09.04.2019

Infectious mononucleosis - Symptoms, Diagnosis, Treatment. Infectious mononucleosis (Epstein-Barr viral infection). Symptoms, diagnosis, treatment and prevention

Infectious mononucleosis is one of the most common viral infections on earth: according to statistics, 80-90% of adults have antibodies to the pathogen in their blood. It is the Epstein-Barr virus, named after the virologists who discovered it in 1964. Children, adolescents and young adults are most susceptible to mononucleosis. In people over 40 years of age, it develops extremely rarely, since before this age stable immunity is formed as a result of an infection.

The virus is especially dangerous for people over 25 years of age and pregnant women (subject to primary infection), as it causes a severe course of the disease, the addition of a bacterial infection, and can cause miscarriage or stillbirth. Timely diagnosis and competent treatment significantly reduce the risk of developing such consequences.

Pathogen and routes of transmission

The cause of mononucleosis is a large DNA-containing virus, a representative of the 4th type of the herpesvirus family. It has tropism for human B lymphocytes, that is, it is able to penetrate them thanks to special receptors on the cell surface. The virus integrates its DNA into cellular genetic information, thereby distorting it and increasing the risk of mutations with the subsequent development of malignant tumors of the lymphatic system. Its role in the development of Burkitt's lymphoma, Hodgkin's lymphoma, nasopharyngeal carcinoma, liver carcinoma, salivary glands, thymus, organs of the respiratory and digestive systems.

The virus is a strand of DNA compactly packaged in a protein shell - a capsid. On the outside, the structure is surrounded by an outer shell formed from the membrane of the cell in which the viral particle was collected. All of these structures are specific antigens, since in response to their introduction the body synthesizes immune antibodies. Detection of the latter is used to diagnose the infection, its stage and monitor recovery. In total, the Epstein-Barr virus contains 4 significant antigens:

EBNA (Epstein-Barr nuclear antigen) - contained in the core of the virus, is an integral part of its genetic information;
EA (early antigen) – early antigen, viral matrix proteins;
VCA (Viral capsid antigen) – viral capsid proteins;
LMP (latent membrane protein) – viral membrane proteins.

The source of the pathogen is a person suffering from any form of infectious mononucleosis. The virus is weakly contagious and requires prolonged and close contact for transmission. In children, the airborne route of transmission predominates; contact route is also possible - through profusely salivated toys and household items. In teenagers and older people, the virus is often transmitted through kissing with saliva or sexual intercourse. Susceptibility to the pathogen is high, that is, most of those infected for the first time become ill with infectious mononucleosis. However, asymptomatic and erased forms of the disease account for more than 50%, so often a person does not know about the infection.

Epstein-Barr virus is unstable in external environment: dies when dried out, exposed to sunlight and any disinfectants. In the human body, it can persist for life, being integrated into the DNA of B-lymphocytes. In this regard, there is another route of transmission - blood contact; infection is possible through blood transfusion, organ transplantation, and injection drug use. The virus causes the formation of stable lifelong immunity, so repeated attacks of the disease are the reactivation of a dormant pathogen in the body, and not a new infection.

Mechanism of disease development

Epstein-Barr virus enters with saliva or its droplets on the mucous membrane oral cavity and is attached to its cells - epithelial cells. From here, viral particles penetrate the salivary glands, immune cells - lymphocytes, macrophages, neutrophils and begin to actively multiply. There is a gradual accumulation of the pathogen and infection of more and more new cells. When the mass of viral particles reaches a certain value, their presence in the body activates the immune response mechanisms. A special type of immune cells - T-killers - destroy infected lymphocytes, and therefore a large amount of biological active substances and viral particles are released into the blood. Their circulation in the blood leads to an increase in body temperature and toxic damage to the liver - at this moment the first signs of the disease appear.

A special feature of the Epstein-Barr virus is its ability to accelerate the growth and reproduction of B lymphocytes - they proliferate and subsequently transform into plasma cells. The latter actively synthesize and release immunoglobulin proteins into the blood, which, in turn, causes the activation of another series of immune cells - T-suppressor cells. They produce substances designed to suppress excessive proliferation of B lymphocytes. The process of their maturation and transition to mature forms is disrupted, and therefore the number of mononuclear cells in the blood - mononuclear cells with a narrow rim of cytoplasm - increases sharply. In fact, they are immature B lymphocytes and serve as the most reliable sign of infectious mononucleosis.

The pathological process leads to an increase in the size of the lymph nodes, since it is in them that the synthesis and further growth of lymphocytes occurs. A powerful inflammatory reaction develops in the palatine tonsils, outwardly indistinguishable from. Depending on the depth of damage to the mucous membrane, its changes vary from friability to deep ulcers and plaque. The Epstein-Barr virus suppresses the immune response due to certain proteins, the synthesis of which occurs under the influence of its DNA. On the other hand, infected mucosal epithelial cells actively release substances that initiate an inflammatory reaction. In this regard, the amount of antibodies to the virus and a specific antiviral substance, interferon, gradually increases.

Most of the viral particles are eliminated from the body, but B-lymphocytes with embedded viral DNA remain in the human body for life, which they pass on to daughter cells. The pathogen changes the amount of immunoglobulins synthesized by the lymphocyte, and therefore can lead to complications in the form of autoimmune processes and atopic reactions. Chronic mononucleosis with a relapsing course is formed as a result of an insufficient immune response in the acute phase, due to which the virus escapes aggression and remains in sufficient quantities for exacerbations of the disease.

Clinical picture

Mononucleosis occurs cyclically and certain stages can be clearly distinguished in its development. The incubation period lasts from the moment of infection to the first signs of the disease and takes on average from 20 to 50 weeks. At this time, the virus multiplies and accumulates in quantities sufficient for massive expansion. The first signs of the disease appear during the prodromal period. A person feels weakness, increased fatigue, irritability, and muscle pain. The prodrome continues for 1-2 weeks, after which the height of the disease begins. Usually a person becomes ill acutely with an increase in body temperature to 38-39 degrees C and enlarged lymph nodes.

Symptoms of mononucleosis

The lymph nodes of the neck, back of the head, elbow and intestines are most often affected. Their size varies from 1.5 to 5 cm; upon palpation, a person feels slight pain. The skin over the lymph nodes is not changed, they are not fused with the underlying tissues, they are mobile, and have an elastic-elastic consistency. Severe enlargement of the intestinal lymph nodes leads to pain in the abdomen, lower back and indigestion. The spleen enlarges significantly, even to the point of rupture, since it belongs to the organs of the immune system and contains a large number of lymphatic follicles. This process is manifested by severe pain in the left hypochondrium, which increases with movement and physical activity. Reverse Development lymph node removal occurs slowly, over 3-4 weeks after recovery. In some cases, polyadenopathy persists for a long time, from several months to lifelong changes.

Temperature during mononucleosis is one of the most common symptoms mononucleosis. Fever lasts from several days to 4 weeks and can change repeatedly throughout the course of the disease. On average, it starts at 37-38 degrees C, gradually increasing to 39-40 degrees C. Despite the duration and severity of the fever general state Few patients suffer. They generally remain active, with only a decrease in appetite and increased fatigue. In some cases, patients experience such severe muscle weakness that they cannot stand on their feet. This condition rarely lasts more than 3-4 days.

Another constant sign of mononucleosis is angina-like changes in the oropharynx. Palatine tonsils increase in size so much that they can completely block the lumen of the pharynx. A white-gray coating in the form of islands or stripes often forms on their surface. It appears on days 3-7 of illness and is associated with a sore throat and a sharp rise in temperature. The nasopharyngeal tonsil also enlarges, which is associated with difficulty in nasal breathing and snoring during sleep. The back wall of the pharynx becomes granular, its mucous membrane is hyperemic and swollen. If the swelling goes down into the larynx and affects the vocal cords, then the patient experiences hoarseness.

Liver damage in mononucleosis can be asymptomatic and with severe jaundice. The liver increases in size, protrudes 2.5-3 cm from under the costal arch, is dense, sensitive to palpation. Pain in the right hypochondrium is not associated with eating, but intensifies with physical activity and walking. The patient may notice a slight yellowing of the sclera, a change in skin tone to lemon yellow. The changes do not last long and disappear without a trace in a few days.

Infectious mononucleosis in pregnant women- This is, as a rule, a reactivation of the Epstein-Barr virus associated with a physiological decrease in immune defense. The incidence increases towards the end of pregnancy and accounts for about 35% of the total number of expectant mothers. The disease manifests itself as fever, enlarged liver, sore throat and reaction of the lymph nodes. The virus can cross the placenta and infect the fetus, which occurs when high concentration it's in his blood. Despite this, infection in the fetus rarely develops and is usually represented by pathologies of the eyes, heart, and nervous system.

A rash with mononucleosis appears on average on the 5-10th day of illness and in 80% of cases is associated with taking the antibacterial drug ampicillin. It is maculopapular in nature, its elements are bright red, located on the skin of the face, torso and limbs. The rash remains on the skin for about a week, after which it turns pale and disappears without a trace.

Mononucleosis in children often occurs asymptomatically or with a blurred clinical picture in the form. The disease is dangerous for babies with congenital immunodeficiency or atopic reactions. In the first case, the virus aggravates the lack of immune defense and promotes the addition of a bacterial infection. In the second, it enhances the manifestations of diathesis, initiates the formation of autoimmune antibodies and can become a provoking factor for the development of tumors of the immune system.

