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Mononucleosis: The Kissing Disease

As one of the many herpes viruses, this one living in the epithelial cells of the pharynx and parotid duct, #mononucleosis infects about 95 percent of adults worldwide, primarily those between the ages of 15 and 24 years or more specifically, freshman university students. Lower rates of infection are found in higher socioeconomic families with better sanitary conditions and interestingly, when EBV is discovered in older adults, it isn't as likely to progress to infectious mononucleosis as it would in the younger population. This infection is caused by the Epstein-Barr virus (EBV), spread by saliva, and is often present without symptoms. Those that do develop clinical symptoms though, can suffer significant sequelae and remains latent within the host, reactivating and shedding when the host's immune system is compromised.


As a clinician, our suspicion is raised when we have clients with sore throats, fever, fatigue, enlarged tonsils, inflammation in the throat or spots on the palate, and enlarged lymph nodes. The incubation period is about four to eight weeks. Children typically have no symptoms, or rather nonspecific symptoms, while young adults tend to present with sore throat, swollen lymph nodes, fever, and tonsillar enlargement. The spots on the palate and throat inflammation is more common in the adolescent population. Older adults are more likely to develop jaundice and less likely to have lymphadenopathy, sore throat, and an enlarged spleen; hence, it is easier to miss.


The best initial test is the #heterophile antibody testing (Monospot) as it is fast, inexpensive and has a high specificity. Although often provided, steroids and antiviral medicines really don't impact the clinical course. What is wise though, is avoidance from athletic participation for the first three weeks to avoid risk of splenic rupture.



Misdiagnosis is common, particularly in the younger and more senior populations. These are more often thought to be acute HIV infections, streptococcal #pharyngitis, or #toxoplasmosis. Both toxoplasmosis and infectious mononucleosis can cause the liver and spleen to enlarge, lymphocytosis, an even positive results from a heterophile antibody test.


If suspected though, heterophile antibody testing should be conducted, but a negative test doesn't rule out infectious mononucleosis, especially during the first week of illness. It this testing is negative, your clinician will obtain a CBC to evaluate your lymphocyte count. If less than 4K then infectious mononucleosis is unlikely (99 percent).


If lymphocytes are higher than 4K, then an EBV-specific antibody test (VCA-IgG and VCA-IgM) will confirm diagnosis, but results do take a little longer and are a bit more costly. If the initial heterophile test is positive, diagnosis is confirmed without further testing. A rapid test for streptococcal #pharyngitis is often performed at the same time, as thirty percent of individuals will have dual infections. Amoxicillin and ampicillin should not be used to treat strep when mono is a comorbidity as this may cause a morbilliform rash.


If initial findings are negative, and the client doesn't improve clinically within five to seven days, a second heterophile antibody test should be performed. If an acute diagnosis is urgently required, for example for a competitive athlete who wants to return to competition as soon as possible, then a VCA-IgM test can be performed. A negative result is strong evidence against the diagnosis of infectious mononucleosis.


Treatment


The approach to treating infectious mononucleosis is supportive. Hydrate. Treat fever as appropriate or offer anti-inflammatories for pain and discomfort. Throat lozenges or sprays may be helpful, or gargling 2 percent lidocaine (Xylocaine) solution if throat pain is significant. Listen to your body. Don't over do it, but also, get outside in the sun and soil. Enforcing bed rest has shown to slow recovery.


Glucocorticoids decrease the severity of sore throat only within the first twelve hours of treatment. Otherwise they have not shown to decrease the severity or length of illness. It is my opinion the risk is greater than any benefit. They are not superior to pain relief modalities either.


Antiviral therapy, such as acyclovir are also ineffective at decreasing the length of severity of infectious mononucleosis. Combining these two methods of treatment do not improve their effectiveness. Valtrex may decrease oral viral shedding though, but there really isn't evidence there is any clinical benefit.


These approaches suppress rather than support the immune system. Our approach is to optimize the nervous system, gut health, and immune health. Lysine (750mg daily for prevention and three times daily during an outbreak) has been used by integrative providers to ward off herpes outbreaks. Supporting adrenal health with adaptogenic herbs, vitamin C, and key B vitamins, as well as vitamin D, is also supportive.


Reduce stress. Sleep. Eat clean. Get your face in the sun and your feet on the mat and in the soil. Take time to connect to your breath to tame your fight-or-flight response. Listen to music. Meditate. These aren't offered to placate, but because they actually are effective - vital even.


Complications from Infectious Mononucleosis


The key risk or the more significant risk related to mononucleosis is splenic rupture. Most all individuals with infectious mononucleosis have enlarged spleens (although not often palpated on clinical exam), so trauma - even Valsalva - is the concern. This is uncommon, but the standard is to abstain from physical activity of any kind within the first three to six weeks of illness to avoid potential trauma (some argue six months).


Young children are at higher risk of airway obstruction due to enlarged tonsils, which is the most common cause of hospitalization related to infectious mononucleosis. Individuals who are immune compromised are more likely to have severe infection, which can be fatal. Less common risks include meningitis, mononeuropathies, hemolytic anemia, encephalitis, cranial nerve palsies, myocarditis, thrombocytopenia, and acute interstitial nephritis.


Recovery & Long-Term Outcomes


Persistent fatigue is common even towards six months after initial infection. Sore throat, fever, headache, rash, cough, and nausea largely resolve within a month from the onset of symptoms. Sore joints also has a bit of a slower recovery. The association between EBV infection and chronic fatigue syndrome remains uncertain, and a positive IgG test for EBV does not imply a causal relationship.


Functional medicine, the model of clinical practice which digs into underlying cause thinking with a system-wide mindset, appreciates that a dormant herpes virus from our childhood are correlated to autoimmune diseases. Our goal then is to send EBV back into dormancy and ultimately reverse autoimmune conditions naturally. Chronic fatigue, Lupus, fibromyalgia, Hashimoto's Graves disease, and multiple sclerosis are those autoimmune diseases found to have some correlation in the literature, particularly multiple sclerosis and #Lupus. Every single person with multiple sclerosis have been found have have EBV, while those without the virus don't seem to develop MS.


Why does this happen? Our immune system may confuse the tags on the individual's cells when they are exposed to EBV and begin to attack their own tissues, as well as the infection itself. As the virus invades the individual's organs, immune cells again are called in for reinforcement, but tissue cells are actually injured and inflammation results. Genes with predisposition to autoimmune disease can also be triggered. Whether via cell mimicry or cryptic antigens hijacking cell DNA to hide from the immune system, the immune system can end up attacking innocent cells along with the virus. Lyme disease, cytomegalovirus antibodies, chlamydophila pneumonia antibodies, and additional herpes viruses are additional evaluations your clinician may want to evaluate.


References


Ebell, M. H. (2004). Epstein-Barr Virus Infectious Mononucleosis. American Family Physicians, 70(7), 1279-1287.

Taylor, G. H. (2003). Cytomegalovirus. American Family Physicians, 67(3), 519-524.

Womack, J. & Jimenez, M. (2015). Common questions about infectious mononucleosis. American Family Physicians, 91(6), 372-376.

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