Positive Monospot Test Research Articles

1219 A Rare Case of EBV Infection Presenting as Acute Appendicitis with Septic Shock - a Case Report and Review of the Literature

Abstract 18yo male presented to the emergency department (ED) with a 2-week history of progressive lower abdominal pain, weight loss of 8kg & diarrhoea. On examination he looked dehydrated, was tachycardic and had a large, tender, palpable mass in his lower abdomen up to the umbilicus. Blood investigations of note were white cell count (WCC) 29.7 and CRP 187. Computerized tomography (CT) reported an extremely large abscess occupying the lower abdomen and pelvis resulting in bilateral hydronephrosis and hydroureter. The appendix was not visualised. On the night of admission, the patient went into septic shock on the ward and was taken to theatre from emergency laparotomy. 4 litres of a large abscess were evacuated, the appendix was identified with an inflamed appearance and an appendicetomy performed. His post operative course was complicated by an ileus and slow resolving, inter-loop abscesses that required multiple courses of antibiotics and eventual return to theatre for further washout. During his early admission, EBV serology was recommended by the microbiology team on foot of a positive monospot test. Serology was also positive for EBV. Histopathological results of the appendix and lymph nodes showed EBV associated changes. Acute appendicitis can be considered a complication of EBV infection with the proposed mechanism being obstruction of the appendiceal lumen due to swollen lymphoid tissue, this most commonly occurs in the acute phase of EBV infection. In this case it has been shown that EBV and subsequent Infectious mononucleosis can cause acute appendicitis and may be its initial presentation.

Acute onset of fever, eosinophilia, rash, acute kidney injury, and a positive Monospot test in a patient on lamotrigine: DRESS syndrome

A 20-year-old daycare teacher presented to our hospital reporting a generalised erythematous maculopapular rash. The patient also had a fever, myalgia, nausea, reduced urine output, peripheral oedema, and dyspnoea on exertion. She reported that the rash had rapidly increased in size over the past 72 h—coinciding with a doubling of the dose of her lamotrigine which she was prescribed for bipolar affective disorder.

P-O12 Atraumatic Splenic Rupture Secondary to Concurrent Cytomegalovirus and Epstein Barr Virus Infection

Abstract Background Infectious Mononucleosis (IM) is a common viral illness among adolescents and young adults. While most cases are self-limiting, a small number of patient can develop life threatening complications, such as atraumatic splenic rupture (ASR). This is a rare but serious sequelae, and the commonest cause of associated mortality. While Epstein Barr Virus is commonly associated with IM, concurrent infection of cytomegalovirus (CMV) and EBV is rarely reported. Both infections are associated with splenomegaly, however this is usually mild and very rarely results in ASR. Methods We present the case of an immunocompetent nineteen year old male who underwent emergency splenectomy for ASR secondary to concurrent EBV and CMV infection. He presented to the Emergency Department with a five hour history of severe, sudden onset left upper quadrant pain preceded by coughing fit. He reported a one year history of incidental splenomegaly and recent positive monospot test in community. Computerised tomography (CT) of abdomen and pelvis confirmed splenic rupture with large haemo-peritoneum and large sub-capsular haematoma. He was haemodynamically unstable and underwent laparotomy and splenectomy. Results Intraoperative findings included two litres of intraperitoneal blood and large spleen with sub-capsular haematoma; approximately seventeen centimetre diameter and weighed nine hundred and seventy grams. Pathology showed features of non-specific lymphoid hyperplasia. Serum virology confirmed high levels of CMV on polymerase chain reaction with low levels of EBV detected. Virology screening was incidentally repeated post discharge and at this time was consistent acute EBV infection. No alternative cause for splenic rupture or pre-existing splenomegaly has been identified. Conclusions The serology results in this case confirm acute CMV infection with most likely concurrent EBV infection. While we cannot confidently identify which virus caused splenic rupture in this case, ASR is a life threatening condition and an important differential in patients presenting with sudden onset LUQ pain and shock. Splenectomy remains the treatment of choice in haemodynamically unstable patients.

Use of Monospot Testing in the Diagnosis of Infectious Mononucleosis in the Collegiate Student-Athlete Population.