Classification

Infectious mononucleosis is divided according to severity into:

By type, infectious mononucleosis is divided into:

Typical– characterized by a cyclical course, angina-like changes, enlarged lymph nodes, liver damage and characteristic changes in the blood picture.
Atypical- combines the asymptomatic course of the disease, its erased form, usually taken for ARVI, and the most severe form - visceral. The latter occurs with the involvement of many internal organs and leads to serious complications.

According to the duration of the course, infectious mononucleosis can be:

Acute– manifestations of the disease last no more than 3 months;
Protracted– changes last from 3 to 6 months;
Chronic– lasts more than six months. This same form of the disease includes repeated fever, malaise, and enlarged lymph nodes within 6 months after recovery.

Relapse of infectious mononucleosis is the re-development of its symptoms a month after recovery.

Diagnostics

The diagnosis and treatment of infectious mononucleosis is carried out by an infectious disease specialist. It is based on:

Typical complaints– prolonged fever, sore throat-like changes in the oropharynx, enlarged lymph nodes;
Epidemiological anamnesis- domestic or sexual contact with a person who has long time had a fever, blood transfusion or organ transplantation in the 6 months before the disease;
Inspection data– hyperemia of the pharynx, plaque on the tonsils, enlargement of the lymph nodes, liver and spleen;
Results laboratory tests – the main sign of Epstein-Barr virus infection is the appearance in venous or capillary blood large quantity(more than 10% of the total number of leukocytes) mononuclear cells. It is from this that the disease got its name - mononucleosis, and before the advent of methods for detecting the pathogen, it was its main diagnostic criterion.

Today, more accurate diagnostic methods have been developed that make it possible to establish a diagnosis even if the clinical picture is not typical for damage by the Epstein-Barr virus. These include:

According to the ratio of antibodies to various proteins virus, the doctor can determine the period of the disease, determine whether there was an initial encounter with the pathogen, a relapse or reactivation of the infection:

The acute period of mononucleosis is characterized by the appearance of IgMk VCA (from the first days of the clinic, persists for 4-6 weeks), IgG to EA (from the first days of the disease, persists throughout life in small quantities), IgG to VCA (appears after IgMVCA, persists for life).
Recovery is characterized absence of IgMk VCA, appearance of IgG to EBNA, gradual decrease IgG level to EA and IgG to VCA.

Also, a reliable sign of acute or reactivation of infection is high (more than 60%) avidity (affinity) of IgG for the Epstein-Barr virus.

In a general blood test, leukocytosis is observed with an increase in the proportion of lymphocytes and monocytes to 80-90% of the total number of leukocytes, and an acceleration of ESR. Changes in the biochemical blood test indicate damage to liver cells - the level of ALT, AST, GGTP and alkaline phosphatase increases, the concentration may increase indirect bilirubin with jaundice. Increase concentration total protein plasma is associated with excessive production of a number of immunoglobulins by mononuclear cells.

Various imaging methods (ultrasound, CT, MRI, X-ray) allow you to assess the condition of the lymph nodes abdominal cavity, liver, spleen.

Treatment

Treatment of mononucleosis is carried out on an outpatient basis for mild cases of the disease; patients with moderate and severe forms are hospitalized in an infectious diseases hospital. Hospitalization is also carried out for epidemiological reasons, regardless of the severity of the disease. These include living in crowded conditions - a dormitory, barracks, orphanage and boarding schools. To date, there are no drugs that can act directly on the cause of the disease - the Epstein-Barr virus - and remove it from the body, so therapy is aimed at alleviating the patient’s condition, maintaining the body’s defenses and preventing negative consequences.

During the acute period of mononucleosis, patients are shown peace, bed rest, plenty of warm drink in the form of fruit drink, weak tea, compote, easily digestible diet. To prevent bacterial complications, it is necessary to rinse the pharynx 3-4 times a day with antiseptic solutions– chlorhexidine, furacillin, chamomile decoction. Physiotherapy methods - ultraviolet irradiation, magnetic therapy, UHF are not carried out, as they cause additional activation of the cellular component of immunity. They can be used after the size of the lymph nodes has normalized.

Among the medications prescribed:

Treatment of pregnant women is aimed at eliminating symptoms and is carried out with drugs that are safe for the fetus:

Human interferon in the form of rectal suppositories;
Folic acid;
Vitamins E, group B;
Troxevasin capsules;
Calcium preparations – calcium orotate, calcium pantothenate.

On average, the duration of treatment is 15-30 days. After suffering from infectious mononucleosis, a person must be monitored by a local physician for 12 months. Every 3 months, laboratory monitoring is carried out, which includes a general and biochemical blood test, and, if necessary, determination of antibodies to the Epstein-Barr virus in the blood.

Complications of the disease

Rarely develop, but can be extremely severe:

Autoimmune hemolytic anemia;
Meningoencephalitis;
Guillain-Barre syndrome;
Psychosis;
Damage to the peripheral nervous system – polyneuritis, cranial nerve palsy, paresis of facial muscles;
Myocarditis;
Rupture of the spleen (usually found in a child).

Specific prevention(vaccination) has not been developed, therefore, to prevent infection, general strengthening measures are carried out: hardening, walks in the fresh air and ventilation, varied and proper nutrition. It is important to promptly and fully treat an acute infection, as this will reduce the risk of chronicity of the process and the development of severe complications.

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Ministry of Education and Science of the Russian Federation

Federal State Autonomous Educational Institution of Higher Professional Education "North-Eastern Federal

University named after M.K.Ammosova"

Medical Institute

Department of Propaedeutics of Childhood Diseases

ABSTRACT ON THE TOPIC:

"TREATMENT OF INFECTIOUS MONONUCLEOSIS".

Completed by: 5th year student of group 502/1

specialty "General Medicine"

Anisimova Alina Ivanovna

Checked by: assistant Marinova L.G.

Yakutsk 2015

Introduction

1. Infectious mononucleosis

5. Treatment

Conclusion

References

Introduction

One of the pressing problems of modern medicine is the high infection rate of the population with one of the representatives of opportunistic pathogens - the Epstein-Barr virus (EBV). Practicing doctors in their daily practice more often encounter clinically manifest forms of primary Epstein-Barr virus infection (EBVI) in the form of an acute, usually unverified respiratory infection (more than 40% of cases) or infectious mononucleosis (about 18% of all diseases). In most cases, these diseases are benign and end in recovery, but with lifelong persistence of EBV in the body of the person who has recovered from the disease.

However, in 10-25% of cases, primary EBV infection, which is asymptomatic, and acute EBV infection can have adverse consequences with the formation of lymphoproliferative and oncological diseases, chronic fatigue syndrome, EBV-associated hemophagocytic syndromes, etc.

To date, there are no clear criteria to predict the outcome of primary EBV infection. A doctor who is approached by a patient with acute EBVI always faces the question: what to do in each specific case in order to minimize the risk of developing chronic EBVI and EBV-associated pathological conditions. This is not an idle question, and it is really very difficult to answer, because ?To. There is still no clear pathogenetically substantiated treatment regimen for patients, and existing recommendations often contradict each other.

Epstein virus infectious mononucleosis

1. Infectious mononucleosis

Infectious mononucleosis (mononucleosis infectiosa, Filatov's disease, monocytic tonsillitis, benign lymphoblastosis) is an acute anthroponotic viral infectious disease with fever, damage to the oropharynx, lymph nodes, liver and spleen and specific changes in the hemogram.

Historical data. Clinical manifestations of the disease were first described by N.F. Filatov (“Filatov’s disease”, 1885) and E. Preiffer (1889). Changes in the hemogram have been studied by many researchers (Bernet J., 1909; Tidy G. et al., 1923; Schwartz E., 1929, etc.). In accordance with these characteristic changes, American scientists T. Sprunt and F. Evans called the disease infectious mononucleosis. The pathogen was first isolated by the English pathologist M.A. Epstein and Canadian virologist I. Barr from Burkitt's lymphoma cells (1964). The virus was later named Epstein-Barr virus.

Etiology.

The causative agent of infectious mononucleosis is a DNA genomic virus of the genus Lymphocryptovirus of the Gammaherpesvirinae subfamily of the Herpesviridae family. The virus is able to replicate, including in B lymphocytes; unlike other herpes viruses, it does not cause cell death, but, on the contrary, activates their proliferation. Virions include specific antigens: capsid (VCA), nuclear (EBNA), early (EA) and membrane (MA) antigens. Each of them is formed in a certain sequence and induces the synthesis of corresponding antibodies. In the blood of patients with infectious mononucleosis, antibodies to the capsid antigen first appear, and later antibodies to EA and MA are produced. The pathogen is not stable in the external environment and quickly dies when it dries out, under the influence of high temperature and disinfectants.

Infectious mononucleosis is only one form of infection with the Epstein-Barr virus, which also causes Burkitt's lymphoma and nasopharyngeal carcinoma. Its role in the pathogenesis of a number of other pathological conditions has not been sufficiently studied.

Epidemiology .

The reservoir and source of infection is a person with a manifest or erased form of the disease, as well as a carrier of the pathogen. Infected individuals shed the virus from the last days of incubation and for 6-18 months after the initial infection. In swabs from the oropharynx in 15-25% of seropositive healthy people the virus is also detected. Epidemic process supported by persons who have previously had an infection and have been secreting the pathogen in their saliva for a long time.

