Chapter 82: Mononucleosis Syndromes

SUMMARY

The defining clinical features of a mononucleosis syndrome are fever and reactive lymphocytes in the blood. The two most common causes of mononucleosis are Epstein-Barr virus (EBV) and cytomegalovirus (CMV) infection. The clinical manifestations of EBV and CMV mononucleosis depend on a vigorous host response to the viral infection. Patients who become infected without a host response develop antibodies to the virus but no or minimal clinical manifestations. Several clinical similarities exist between EBV and CMV mononucleosis. Both infections have a febrile prodrome before the mononucleosis phase develops. Both infections can induce fever, an enlarged spleen, and an erythematous skin rash—the mononucleosis phase. The disease is self-limited in the vast majority of patients, although resolution may take several weeks, especially in older individuals. In both viral infections, lymphocytes represent greater than 50 percent of blood cells, and at least 10 percent are reactive lymphocytes. Differences in clinical and laboratory findings are observed. Severe pharyngitis and tender lymph node enlargement, often in several lymph node groups, occur in infection with EBV and perhaps with some unknown agents, but not to the same degree in infections with CMV. The majority of cases of EBV mononucleosis occur in teenagers and young adults, whereas CMV-induced disease occurs most commonly in adults in their 30s to 60s. A much larger percentage of adults have unrecognized primary infection with CMV than with EBV. EBV results in the development of heterophile antibodies, active against sheep and horse red cells among others, but this development does not occur in CMV. The pathway leading to lymphocytosis and reactive lymphocytes differs between the two agents. The B cell is infected in EBV infection which eventually may lead to hematologic malignancy, whereas the macrophage is infected in CMV. This may explain its important role after allogeneic transplantation. In both infections, the T lymphocyte is the reactive cell. Other agents, including Toxoplasma gondii, human immune deficiency virus type 1, and several other viruses, can cause a mononucleosis-like syndrome with reactive lymphocytes in the blood.