To determine the utility of monospot testing in the diagnosis of mononucleosis in the collegiate student-athlete clinical setting. Retrospective cohort study. National Collegiate Athletic Association Division I sports medicine clinic. All varsity student athletes who had a monospot test and Epstein-Barr virus (EBV) titers obtained from January 1, 2016, through March 31, 2020, (n = 199) were included. Monospot, EBV antibody titers, and liver transaminase results. Using EBV titers indicating acute or recent infection as the gold standard for diagnosing infectious mononucleosis (IM), the reliability of a positive monospot test and elevated liver transaminases for the diagnosis of IM were examined. The monospot test had a sensitivity and specificity of 80.0% and 90.6%, respectively, with a positive predictive value of 36.4% and a negative predictive value of 98.5% in this cohort. All athletes diagnosed with IM also had elevated liver transaminases. The specificity of the monospot test is lower than previously reported in the literature, and a positive test is not sufficient to diagnose mononucleosis in this clinical setting. Positive monospot results should be confirmed with EBV antibody testing. Elevated transaminase levels are highly correlated with acute IM and could play a supporting role in the diagnosis.

Abstract 14357: Straight for the Jugular: Cardiomyopathy After Recent EBV Infection and Lemierre Syndrome

A 21-year-old man presented to an outside hospital with 10 days of fever, fatigue, and malaise. On exam, temperature was 106F, blood pressure 85/50 mm Hg, and heart rate 121 bpm. He was cold and clammy, with elevated jugular venous pressure, normal heart sounds, clear lungs, and cool extremities without edema. Laboratory results were notable for elevated white blood cell count (predominantly neutrophils), serum triglycerides, ferritin, C-reactive protein, coagulation parameters, and positive Monospot test. Following blood cultures, he was initiated on broad spectrum antibiotics, fluid resuscitated, and started on norepinephrine, epinephrine, and phenylepehrine. Shortly after transfer to our institution, although asymptomatic, an electrocardiogram demonstrated diffuse 5 mm ST-elevations with elevated cardiac biomarkers. A transthoracic echocardiogram demonstrated biventricular contractile dysfunction with ejection fraction 20% and apical akinesis. The patient was diagnosed with mixed cardiogenic and distributive shock. Cardiogenic shock was attributed to myocarditis with possible vasospasm or cytokine-induced myocardial suppression. Coronary angiogram was deferred given low suspicion for thrombotic acute coronary syndrome. Cardiac MRI showed subepicardial early and late gadolinium enhancement consistent with myocarditis, but negative viral serologies. Distributive shock was thought to be due to sepsis or hemophagocytic lymphohistiocytosis (HLH). The patient received empiric dexamethasone for HLH; and the diagnosis was confirmed on bone marrow biopsy. Blood cultures grew Fusobacterium necrophorum and neck imaging revealed thrombosis of the left internal jugular vein. Lemierre syndrome, thought to be bacterial invasion in the setting of tonsillitis was diagnosed. He was treated with antibiotics and dexamethasone with rapid clinical improvement and recovery of biventricular function. We suspect EBV infection lead to Lemierre syndrome and HLH with secondary myocardial suppression from the resultant cytokine storm. This case describes the first case of HLH-related myocarditis and highlights clinical decision-making surrounding the workup and management of mixed etiologies of shock with suspected myocarditis.

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Diagnostic dilemma: Epstein–Barr virus (EBV) infectious mononucleosis with lung involvement or co-infection with Legionnaire's disease?

BackgroundHospitalized adults with fever and “pneumonia” can be a difficult diagnostic challenge particularly when the clinical findings may be due to different infectious diseases. MethodsWe recently had an elderly female who presented with fever, fatigue and dry cough with elevated serum transaminases and lung infiltrates. The diagnosis of Epstein–Barr virus (EBV) infectious mononucleosis (IM) was made based on a positive Monospot test, elevated EBV VCA IgM titer, and highly elevated EBV viral load. Her chest infiltrates were not accompanied by hilar adenopathy which may occur with EBV IM. Her dry cough persisted and she developed abdominal pain. ResultsLegionnaire's disease was considered because she had extra-pulmonary findings characteristic of Legionnaire's disease, e.g., relative bradycardia, abdominal pain, hyponatremia, hypophosphatemia, elevated ferritin levels, microscopic hematuria. Legionella titers were negative, but Legionella (serogroup 1) urinary antigen was positive. ConclusionsWe present a diagnostic dilemma in an elderly female with both Legionnaire's disease and Epstein–Barr virus infectious mononucleosis with pulmonary involvement.

Lessons Learnt in a 17 Year Old with Fever of Unknown Origin: Haemophagocytic Lymphohistiocytosis-The Most Fatal Outcome of EBV Infection

We report a young patient who had persistent fever as a result of the most fatal outcome of an Epstein-Barr Virus infection-haemophagocytic lymphohistiocytosis (EBV-HLH). A 17 year old girl with a background of IgG subclass deficiency presented with a history of fever, sore throat and vomiting. The impression was of EBV related infectious mononucleosis which was supported by a positive monospottest and high EBV DNA levels. Despite a decreasing level of EBV DNA levels, she remained febrile and tachycardic with worsening liver function, cytopenia and no improvement on broad spectrum antimicrobials. Repeated septic screens were negative. By day 16 HLH was considered and a bone marrow aspirate showed haemphagocytosis. She was started on steroids with a rapid clinical and biochemical response. This case highlights the importance of having a low threshold of suspicion for EBV-HLH in patients with EBV that continue to deteriorate, particularly with a history of immunodeficiency.