Mechanism transfers- aerosol, transmission route - airborne droplets. Very often, the virus is released in saliva, so infection is possible through contact (kissing, sexual intercourse, through hands, toys and household items). Infection can be transmitted through blood transfusions, as well as during childbirth.

Natural susceptibility people are high, however, mild and erased forms of the disease predominate. The presence of innate passive immunity can be evidenced by the extremely low morbidity rate in children in the first year of life. Immunodeficiency states contribute to the generalization of infection.

Basic epidemiological signs. The disease is widespread; Mostly sporadic cases are recorded, sometimes small outbreaks. The polymorphism of the clinical picture and the rather frequent difficulties in diagnosing the disease give reason to believe that the level of officially registered morbidity in Ukraine does not reflect the true extent of the spread of the infection. Teenagers most often get sick; in girls, the maximum incidence is recorded at 14-16 years old, in boys - at 16-18 years old. Therefore, infectious mononucleosis is sometimes also called “students’ disease.” People over 40 years of age rarely get sick, but in HIV-infected people there is reactivation latent infection possible at any age. If infected early childhood The primary infection occurs in the form of a respiratory disease, and in older ages it is asymptomatic. By the age of 30-35, most people have antibodies to the infectious mononucleosis virus in their blood, so clinically pronounced forms are rarely found among adults. Diseases are recorded throughout the year, somewhat less frequently in the summer months. Infection is facilitated by overcrowding, sharing of shared linen, utensils, and close household contacts.

Immunity persistent after infectious mononucleosis, repeated diseases not visible.

Mortality low. There is information about isolated cases of death due to splenic rupture, laryngeal stenosis and damage to the central nervous system.

Pathogenesis

Penetration of the virus into the upper sections respiratory tract leads to damage to the epithelium and lymphoid tissue of the oropharynx and nasopharynx. Swelling of the mucous membrane, enlargement of the tonsils and regional lymph nodes are noted. With subsequent viremia, the pathogen invades B lymphocytes; being in their cytoplasm, it disseminates throughout the body. The spread of the virus leads to systemic hyperplasia of lymphoid and reticular tissues, and therefore atypical mononuclear cells appear in the peripheral blood. Lymphadenopathy, swelling of the mucous membrane of the nasal concha and oropharynx develop, the liver and spleen enlarge. Histologically, hyperplasia of lymphoreticular tissue is revealed in all organs, lymphocytic periportal infiltration of the liver with minor dystrophic changes hepatocytes.

Virus replication in B lymphocytes stimulates their active proliferation and differentiation into plasmacytes. The latter secrete immunoglobulins of low specificity. At the same time, during the acute period of the disease, the number and activity of T-lymphocytes increase. Suppressor T cells inhibit the proliferation and differentiation of B lymphocytes. Cytotoxic T lymphocytes destroy virus-infected cells by recognizing membrane virus-induced antigens. However, the virus remains in the body and persists in it throughout subsequent life, causing a chronic course of the disease with reactivation of the infection when immunity decreases.

The severity of immunological reactions during infectious mononucleosis allows us to consider it a disease of the immune system, therefore it is classified as a group of diseases of the AIDS-associated complex.

Pathomorphology

In the acute period of the disease, a biopsy of the lymph nodes determines the proliferation of reticular and lymphoid tissue with the formation of large mononuclear cells and circulatory disorders. At the same time, Kupffer cell hyperplasia and, in some cases, focal and widespread necrosis are detected. Similar histological changes are noted in the tonsils and peritonsillar tissue. In the spleen, hyperplasia of the follicles, edema and infiltration of its capsule by mononuclear cells are observed. In the liver with severe forms infectious mononucleosis there is deposition of bile pigment in the hepatocytes of the central zones of the lobules. The detection of wide-plasma mononuclear cells in the lungs, spleen, kidneys, and central nervous system indicates that proliferation of lymphoreticular tissue is observed in various organs.

2. Classification of infectious mononucleosis

By type: 1. Typical

2. Atypical

Erased

Asymptomatic

By severity:

1. Light form

2. Medium-heavy

3. Heavy

Severity criteria

Severity of intoxication syndrome

Expression of local changes

By flow (by character):

1) Smooth

2) Unsmooth

With complications

With a layer of secondary infection

With exacerbation of chronic diseases

3. Clinical picture of infectious mononucleosis

The incubation period varies from 5 days to 1.5 months. A prodromal period without specific symptoms is possible. In these cases, the disease develops gradually: within a few days, low-grade body temperature, malaise, weakness, increased fatigue, catarrhal phenomena in the upper respiratory tract - nasal congestion, hyperemia of the mucous membrane of the oropharynx, enlargement and hyperemia of the tonsils are observed.

With the acute onset of the disease, body temperature quickly rises to high levels. Patients complain about headache, sore throat when swallowing, chills, increased sweating, body aches. In the future, the temperature curve may be different; The duration of fever varies from several days to 1 month or more.

By the end of the first week of the disease, the peak period of the disease develops. Characterized by the appearance of all the main clinical syndromes: general toxic phenomena, tonsillitis, lymphadenopathy, hepatolienal syndrome. The patient’s health deteriorates; high body temperature, chills, headache and body aches are noted. Nasal congestion with difficulty in nasal breathing and a nasal voice may appear. Lesions of the pharynx are manifested by an increase in sore throat, the development of sore throat in catarrhal, ulcerative-necrotic, follicular or membranous forms. Hyperemia of the mucous membrane is not clearly expressed, loose yellowish plaques that can be easily removed appear on the tonsils. In some cases, plaques may resemble diphtheria. Hemorrhagic elements may appear on the mucous membrane of the soft palate; the posterior wall of the pharynx is sharply hyperemic, loose, granular, with hyperplastic follicles.

From the very first days, lymphadenopathy develops. Enlarged lymph nodes can be found in all areas accessible to palpation; Their lesions are characterized by symmetry. Most often with mononucleosis, the occipital, submandibular and especially posterior cervical lymph nodes on both sides along the sternocleidomastoid muscles are enlarged. Lymph nodes are compacted, mobile, painless or slightly painful on palpation. Their sizes vary from pea to walnut. The subcutaneous tissue around the lymph nodes may be swollen in some cases.

In most patients, during the height of the disease, an enlargement of the liver and spleen is noted. In some cases, icteric syndrome develops: dyspeptic symptoms intensify (decreased appetite, nausea), urine darkens, icterus appears in the sclera and skin, bilirubin content in the blood serum increases and aminotransferase activity increases.

Sometimes an exanthema of a maculopapular nature appears. It has no specific localization, is not accompanied by itching and quickly disappears without treatment, leaving no changes on the skin.

Following the period of the height of the disease, which lasts on average 2-3 weeks, a period of convalescence begins. The patient’s well-being improves, body temperature normalizes, and sore throat and hepatolienal syndrome gradually disappear. Subsequently, the size of the lymph nodes is normalized. The duration of the convalescence period varies from person to person; sometimes low-grade body temperature and lymphadenopathy persist for several weeks.

The disease can take a long time, with alternating periods of exacerbations and remissions, which is why its total duration can last up to 1.5 years.

Clinical manifestations infectious mononucleosis at adults sick differ near features.

The disease often begins with the gradual development of prodromal phenomena, fever often persists for more than 2 weeks, the severity of lymphadenopathy and tonsil hyperplasia is less than in children. However, in adults, manifestations of the disease associated with involvement of the liver in the process and the development of icteric syndrome are more often observed.

Complications infectious mononucleosis

The most common complication is joining bacterial infections caused by Staphylococcus aureus, streptococci, etc. Meningoencephalitis, obstruction are also possible upper sections respiratory tract with enlarged tonsils. In rare cases, bilateral interstitial infiltration of the lungs with severe hypoxia, severe hepatitis (in children), thrombocytopenia, and splenic ruptures are noted. In most cases, the prognosis of the disease is favorable.

Differentialdiagnostics:

Infectious mononucleosis should be distinguished from lymphogranulomatosis and lymphocytic leukemia, tonsillitis of coccal and other etiologies, oropharyngeal diphtheria, as well as viral hepatitis, pseudotuberculosis, rubella, toxoplasmosis, chlamydial pneumonia and ornithosis, some forms adenovirus infection, CMV infection, primary manifestations of HIV infection. Infectious mononucleosis is distinguished by a combination of the main five clinical syndromes: general toxic phenomena, bilateral tonsillitis, polyadenopathy (especially with damage to the lymph nodes along the sternocleidomastoid muscles on both sides), hepatolienal syndrome, and specific changes in the hemogram. In some cases, jaundice and (or) maculopapular exanthema are possible.

4. Laboratory diagnosis of infectious mononucleosis

The most characteristic sign is changes in the cellular composition of the blood. The hemogram reveals moderate leukocytosis, relative neutropenia with a shift in the leukocyte formula to the left, a significant increase in the number of lymphocytes and monocytes (over 60% in total). Atypical mononuclear cells are present in the blood - cells with wide basophilic cytoplasm, having different shape. Their presence in the blood determined modern name diseases. Diagnostic value has an increase in the number of atypical mononuclear cells with wide cytoplasm of at least 10-12%, although the number of these cells can reach 80-90%. It should be noted that the absence of atypical mononuclear cells in the characteristic clinical manifestations of the disease does not contradict the expected diagnosis, since their appearance in the peripheral blood may be delayed until the end of the 2-3rd week of the disease.

During the period of convalescence, the number of neutrophils, lymphocytes and monocytes gradually normalizes, but quite often atypical mononuclear cells persist for a long time.

