious mononucleosis (IM), acute tonsillectomy is advocated only in the minority who develop severe airway compromise. In such florid cases, the pathological diagnosis of IM, well known to morphologically simulate that of lymphoma, is particularly challenging. The present case describes a 15-year old male with a clinical course consistent with IM in whom acute tonsillectomy was performed due to progressive airway obstruction. The striking histological findings emphasize the need for close clinicopathological correlation. Recently available ancillary studies are described which both surgeon and pathologist should be familiar with in the differentiation of IM from other lymphoproliferative conditions.

[Profile of microorganisms isolated in nasopharyngeal swabs from the patients with acute infectious mononucleosis]. / Charakterystyka drobnoustrojów izolowanych z blon sluzowych jamy nosowo-gardlowej u chorych z mononukleoza zakazna.

Infectious mononucleosis is a self-limiting lymphoproliferative disorder, which contribute to the development of the various clinical symptoms. Exudative tonsillitis was found to be caused by Epstein-Barr virus in 19% of all viral infections and may imitate a bacterial etiology. The aim of this study was to identify the microbes from the nasopharyngeal swabs obtained from the patients with exudative tonsillitis and to assess their susceptibility to antibiotics. The patients were hospitalized as an infectious mononucleosis after unsuccessful antibiotic therapy. 84 patients were investigated: group I--patients with serological positive infectious mononucleosis tests and group II--patients with acute exudative tonsillitis and with serologically excluded infectious mononucleosis. The diagnosis was confirmed clinically, haematologically, biochemically and serologically. Nasopharyngeal specimens were taken, once, at the first day of hospitalization. Then, routine microbiological assays were performed. Isolated strains were identified biochemically: API Strep, API Staph, API E, API Ne, APINH (bioMerieux). The susceptibility to antibiotics with an agar diffusion assay was performed according to Kirby-Bauer. We concluded that various, potentially pathogenic bacterial flora was found in throat during infectious mononucleosis. Haemophilus spp. and Staphylococcus aureus MSSA were isolated more frequently. Haemophilus influence was susceptible to cefotaxime and azytromycine. Candida albicans was isolated in every fourth patient. Streptococcus pyogenes as an etiological agent of exudative tonsillitis was confirmed in the group II. The pharyngeal candidiosis was also observed more frequently in the group II.

[Proliferative activity of lymphocytes of peripheral blood in infectious mononucleosis in children]. / Proliferativnaia aktivnost' limfotsitov perifericheskoi krovi pri infektsionnom mononukleoze u detei.

Changes in proliferative activity of lymphocytes from peripheral blood may serve an additional diagnostic criterion of etiological variants of infectious mononucleosis (IM)(viral and bacterial). In MN of viral etiology in evident disease the ability of lymphoid cells to blasttransformation in the presence of PHA is low vs healthy children. In convalescence the changes persist, proliferative activity of cells increase in stimulation by lipopolysaccharide. Later blast-transformation of lymphocytes return to normal. In bacterial IM proliferative activity of PHA- and LPS-stimulated lymphocytes is normal.

Bacterial coating with immunoglobulins on the palatine tonsils during infectious mononucleosis: immunocytochemical study with gold markers.

Epithelial cells and bacteria were sampled from the tonsillar surfaces of seven patients (six males, one female; median age 16 years, range 10 to 21 years) suffering from acute infectious mononucleosis with concomitant pharyngotonsillitis. By using gold-labelled antiserum to human IgG and secretory IgA (sIgA), micro-organisms on the tonsillar surfaces coated with these immunoglobulins could be identified by tracing the gold particles in the transmission electron microscope. The patients harboured significantly fewer bacteria coated with immunoglobulins than did healthy controls. More bacteria were coated with IgG immunoglobulins than with sIgA. Reduced immunoglobulin-coating of the bacteria on the tonsillar surfaces during infectious mononucleosis can explain their tendency to immense local colonization and proneness to penetrate into the epithelial cells.