Vitamin D levels and monospot tests in military personnel with acute pharyngitis: a retrospective chart review.

Some recent studies have proposed an important role for vitamin D in reducing the risk of infection by assisting in the suppression of viruses and by controlling the inflammatory response. A low vitamin D state may have a detrimental effect on the immune system’s ability to produce activated CD8+ T cells, and it may increase the inflammatory reaction to Epstein Barr virus. The aim of this chart review was to see if serum 25 OH vitamin D3 levels in service members with acute pharyngitis were lower in those who had positive rather than negative monospot tests. A retrospective chart review was conducted on the medical records of service members who presented to sick call at Camp Lejeune, NC with acute pharyngitis from October 8, 2010 until June 30, 2011. Serum 25 OH vitamin D3 levels were compared between those with positive and negative monospot test results. Of the 25 records that were reviewed, there were 9 (36%) service members with positive results, and they were found to have lower vitamin D levels (Median = 20.80 ng/ml, Interquartile range = 10.15) than those with negative test results (Median = 30.35 ng/ml, Interquartile range = 17.05), Mann-Whitney U = 41, p = .039. Only 1 of the 9 with positive test results had a normal serum 25 OH vitamin D3 level (30 ng/ml or greater) compared with 9 of the 16 with negative test results. Optimal vitamin D stores may play a significant role in reducing the risk of developing acute mononucleosis but larger, prospective studies will be needed to verify these findings.

Post-EBV Cerebellitis: A Very Rare Complication of Infectious Mononucleosis

Post-Epstein-Barr virus (EBV) cerebellitis is a very rare complication of infectious mononucleosis. It is almost always seen before 6 years of age and very few adult cases are reported in literature. We present a 21-year-old patient with p ost - EBV cerebellitis who presented with ataxia and slurred speech 2 weeks after infectious mononucleosis. The p atient had a positive monospot test and positive EB viral capsid IgM and IgG, and negative Epstein-Barr nuclear antigen IgG which is consistent with recent infection. The p atient’s brain imaging and CSF evaluation were normal. His symptoms resolved almost completely after 3 - 4 weeks. J Med Cases. 2014;5(5):302-303 doi: http://dx.doi.org/10.14740/ jmc1779w

Post-EBV Cerebellitis: A Very Rare Complication of Infectious Mononucleosis

Post-Epstein-Barr virus (EBV) cerebellitis is a very rare complication of infectious mononucleosis. It is almost always seen before 6 years of age and very few adult cases are reported in literature. We present a 21-year-old patient with post-EBV cerebellitis who presented with ataxia and slurred speech 2 weeks after infectious mononucleosis. The patient had a positive monospot test and positive EB viral capsid IgM and IgG, and negative Epstein-Barr nuclear antigen IgG which is consistent with recent infection. The patient’s brain imaging and CSF evaluation were normal. His symptoms resolved almost completely after 3 - 4 weeks. J Med Cases. 2014;5(5):302-303 doi: https://doi.org/10.14740/jmc1779w

HLA Associated Susceptibility to EBV+ Hodgkin Lymphoma: No Correlation with Infectious Mononucleosis or Number of Circulating EBV+ B Cells.