Virological diagnostic methods (isolation of the virus from the oropharynx) are not used in practice. The PCR method can detect viral DNA in whole blood and serum.

Serological methods have been developed for the determination of antibodies of various classes to capsid (VCA) antigens. Serum IgM to VCA antigens can be detected already during the incubation period; subsequently they are detected in all patients (this serves as reliable confirmation of the diagnosis). IgM to VCA antigens disappear only 2-3 months after recovery. After an illness, IgG to VCA antigens remain for life.

In the absence of the ability to detect anti-VCA-IgM, serological methods for detecting heterophilic antibodies are still used. They are formed as a result of polyclonal activation of B lymphocytes. The most popular are the Paul-Bunnell reaction with sheep erythrocytes (diagnostic titer 1:32) and the more sensitive Hoff-Bauer reaction with horse erythrocytes. Insufficient specificity of reactions reduces their diagnostic value.

All patients with infectious mononucleosis or if they are suspected of having it should undergo three laboratory tests (in the acute period, then after 3 and 6 months) for antibodies to HIV antigens, since mononucleosis-like syndrome is also possible at the stage of primary manifestations of HIV infection.

5. Treatment

Patients with mild and moderate forms of infectious mononucleosis can be treated at home

Bed rest for the entire acute period.

Diet: liquid and semi-liquid recommended dairy-vegetable food, rich in vitamins, extra drink ( cranberry juice, tea with lemon, compote) and fruits. In cases of illness with manifestations of hepatitis, a diet is recommended (table No. 5).

Recombinant interferon preparations (Viferon) and its inducers (Cycloferon, Neovir) are used as etiotropic therapy for moderate and severe forms of the disease.

Specific therapy has not been developed. Detoxification therapy, desensitizing therapy (claritin, pipolfen, suprastin), symptomatic and restorative treatment, and rinsing the oropharynx with antiseptic solutions are carried out. According to indications, hepatoprotectors are prescribed (LIV-52, Essentiale, Karsil).

Antibiotics are not prescribed in the absence of bacterial complications. In case of hypertoxic course of the disease, as well as in case of threat of asphyxia caused by swelling of the pharynx and pronounced enlargement of the tonsils, a short course of treatment with glucocorticoids is prescribed (oral prednisolone in a daily dose of 1-1.5 mg/kg for 3-4 days).

Local treatment includes instillation of naphthyzine, galazolin, adrenaline-furacillin drops, protargol, sodium sulfacyl into the nose.

6. Modern approaches to the treatment of Epstein Barr virus infection

According to many researchers, treatment of EBVI-mononucleosis (EBVIM) does not require specific therapy. Treatment of patients is usually carried out on an outpatient basis; patient isolation is not required. Indications for hospitalization include prolonged fever, pronounced syndrome tonsillitis and/or tonsillitis syndrome, polylymphadenopathy, jaundice, anemia, airway obstruction, abdominal pain and the development of complications (surgical, neurological, hematological, cardiovascular and respiratory system, Reye's syndrome).

In mild to moderate cases of EBV MI, it is advisable for patients to be recommended a ward or general regimen with a return to normal activities at a physical and energetic level that is adequate for each individual patient. A multicenter study showed that unreasonably recommended strict bed rest prolongs the recovery period and is accompanied by a long-term asthenic syndrome, often requiring drug treatment.

In mild cases of EBV MI, treatment of patients is limited to supportive therapy, including adequate hydration, rinsing the oropharynx with an antiseptic solution (with the addition of a 2% solution of lidocaine (xylocaine) for severe discomfort in the throat), non-steroidal anti-inflammatory drugs such as paracetamol (Acetaminophen, Tylenol). According to a number of authors, the prescription of H2 receptor blockers, vitamins, hepatoprotectors and local treatment of the tonsils with various antiseptics are ineffective and unfounded methods of treatment. Of the exotic methods of treatment, mention should be made of those recommended by F.G. Bokov et al. (2006) the use of megadoses of bifidobacteria in the treatment of patients with acute mononucleosis.

Opinions about the advisability of prescribing antibacterial drugs in the treatment of EBVIM are very controversial. According to Gershburg E. (2005), tonsillitis in MI is often aseptic and the prescription of antibacterial therapy is not justified. There is also no point in using antibacterial agents with catarrhal sore throat. The indication for prescribing antibacterial drugs is the addition of a secondary bacterial infection (the development of lacunar or necrotizing tonsillitis, complications such as pneumonia, pleurisy, etc.), as evidenced by pronounced inflammatory changes in blood parameters and febrile fever that persist for more than three days. The choice of drug depends on the sensitivity of the microflora on the patient’s tonsils to antibiotics and possible adverse reactions from organs and systems.

In patients, hemophilus influenzae, staphylococcus and streptococcus pyogenes are more often isolated, less often - fungi of the genus Candida], therefore it should be considered justified to prescribe to these patients drugs from the group of 2-3 generation cephalosporins, lincosamides, macrolides and antifungal agents(fluconazole) in therapeutic doses for 5-7 days (less often - 10 days). Some authors, in the presence of necrotizing sore throat and putrefactive breath, probably caused by associated anaerobic flora, recommend the use of metronidazole 0.75 g / day, divided into 3 doses, for 7-10 days.

Contraindicated drugs from the group of aminopenicillins (ampicillin, amoxicillin (Flemoxin Solutab, Hiconcil), amoxicillin with clavulanate (Amoxiclav, Moxiclav, Augmentin)) due to the possibility of developing an allergic reaction in the form of exanthema. The appearance of a rash to aminopenicillins is not an IgE-dependent reaction, therefore the use of H1 histamine receptor blockers has neither a preventive nor a therapeutic effect.

According to a number of authors, the empirical approach to prescribing glucocorticosteroids to patients with EBVI is still maintained. Glucocorticosteroids (prednisolone, prednisone (Deltazone, Meticorten, Orazon, Liquid Pred), Solu Cortef (hydrocortisone), dexamethasone) are recommended for patients with severe EBVIM, airway obstruction, neurological and hematological complications (severe thrombocytopenia, hemolytic anemia). Daily dose Prednisolone is 60-80 mg for 3-5 days (less often 7 days), followed by rapid discontinuation of the drug. There is no identical point of view on prescribing glucocorticosteroids to these patients with the development of myocarditis, pericarditis and central nervous system lesions.

In severe cases of EBVIM, intravenous detoxification therapy is indicated; in case of splenic rupture, surgical treatment is indicated.

The most controversial question remains about the purpose antiviral therapy patients with EBVI. Currently, a large list of drugs is known that are inhibitors of EBV replication in cell culture.

All modern "candidates" For treatment EBVI can be separated on two groups:

I. Suppressing the activity of EBV DNA polymerase:

Acyclic nucleoside analogues (acyclovir, ganciclovir, penciclovir, valacyclovir, valganciclovir, famciclovir);

Acyclic nucleotide analogues (cidofovir, adefovir);

Pyrophosphate analogues (Foscarnet (foscavir), phosphonoacetylic acid);

4 oxo-dihydroquinolines (possibly).

II. Various compounds that do not inhibit viral DNA polymerase (mechanism under study): maribavir, beta-L-5 uracil iododioxolane, indolocarbazole.

However, a meta-analysis of five randomized controlled trials involving 339 EBVIM patients taking acyclovir (Zovirax) showed the drug to be ineffective.

One of possible reasons lies in the development cycle of EBV, in which the DNA of the virus has a linear or circular (episome) structure and multiplies in the nucleus of the host cell. Active replication of the virus occurs during the productive (lytic) stage of the infectious process (EBV DNA of linear form). With acute EBVI and activation of chronic EBVI, a cytolytic cycle of virus development occurs, during which it triggers the expression of its own early antigens and activates some genes of the host cells, the products of which are involved in the replication of EBV. In latent EBVI, the DNA of the virus has the form of an episome (circular supercoiled genome) located in the nucleus. The circular genome of EBV DNA is characteristic of CD21+ lymphocytes, in which, even during primary infection with the virus, the lytic stage of the infectious process is practically not observed, and DNA is reproduced in the form of an episome synchronously with the cell division of infected cells. The death of EBV-affected B lymphocytes is not associated with virus-mediated cytolysis, but with the action of cytotoxic lymphocytes.

When prescribing antiviral drugs for EBVI, the doctor must remember that their clinical effectiveness depends on the correct interpretation of the clinical manifestations of the disease, the stage of the infectious process and the development cycle of the virus at this stage. However, no less important is the fact that most of the symptoms of EBV are associated not with the direct cytopathic effect of the virus in infected tissues, but with the indirect immunopathological response of EBV-infected B lymphocytes circulating in the blood and located in the cells of the affected organs. That is why nucleoside analogues (acyclovir, ganciclovir, etc.) and polymerase inhibitors (Foscarnet), which suppress EBV replication and reduce the virus content in saliva (but do not completely sanitize it, do not have a clinical effect on the severity and duration of EBVIM symptoms.

Indications for the treatment of EBVIM with antiviral drugs are: severe, complicated course of the disease, the need to prevent EBV-associated B-cell lymphoproliferation in immunocompromised patients, EBV-associated leukoplakia. It is recommended to use acyclovir (Zovirax) orally at a dose of 800 mg orally 5 times a day for 10 days (or 10 mg/kg every 8 hours for 7-10 days). For lesions of the nervous system, the preferred route of administration is intravenous at a dose of 30 mg/kg/day 3 times a day for 7-10 days.

According to Gershburg, (2005), if under the influence of any factors (for example, immunomodulators, in EBV-associated malignant tumors - the use radiation therapy, gemcitabine, doxorubicin, arginine butyrate, etc.) it is possible to transfer EBV DNA from the episome into an active replicative form, i.e. activate the lytic cycle of the virus, then in this case a clinical effect from antiviral therapy can be expected.

IN last years increasingly, recombinant alpha interferons (Intron A, Roferon-A, Reaferon-EC) at a dose of 1 million IU intramuscularly for 5-7 days or every other day began to be used for the treatment of EBVI; for chronic active EBVI - 3 million IU intramuscularly 3 times a week, course 12-36 weeks.

As an interferon inducer in severe cases of EBVI, it is recommended to use Cycloferon 250 mg (12.5% 2.0 ml) IM, 1 time per day, No. 10 (the first two days daily, then every other day) or according to the scheme: 250 mg/day, IM on the 1st, 2nd, 4th, 6th, 8th, 11th, 14th, 17th, 20th, 23rd, 26th 1st and 29th day in combination with etiotropic therapy. Orally, Cycloferon is prescribed at 0.6 g/day, course dose (6-12 g, i.e. 20-40 tablets).

Drug correction of asthenic syndrome in chronic EBVI includes the administration of adaptogens, high doses of B vitamins, nootropic drugs, antidepressants, psychostimulants, drugs with a procholinergic mechanism of action and correctors of cellular metabolism.

The key to successful treatment of a patient with EBVI is complex therapy and strictly individual management tactics both in the hospital and during dispensary observation.

Conclusion

Thus, inclusion in complex therapy children with infectious mononucleosis, preparations of recombinant alpha 2b-interferon Reaferon -EC- Lipinta, Viferon, Kipferon are accompanied by positive clinical and hematological changes, more pronounced when using the liposomal form of interferon alpha. However, the administration of Viferon and Kipferon in the form rectal suppositories brought to many children discomfort. Therefore, the more physiological oral use of Reaferon-EC-Lipint is preferable.

References

1. E.M. Klimanova, G.D. Guseva, E.N. Kurnosenok, O.S. Zotova, S.A. Guy; Reaferon-ES-Lipint in the treatment of children with infectious mononucleosis // Journal "Polyclinic" No. 4 (1) 2011, pp. 44-45.

2. A.P. Kudin; Some issues in the treatment of infectious mononucleosis in children // Medical Journal; 2012 No. 3, pp. 138-143.

3. V.N. Timchenko and L.V. Bystryakov // Infectious diseases in children: Textbook for pediatric faculties of medical universities. St. Petersburg: SpetsLit, 2001. p. 197.

4. N.M. Shvedova, E.V. Mikhailova, Yu.S. Tseka, T.K. Chudakova: Infectious mononucleosis in children: Clinical and laboratory justification and economic efficiency of the use of immunocorrectors // Saratov scientific and medical magazine; 2013: T 9: No. 3 pp. 512-517.

5. I.V. Shestakova, N.D. Yushchuk Modern approaches to the treatment of Epstein-Barr virus infection in adults//Attending physician. 2011. No. 2: pp. 98-103.

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CAUSES

The causative agent of infectious mononucleosis in more than half of cases of infection is the Epstein-Barr virus (EBV) type 4 from the Herpesviridae family. In more rare cases, the disease is provoked by herpes virus type six.

EBV is unstable in the external environment, it quickly dies when boiled, exposed to high pressure, disinfectant solutions and after drying.

Source of disease:

a sick person with typical symptoms;
virus carrier without signs of disease;
patient with mild symptoms.

The virus is released in the latent period, during typical clinical manifestations of the disease and for a long time after recovery. In people who have previously had mononucleosis, the virus remains in a latent form throughout life, thereby maintaining its epidemiological spread among the population.

Ways of transmission of infection:

aerogenic, or airborne (main), with saliva during close contact or during general use dishes and personal items;
transmissible (during transfusions of contaminated blood);
during sexual intercourse;
infection of a child during natural childbirth from the mother.

Pathogen enters the body through the tissues of the nasopharynx and enters the lymph nodes, where B-lymphocytes are present. Once inside these cells, the virus begins the process of replication, or reproduction. A special feature of EBV is its ability to provoke active growth of lymphocytes, and not cause their death.

As viral particles accumulate, they migrate to regional lymph nodes, and after 30-50 days they infect blood lymphocytes and spread to organs consisting of lymphoid tissue (liver, spleen). Here the process of growth of structural elements begins, as a result of which characteristic cells appear in the blood - atypical mononuclear cells.

CLASSIFICATION

Forms of mononucleosis:

Manifest - symptoms of the disease appear in varying degrees of severity, the disease proceeds in a typical or atypical scenario.
Subclinical - there are no symptoms, the disease can be detected only through a targeted examination of people in contact with sick people or by chance.

Classification of mononucleosis according to its course:

smooth;
complicated;
uncomplicated;
protracted.

SYMPTOMS

The incubation period lasts from several days to two weeks, but most often it is 4-6 days. Further, prodromal phenomena of mononucleosis are observed.

Symptoms of the prodromal period:

weakness;
nausea;
muscle pain;
chills;
loss of appetite.

After a few days they develop typical signs diseases.

Typical symptoms of the acute stage of mononucleosis:

Fever. An increase in body temperature to high levels occurs suddenly. This symptom is observed in 90% of patients, but cases of low-grade fever cannot be excluded. Also, the disease can proceed without any change at all. Fever can last from several days to a month or longer.
(typical tonsillitis) begins with nasal congestion, increasing pain, soreness and a feeling of dryness in the throat. The mucous surface of the posterior wall of the pharynx is red and swollen, enlarged follicles in the form of granulosa pharyngitis are visible. A whitish layer of plaque is found on the tonsils, they are enlarged and have a loose surface. Against the background of the disease, a bacterial infection represented by streptococcal and staphylococcal microflora may develop.
Lymphadenopathy is an early sign of pathology. First, the lymph nodes in the neck enlarge, and later a change in the size of the peripheral and internal lymph nodes is detected. With an increase in the internal mesenteric and peribronchial groups, symptoms may occur in the form of cough, difficulty breathing and pain on the right side of the lower abdomen.
Hepatolienal syndrome. Liver enlargement is observed in 90% of patients with ultrasound examination. Possible mild yellowness of the skin and sclera. An enlarged spleen is accompanied by a feeling of heaviness on the left under the rib.
Rashes on mucous membranes and skin are diagnosed in 10-15% of patients. The nature of the rash and the timing of its appearance vary widely.
The duration of the disease is about 2-4 weeks, usually recovery begins in the second or third week.

Signs of recovery:
- reducing the severity of intoxication;
- reduction of lymph nodes and internal organs;
- normalization of blood counts.
In some patients, the infection becomes chronic and the disease continues for up to 18 months or longer.

Children under one year of age are not susceptible to the disease thanks to innate passive immunity received from the mother. More than half of patients experienced mononucleosis before adolescence. The first increase in incidence is observed in children from 2 to 10 years. The following outbreaks are recorded in adolescents, with girls more often suffering from mononucleosis at 14-16 years of age, and boys a little later - at 16-18 years of age. Most mature people develop antibodies to the pathogen by the age of 35-40, but in people infected with the immunodeficiency virus, signs of the disease may appear regardless of age.

In children under two years of age, mononucleosis often occurs without symptoms.. The ratio of manifest and subclinical forms of the disease in adults is 1 to 3, and sometimes 1 to 10.

Mononucleosis is characterized by a polymorphic clinical picture, so reported cases do not provide information about the real spread of the disease.

DIAGNOSTICS

Basic diagnostic methods:
- Clinical research methods if mononucleosis is suspected, consist of studying the results of a general blood test. A constant sign for mononucleosis is lymphocytosis, or a decrease in the number of white blood cells. It appears from the first week of the disease and is observed for a long time after recovery. The presence of band neutrophils may also support the diagnosis, but the main sign of mononucleosis is the identification of atypical mononuclear cells. Their number can vary depending on the severity of the infectious process and range from 10 to 40-50%. In the first days of the onset of the disease, this triad of signs may be absent; the obvious presence of mononuclear cells is detected in the second week of the disease. Against the background of the described changes, ESR increases moderately, while platelet and red blood cell values remain normal.
- Specific diagnostics. Methods based on serological analysis, help identify antigens and antibodies to the virus. With help enzyme immunoassay Determine IgG and IgM to the Epstein-Barr virus.
- For checking the condition of internal organs held ultrasound diagnostics liver and spleen.
A person who has had mononucleosis must be tested for HIV three times with an interval of three months, since initial stage This disease develops signs of mononucleosis.

TREATMENT

Mainly treatment of mononucleosis carried out at home, sometimes in severe cases of the disease or when there is a threat of complications, hospitalization in a hospital is required. There is currently no specific therapy for EBV, so nonspecific treatment methods are used.

Treatments for infectious mononucleosis:
- immunomodulators;
- antiviral drugs (effectiveness has not been clinically proven);
- antiseptics for throat irrigation;
- hot drinks, inhalations, rinses;
- antipyretic drugs;
- desensitizing agents;
- detoxification drugs;
- glucocorticosteroids (in severe cases);
- antibiotics to suppress secondary infection (penicillin drugs are contraindicated);
- choleretic drugs for functional changes liver;
- diet, table No. 5 or 5a;
- antihistamines.
As a rule, doctors choose gentle treatment tactics due to the strain of the immune system and the tendency to allergic manifestations in this disease.

COMPLICATIONS

For infectious mononucleosis complications are quite rare and are characteristic of severe disease or decreased immunity.

Complications of mononucleosis:
- The most common consequence of the disease is inflammation of the liver with the development of jaundice with characteristic darkening of urine and yellowing of the skin.
- One in a thousand patients has a splenic rupture. This life-threatening condition requires urgent surgery to prevent internal bleeding and death.
- With mononucleosis, the susceptibility to secondary infection by pathogenic bacterial microflora increases. Against the background of these infections, meningoencephalitis, pneumonia and interstitial infiltration in the lung tissues can develop.
PREVENTION

Methods of nonspecific prevention of mononucleosis:
- increasing the body's resistance to infectious diseases;
- hardening;
- wet cleaning and disinfection of disease areas.
Preventive measures after suffering from mononucleosis:
- cessation of vaccination over the next 6-12 months;
- maximum limitation of contacts in teams;
- long trips are undesirable;
- following a strict diet;
- gentle regime with sufficient time for rest;
- clinical examinations for 6 months after past illness;
- regular walks in the fresh air;
- limiting sun exposure.
PROGNOSIS FOR RECOVERY

For uncomplicated infectious mononucleosis the prognosis is favorable. Long-term decline immunity against the background of a previous illness contributes to susceptibility to colds. Severe complications of mononucleosis develop extremely rarely and can significantly worsen the prognosis of its course.

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Etiology

Time frame for infection

1) Epstein-Barr viral

2) Cytomegalovirus

3) Caused by human herpes virus type 6

4) Mixed infections

Typical

Light form

Moderate form

Severe form

1) Spicy.

2) Protracted.

3) Chronic.

4) Smooth (without complications).

5) With complications:

myocarditis, encephalitis,

neutropenia,

thrombocytopenia, aplastic anemia.

Primary infection or

reactivation of latent infection

Atypical forms:

Subclinical

(asymptomatic)

Visceral (rare)

Infectious mononucleosis is divided by type, severity and course. Typical cases include cases of the disease accompanied by main symptoms (enlarged lymph nodes, liver, spleen, tonsillitis, lymphomonocytosis and/or atypical mononuclear cells in a blood test). Atypical include erased, asymptomatic and visceral forms of the disease. Typical forms are divided by severity into light, moderate and severe. Indicators of severity are the severity of intoxication, the degree of enlargement of the lymph nodes, liver and spleen, damage to the oropharynx and nasopharynx, and the number of atypical mononuclear cells in the peripheral blood. The visceral form is always regarded as severe. The course of infectious mononucleosis can be acute, protracted, chronic, smooth (without complications), with complications (encephalitis, myocarditis, neutropenia, thrombocytopenia, aplastic anemia, splenic rupture).

Scheme of examination of a patient with infectious mononucleosis.

When collecting anamnesis, you need to find out the source of infection. For this purpose, it is necessary to find out whether the child has been in contact with patients with infectious mononucleosis or “carriers” of the Epstein-Barr virus, CMV or HHV-6 type. Were any parenteral manipulations carried out? If so, what, when and in connection with what? Does the child suffer from any physical disease (especially those accompanied by a state of immunosuppression).

It is necessary to pay attention to the severity and timing of the appearance of enlarged lymph nodes, difficulty in nasal breathing, fever, symptoms of intoxication, damage to the oropharynx, enlargement of the liver and spleen, and skin rashes.

When examining a patient, it is necessary to pay attention to the general condition and well-being of the patient, body temperature, body weight and its compliance age norm, coloring of the skin and visible mucous membranes, condition of the lymph nodes, subcutaneous fat, and oropharynx.

Identify changes in the digestive, cardiovascular system, respiratory system, liver, spleen, kidneys. Determine the nature of stool and urination. Conduct an examination of the central nervous system.

When monitoring a patient over the course of the disease, the severity of the disease should be assessed, taking into account the degree of temperature increase, the severity and duration of symptoms of intoxication, enlargement of lymph nodes, liver, spleen, lesions of the oropharynx, skin rashes, the number of atypical mononuclear cells in the peripheral blood, changes in biochemical analysis blood (increased ALT and AST levels).

When substantiating the diagnosis, it is necessary to take into account the results of laboratory and instrumental studies: examination of blood, urine and saliva in PCR for the presence of EBV DNA, CMV DNA, HHV-6 DNA (qualitative and quantitative) and/or their antigens in blood lymphocytes in RIF with monoclonal antibodies , serological examination for the presence of antibodies of class IgM and IgG (qualitative and quantitative) to EBV antigens (EBNA, VCA, EA), CMV and HHV-6 type, biochemical blood test (ALT, AST, LDH, ASL-O, protein, protein fractions, urea), serological examination for HIV, hepatitis B and C, G and TTV, bacteriological examination of the microflora of the oropharynx, ultrasound examination of the abdominal organs, general blood and urine tests.

Determine the presence of complications and concomitant diseases in the child.

Check your self-preparation by answering test control questions and situational tasks:

1. What viruses are the causative agents of infectious mononucleosis:

a) herpes simplex virus

b) cytomegalovirus

c) vericella-zoster virus

d) Epstein–Barr virus

e) adenovirus

e) human herpes virus type 6?

2. Which family does the causative agent of infectious mononucleosis belong to:

a) picornaviruses

b) herpes viruses

c) paramyxoviruses?

3. Herpes viruses are:

4. Epstein-Barr virus has the following antigens:

a) surface S-antigen, core C-antigen

b) somatic O-antigen, capsular K-antigen, flagellar H-antigen

c) X-antigen, Y-antigen, R-antigen

d) very early antigens - IE (immediate early), early antigens - EA (early), late antigens - LA (late).

e) viral capsid antigen (VCA), nuclear antigen (EBNA), early antigen (EA), membrane antigen (MA).

5. Cytomegalovirus is characterized by:

a) fast replication

b) slow replication

c) has very early antigens - IE (immediate early), early antigens - EA (early), late antigens - LA (late)

d) has a wide tissue tropism

d) affects only the salivary glands

e) in case of MI, it affects T-lymphocytes

g) in MI it affects B-lymphocytes.

6. Epstein-Barr virus causes:

a) infectious mononucleosis

b) sarcoidosis

c) Burkitt's lymphoma

d) DiGeorge syndrome

e) nasopharyngeal carcinoma

e) cystic fibrosis

g) hairy leukoplakia of the tongue

h) Duncan syndrome.

7) Cytomegalovirus is associated with:

a) sepsis

b) perinatal infection

c) infectious mononucleosis

d) mumps

e) complications of organ and tissue transplantation

e) retinitis

g) pneumonia

h) hepatitis

i) encephalitis.

8) Human herpes virus type 6 (HHV-6) is associated with:

a) herpes zoster

b) sudden exanthema in children

c) infectious mononucleosis

d) herpes labialis

e) lymphomas

e) hepatitis

g) encephalitis

h) psychoses.

9. Herpes - viruses of types IV, V and VI are infected:

a) 5-7% of the world's population

b) 10-20% of the world's population

c) 50% of the world's population

d) 80-100% of the world's population.

10. The highest prevalence of EBV, CMV and HHV-6 types is observed:

a) in developed countries

b) in developing countries

c) in socially disadvantaged families.

11. Transmission of EBV, CMV and HHV-6 type can occur:

a) by airborne droplets

b) by airborne dust

c) through contact and everyday life

d) sexually

e) by blood transfusion

e) through vertical transmission

g) through breast milk.

12. The incubation period for MI is:

b) 5-7 days

c) 15 days – 2 months

d) 9 – 12 months.

13. The pathogenesis of infectious mononucleosis is based on:

a) lymphoproliferative process

b) infection of the gastrointestinal tract epithelium by viruses

V) scattered foci of demyelination in the brain and spinal column

d) atrophy of motor neurons in the anterior horns of the spinal cord

e) infection of the epithelium of the upper respiratory tract by viruses.

14. The main symptom complex of infectious mononucleosis includes:

a) fever

b) lymphadenopathy

c) chronic fatigue syndrome

d) damage to the oropharynx

e) peripheral paresis

e) hepatosplenomegaly

g) muscle atrophy

h) lymphomonocytosis and/or the appearance of atypical mononuclear cells in the peripheral blood.

15. In addition to the main symptom complex of infectious mononucleosis, the following may be observed:

a) exanthema

b) encephalitis

c) nasal congestion and snoring

e) thyroiditis

e) puffiness of the face

g) encopresis

h) pasty eyelids

i) catarrhal manifestations of the upper respiratory tract

j) intermittent claudication

k) gastrointestinal disorders.

16. The most typical for infectious mononucleosis is an increase in the following groups lymph nodes:

a) posterior cervical

b) axillary

c) cubital

d) inguinal.

17. Suppuration of the lymph nodes in infectious mononucleosis occurs:

a) in 80-90% of cases

b) doesn't happen

c) in 20-30% of cases

d) in 5-10% of cases.

18. Damage to the oropharynx in children with infectious mononucleosis has:

a) viral etiology

b) viral-bacterial etiology

c) bacterial etiology

d) fungal etiology.

19. Difficulty in nasal breathing during infectious mononucleosis is associated with:

a) copious mucous discharge from the nose

b) enlargement of the nasopharyngeal tonsil

c) sinusitis.

20. Infectious mononucleosis is characterized by:

a) leukocytosis

b) neutrophilia

c) thrombocytopenia

d) acceleration of ESR

e) lymphomonocytosis

e) appearance of atypical mononuclear cells

g) anemia

h) increased transaminase activity

i) increased activity of alkaline phosphatase.

21. Among the atypical forms of infectious mononucleosis are:

a) erased

b) subclinical

c) visceral

d) fulminant.

22. To diagnose infectious mononucleosis, the following reactions with heterophilic antibodies are used:

a) Horner

b) Paul-Bunnel-Davidson

c) Belsky-Filatov-Koplik

d) Tomchik

d) Waterhouse-Frederiksen

e) Goff-Bauer.

23. A test for heterophile antibodies can be positive if:

a) EBV etiology of MI

b) CMV etiology of MI

c) HHV-6 – etiology of MI

d) EBV + CMV - etiology of MI

e) EBV + HHV-6 – etiology of MI

e) CMV + HHV-6 – etiology of MI

g) EBV+CMV+HHV-6 – etiology of MI.

24. Epstein - Barr viral The etiology of infectious mononucleosis is confirmed by the detection in the blood of:

a) anti-EBNA Ig M

b) anti TOXO Ig M

c) anti-EA EBV Ig G

d) anti-EA EBV Ig M

e) anti HBc Ig M

f) EBV DNA in blood, saliva, urine

g) anti-VCA EBV Ig G

h) anti-VCA EBV Ig M.

25. CMV etiology of MI is confirmed by the detection of:

a) CMV DNA in the blood and/or CMV Ag in blood lymphocytes

b) anti HBc Ig M

c) anti-СMV Ig G

d) anti-CMV Ig M

e) anti-CMV Ig A

e) CMV DNA in saliva, urine

g) anti-HAV Ig M.

26. HHV-6 – the viral etiology of infectious mononucleosis is confirmed by detection in the blood:

a) anti-HAV IgM

b) HHV-6 DNA in blood, saliva, urine

c) anti-CMV IgG

e) anti-HHV-6 IgM.

27. MI must be differentiated from:

a) adenoviral infection

b) subtoxic diphtheria of the oropharynx

c) toxoplasmosis

d) listeriosis

e) localized form of oropharyngeal diphtheria

e) diphtheria of the respiratory tract

g) toxic diphtheria of the oropharynx

h) chlamydial, mycoplasma infection

i) hemoblastoses

j) candidiasis of the oropharynx

l) mumps infection.

28. Complications of infectious mononucleosis include:

a) encephalitis

b) paresis of the facial nerve

c) bacterial infection of the oropharynx

d) osteomyelitis

e) splenic rupture

f) immune: anemia, thrombocytopenia, neutropenia

g) respiratory arrest

h) myocarditis.

29. For the etiological treatment of MI, the following is used:

a) fluoroquinolones

b) preparations of recombinant interferon - alpha

c) proteolysis inhibitors

d) interferon inducers

e) intravenous immunoglobulins

e) ganciclovir

g) acyclovir

30. For a patient with infectious mononucleosis, due to pronounced difficulty in nasal breathing, it is advisable to prescribe:

a) oxygen therapy

b) antibiotics for 5–7 days

c) short course prednisolone.

Check your answers:

1- b, d, f; 2- b ; 3 - b; 4 - d; 5- b,c,d,f; 6 - a,c,e,g,h;

7 - b, c, d, f, g, h, i; 8 - b, c, d, f, g, h; 9 - G; 10 - b,c;

11 - a, c, d, e, f, g; 12 - V; 13 - A; 14 - a, b, d, f, h; 15 - a,c,e,h,i,l;

16 - A; 17 - b; 18 - A; 19 - b; 20 - a, d, e, f, h; 21 - a B C; 22 - b,d,f;

23 - a, d, e, g; 24 - a,c,d,f,g,h; 25 - And where; 26 - b,d;

27 - a, b, d, g, h, i, j; 28) - a,c,e,f,g,h; 29 - b, d, e, g; 30 - V.

Sum of standard answers – 99

Calculation of student answer score:

A (sum of correct answers)

K (assimilation coefficient) = --------------

B (sum of standard answers)

If K is below 0.7 the rating is unsatisfactory

- “ - = 0.7-0.79 - satisfactory

- “ - = 0.8-0.89 - good

- “ - = 0.9-1.0 – excellent

Answer the task questions

I. A 6-month-old child became acutely ill with an increase in body temperature to febrile levels, and symptoms of rhinitis and cough were noted. On the fourth day of illness, a puffy face, pasty eyelids, and snoring appeared. By the end of the week, a sore throat and a maculopapular rash appeared without stages of rashes and preferential locations of localization.

In the peripheral blood, there was an increase in the level of band and segmented neutrophils in the first week of the disease, lymphomonocytosis and atypical mononuclear cells in the second week of the disease. The Paul-Bunnel-Davidson and Goff-Bauer reactions are positive. EBV DNA is detected in the child’s blood, urine, and saliva; type HHV-6 DNA is detected in the blood and saliva.

3. What additional studies should be performed to confirm the diagnosis?

4. Consultations with which specialists will be needed to determine the scope of additional research and clarify treatment tactics?

6. What are the features of this disease in young children?

II. An 8-year-old child suffering from hemophilia received an injury to the frenulum of the tongue, which was accompanied by prolonged bleeding. For hemostatic purposes, a transfusion of fresh frozen plasma was performed in the hospital. As a result of the therapy, the bleeding was stopped, the condition returned to normal and the patient was discharged home

1 month after discharge from the hospital, the child’s condition worsened. There was a gradual increase in body temperature, yellowness of the skin and sclera, a sore throat when swallowing, enlarged peripheral lymph nodes, as well as the liver and spleen, darkened urine and discolored feces. Headaches, anorexia, abdominal pain, feelings of weakness and malaise were noted. The mucous membrane of the oropharynx was moderately hyperemic and edematous, the palatine tonsils were enlarged and there were overlaps on them.

During the examination, atypical mononuclear cells were detected in the peripheral blood, and a biochemical blood test revealed an increase in the level of conjugated bilirubin, alkaline phosphatase activity, ALT, and AST. Anti-CMV IgM, anti-CMV IgA, and a high level of anti-CMV IgG were detected in the blood serum.

1. Indicate the presumptive clinical diagnosis.

2. Based on what clinical symptoms can this diagnosis be made?

5. What diseases need differential diagnosis?

III. A 6-year-old child fell ill acutely with a rise in temperature to 37.7ºC, which remained at 38-38.5ºC in recent days. On the fifth day of illness, enlargement of the cervical lymph nodes was noted. On the tenth day of illness - tonsils. On the eleventh day of illness the child was hospitalized.

Upon admission, the patient was in moderate condition, temperature 37.9ºC, complaints of sore throat when swallowing. The skin is pale and clean. The anterior and posterior cervical lymph nodes are palpated, enlarged to 2 cm, mobile, moderately painful. Axillary, inguinal up to 1 cm, elastic, mobile, painless. Nasal breathing is moderately difficult, there is no discharge from the nasal passages. Vesicular breathing in the lungs. Heart sounds are rhythmic and sonorous. The pharynx is clearly hyperemic, edematous, hypertrophy of the left lateral column of the posterior pharyngeal wall and yellowish deposits on it are determined. The tonsils are enlarged to degree II, hyperemic, without overlap. The abdomen is soft and painless. The liver protrudes below the edge of the costal arch by 3 cm, the spleen by 2 cm.

In the blood test on the eleventh day of illness: HB-103 g/l, er. 3.5·10 12/l, L-9.4·10 9/l, e-1, n-3, s 17, l 39, m-12, thrombus. 105·10 9/l, pl.cl -4, ESR -20 mm/hour, atypical mononuclear cells -24%.

The Paul-Bunnell test on the 13th day of illness was negative.

PCR detected EBV DNA in blood and saliva and CMV DNA in blood, saliva and urine.

In ELISA - anti-VCA EBV Ig M; anti-VCA EBV Ig G; anti-EA EBV Ig M; anti-EA EBV Ig G; anti-CMV Ig M; anti-CMV Ig G.

1. Indicate the presumptive clinical diagnosis.

2. Based on what clinical symptoms can this diagnosis be made?

3. What studies should be performed to confirm the diagnosis?

4. Consultations with which specialists will be needed to determine the scope of additional research and clarify treatment tactics?

5. What diseases need differential diagnosis?

TEST TASK.

A 5-year-old boy became acutely ill with a rise in temperature to febrile levels. The disease was accompanied by pronounced symptoms of intoxication: weakness, lethargy, adynamia, and repeated vomiting. The child was taken to the hospital on the 5th day of illness.

The mother noted that the child had nasal congestion, which intensified towards the end of the first week of illness, a nasal tone of voice appeared, and snoring breathing occurred during sleep. Upon admission, the patient was in a serious condition and had a febrile fever. The boy is lethargic and adynamic. The skin is pale. Lymph nodes were sharply enlarged, conglomerates of cervical lymph nodes changed the configuration of the neck. Breathing through the nose was completely absent, carried out through the mouth, was “snoring”, the face was puffy, the eyelids were pasty. Changes in the cardiovascular system were detected: tachycardia, increased blood pressure, muffled heart sounds. The mucous membrane of the oropharynx was hyperemic, the palatine tonsils were in contact along the midline, and there were continuous filmy deposits on them. Liver +5 +5 +in/3, spleen +5 from under the edge of the costal arch. The liver and spleen were tender to palpation, and abdominal pain was noted. On the 6th day of the disease, manifestations of hemorrhagic syndrome were noted: petechiae on the mucous membrane of the oral cavity and oropharynx, petechial rash on the torso, nosebleeds. Body temperature reached 41.2 ºС. On the 7th day of illness, yellowness of the skin and sclera appeared, urine darkened, and feces became discolored.

52% of atypical mononuclear cells were detected in peripheral blood. In the biochemical blood test - increased activity of ALT to 483 U/l and AST to 467 U/l. The Paul-Bunnell-Davidson reaction is positive. Anti-EBV EA IgM, anti-EA EBV Ig G, anti-VCA EBV Ig M were detected in the blood serum; anti-VCA EBV Ig G.

EBV DNA was detected in blood, saliva, and urine.

Answer the following questions:

Make a detailed clinical diagnosis.

Based on what clinical symptoms and laboratory results was the clinical diagnosis made?

Name the possible source and route of infection.

Based on what data can we judge the timing of infection?

What leading symptoms determined the severity of the disease?

What other pathological conditions, besides those identified in of this child, are characteristic of the visceral form of infectious mononucleosis?

Is liver damage characteristic of this disease?

What is the action herpetic viruses Types IV, V and VI on the immune system?

What is it connected with? positive result Paul-Bunnel-Davidson reactions in this patient?

What other reactions with heterophilic antibodies are used to diagnose infectious mononucleosis?

What is the prognosis for this child?

What etiotropic drugs can be used in this case?

What methods of specific prevention of Epstein-Barr viral infection currently exist?

Standard answers to the test task

1. Epstein-Barr infectious mononucleosis of viral etiology. Typical. Severe form.

2. Expressed symptoms of intoxication, fever, manifestations of lymphoproliferative syndrome: significant enlargement of lymph nodes, liver and spleen, damage to the oropharynx, the appearance of hemorrhagic syndrome, jaundice. In the blood test - the appearance of atypical mononuclear cells (52%), detection in the blood serum of anti-EBV EA IgM, anti-EA EBV Ig G, anti-VCA EBV Ig M; anti-VCA EBV Ig G. Detection of EBV DNA in blood, saliva, urine, positive result of the Paul-Bunnell-Davidson reaction, increased activity of hepatocellular (ALAT, AST).

3. The source of infection may be a patient with infectious mononucleosis or a carrier of the Epstein-Barr virus.

4. In this case, we can think that the infection occurred no earlier than 1 month ago.

5. Symptoms of intoxication, fever, lymphadenopathy, damage to the oropharynx, hepatosplenomegaly, hemorrhagic syndrome, jaundice, the appearance of 52% of atypical mononuclear cells in the peripheral blood.

6. Damage to the central nervous system, kidneys, adrenal glands, and other vital organs. The visceral form of infectious mononucleosis often ends in death.

7. Yes. It has now been convincingly proven that the Epstein-Barr virus is an undoubted hepatotropic pathogen.

8. Infectious mononucleosis can be considered as a disease of the immune system due to the replication of viruses in B and T lymphocytes and the possible formation of an immunodeficiency state. The virus is contained and reproduced in B lymphocytes.

9. The positive result of the Paul-Bunnell-Davidson test in this patient is associated with the production of heterophilic IgM antibodies to the EVV antigen, which agglutinate sheep erythrocytes.

10. Tomczyk reaction is a reaction of agglutination of trypsinized bovine red blood cells with patient serum treated with guinea pig kidney extract. The Hoff-Bauer reaction is an agglutination reaction of horse erythrocytes with patient serum on glass.

11. The severe form of infectious mononucleosis in the vast majority of cases ends in recovery.

12. Preparations of recombinant interferon alpha: "Viferon" in suppositories, "Grippferon" intranasally, interferon inducers (including "Cycloferon"), inhibitors of viral DNA replication: acyclovir, intravenous immunoglobulins ("Octagam", "Pentaglobin", "Introglobin" , “Immobio”, “Pentaglobin”, etc.).

13. Methods for specific prevention of Epstein-Barr viral infection have not yet been developed.

(otherwise called benign lymphoblastosis, Filatov's disease) is an acute viral infection characterized by primary damage to the oropharynx and lymph nodes, spleen and liver. A specific sign of the disease is the appearance of characteristic cells in the blood - atypical mononuclear cells. The causative agent of infectious mononucleosis is the Epstein-Barr virus, which belongs to the herpesvirus family. Its transmission from the patient is carried out by aerosol. Typical symptoms of infectious mononucleosis are general infectious phenomena, tonsillitis, polyadenopathy, hepatosplenomegaly; maculopapular rashes are possible on various areas of the skin.

Complications

Complications of infectious mononucleosis are mainly associated with the development of an associated secondary infection (staphylococcal and streptococcal lesions). Meningoencephalitis, obstruction of the upper respiratory tract by hypertrophied tonsils, may occur. Children may experience severe hepatitis, and sometimes (rarely) interstitial bilateral infiltration of the lungs develops. Rare complications also include thrombocytopenia; overstretching of the lienal capsule can cause rupture of the spleen.

Diagnostics

Nonspecific laboratory diagnostics includes a thorough examination of the cellular composition of the blood. General analysis blood shows moderate leukocytosis with a predominance of lymphocytes and monocytes and relative neutropenia, a shift in the leukocyte formula to the left. Large cells of various shapes with wide basophilic cytoplasm appear in the blood - atypical mononuclear cells. For the diagnosis of mononucleosis, it is significant to increase the content of these cells in the blood to 10-12%; often their number exceeds 80% of all white blood elements. When examining blood in the first days, mononuclear cells may be absent, which, however, does not exclude the diagnosis. Sometimes these cells can take 2-3 weeks to form. The blood picture usually gradually returns to normal during the period of convalescence, while atypical mononuclear cells often persist.

Specific virological diagnostics are not used due to laboriousness and irrationality, although it is possible to isolate the virus in swabs from the oropharynx and identify its DNA using PCR. There are serological diagnostic methods: antibodies to the VCA antigens of the Epstein-Barr virus are detected. Serum immunoglobulins type M are often detected during the incubation period, and at the height of the disease they are observed in all patients and disappear no earlier than 2-3 days after recovery. The detection of these antibodies serves as a sufficient diagnostic criterion for infectious mononucleosis. After an infection, specific immunoglobulins G are present in the blood and remain for life.

Patients with infectious mononucleosis (or persons suspected of having this infection) undergo serological testing three times (the first time during an acute infection, and twice more at an interval of three months) to detect HIV infection, since it may also be accompanied by the presence of mononuclear cells in the blood. For differential diagnosis tonsillitis with infectious mononucleosis and tonsillitis of other etiologies requires consultation with an otolaryngologist and pharyngoscopy.

Treatment of infectious mononucleosis

Mild and moderate infectious mononucleosis is treated on an outpatient basis; bed rest is recommended in cases of severe intoxication and severe fever. If there are signs of liver dysfunction, diet No. 5 according to Pevzner is prescribed.

There is currently no etiotropic treatment; the complex of indicated measures includes detoxification, desensitization, restorative therapy and symptomatic remedies, depending on the available clinic. Severe hypertoxic course, threat of asphyxia when the larynx is compressed by hyperplastic tonsils are an indication for short-term prescription of prednisolone.

Antibiotic therapy is prescribed for necrotizing processes in the pharynx in order to suppress the local bacterial flora and prevent secondary bacterial infections, as well as in case of existing complications (secondary pneumonia, etc.). The drugs of choice are penicillins, ampicillin and oxacillin, and tetracycline antibiotics. Sulfonamide drugs and chloramphenicol are contraindicated due to the side inhibitory effect on the hematopoietic system. Splenic rupture is an indication for emergency splenectomy.

Prognosis and prevention

Uncomplicated infectious mononucleosis has a favorable prognosis, dangerous complications, which can significantly aggravate it, occur quite rarely in this disease. Residual effects in the blood are a reason for clinical observation for 6-12 months.

Preventive measures aimed at reducing the incidence of infectious mononucleosis are similar to those for acute respiratory infectious diseases; individual measures of nonspecific prevention consist of increasing immunity, both with the help of general health measures and with the use of mild immunoregulators and adaptogens in the absence of contraindications. Specific prevention (vaccination) for mononucleosis has not been developed. Emergency preventive measures are applied to children who have been in contact with the patient and consist of prescribing a specific immunoglobulin. The area where the disease is occurring is thoroughly cleaned and personal belongings are disinfected.

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Pathogen and routes of transmission

Mechanism of disease development

Clinical picture

Classification

Diagnostics

Treatment

Complications of the disease

Video: infectious mononucleosis, “Doctor Komarovsky”

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CAUSES

Source of disease:

Ways of transmission of infection:

CLASSIFICATION

Forms of mononucleosis:

Classification of mononucleosis according to its course:

SYMPTOMS

Symptoms of the prodromal period:

Typical symptoms of the acute stage of mononucleosis:

Signs of recovery:

DIAGNOSTICS

Basic diagnostic methods:

TREATMENT

Treatments for infectious mononucleosis:

COMPLICATIONS

Complications of mononucleosis:

PREVENTION

Methods of nonspecific prevention of mononucleosis:

Preventive measures after suffering from mononucleosis:

PROGNOSIS FOR RECOVERY

Complications

Diagnostics

Treatment of infectious mononucleosis

Prognosis and prevention

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