AbstractAbstract 2635EBV+ Hodgkin lymphoma (HL) arises from a latently EBV infected B cell and is associated with infectious mononucleosis (IM), a febrile illness that presents upon primary EBV infection of B cells in a proportion of adolescents and young adults. After primary infection, the virus establishes lifelong persistence in a small number of circulating B cells and this number is strongly controlled by the immune system, with a prominent role for HLA class I restricted recognition of EBV antigenic peptides by cytotoxic CD8 T cells.Interestingly, in the western European population, HLA-A1 is a susceptibility type for EBV+ HL, while HLA-A2 is protective. This corresponds well to known HLA restricted immune responses to EBV in healthy individuals, with consistent cytotoxic responses in the context of HLA-A2 and no responses in the context of HLA-A1. Because EBV+ HL tumor cells usually express all components of the antigen presenting pathway, including HLA class I, the effect of HLA type on susceptibility may act at any stage of disease pathogenesis. We therefore tested 2 hypotheses in this study: 1. HLA-A type is associated with IM risk and 2. HLA-A type determines EBV+ HL risk by influencing the number of circulating EBV+ B cells.To test the first hypothesis a total of 158 consecutive IM patients diagnosed from 1993 to 2011 at the Queen Elizabeth Hospital Birmingham, United Kingdom were included. These were all Caucasians patients with a clinical diagnosis of IM, including positive EBV antibody titers and/or Monospot test. HLA class I typing (HLA-A, B and C) was performed and allele frequencies were compared to 12,762 regional Blood Bank volunteers. The HLA-A1 type was clearly under represented in IM patients (12.3%) compared to controls (19.3%, OR 0.59; 95%CI 0.42–0.83), in sharp contrast to the situation in EBV+ HL. The uncommon HLA-B53 type was overrepresented in IM patients (1.6% vs. 0.3%, OR 5.313; 95%CI 2.14–13.2). Some other types showed borderline significance: HLA-A3 (OR 1.41; 95%CI 1.07–1.87), HLA-B14 (OR 1.68, 95%CI 1.07–2.62), HLA-C7 (OR 0.75; 95%CI 0.58–0.97) and HLA-C8 (OR 1.76, 95%CI 1.10–2.81). These data indicate that the known association of HLA-A1 and HLA-A2 with EBV+ HL is not paralleled by a similar association with IM. The unexpected negative correlation between HLA-A1 and IM may be caused by an association with less severe IM symptoms as suggested in another study (McAulay et al J Clin Invest 2007), if individuals with less severe IM symptoms did not seek medical attention.To answer the second hypothesis, first year medical students from the University of Birmingham, UK were asked to participate and donate blood in the years 2007 and 2008. EBV viral load was measured by Q-PCR using PBMC DNA from 270 students with positive EBV serology (30% of all students were serology negative) and no recent IM symptoms. Viral load was considered indicative for number of circulating EBV+ B cells. HLA-typing was done for HLA-A1, A2, B7, B8 and B35. For each type EBV loads were compared between HLA type carriers and non-carriers. Results with medians are shown in figure 1. The percentages of EBV seropositive students with detectable EBV loads per HLA-type are indicated under the x-axis (57.5% for all subjects). EBV seropositive students with undetectable EBV loads were also included in the statistical analyses. Of the individuals with HLA types previously shown to be involved in cytotoxic immune responses to latent EBV (A2, B7, B8 and B35), only HLA-B7 positive individuals had a significantly lower viral load than HLA-B7 negative individuals (p=0.038, median: 0 vs. 44). None of the other HLA types showed a significant difference between HLA type carriers and non-carriers, including HLA-A1 (expected to have higher viral loads in A1+ donors).In conclusion, the risk effect of HLA-A1 and the protective effect of HLA-A2 in the development of EBV+ HL are unlikely to be explained by differences occurring during primary EBV infection or differences in the lifelong virus-host balance. Instead, these effects probably relate to immune surveillance of EBV infected Hodgkin (precursor) cells at later stages of disease pathogenesis. [Display omitted] Disclosures:No relevant conflicts of interest to declare.

Spontaneous splenic rupture resulted from infectious mononucleosis

INTRODUCTIONInfectious mononucleosis is common among young adults and teenagers. However, spontaneous rupture of spleen secondary to IM is rare and it is the most frequent cause of death in infectious mononucleosis. PRESENTATION OF CASEA previously healthy 16-year-old girl presented with a one-week history of sore throat, non-productive cough, fever, malaise and a positive Monospot test. Prior to transfer to the hospital, she had two syncopal episodes and a complaint of abdominal pain at home. Clinical examination revealed that she was febrile and mildly tachycardic with an evidence of localised peritonism on her left upper quadrant. Urgent abdominal ultrasound and computed tomography scan showed subcapsular haematoma with a significant amount of complex fluid within the abdominal cavity, especially the left flank. Emergency laparotomy was performed and a moderate amount of haemoperitoneum was evacuated. The spleen was found grossly enlarged with a haematoma identified on the ruptured capsule. Splenectomy was performed and peritoneal cavity was washed out meticulously prior to the closure of the abdominal wall. DISCUSSIONDespite the fact that infectious mononucleosis is a self-limiting disease, it may cause serious and lethal complications. The best treatment of splenic rupture secondary to infectious mononucleosis has been controversial but it is mainly based on the haemodynamical status of the patient and the experience of the treating surgeon. CONCLUSIONSpontaneous rupture of spleen secondary to IM can be lethal in those patients with high possibility of deterioration with conservative management, thus timely surgical intervention is required.

Erythema multiforme-like lesions in the course of infectious mononucleosis

The rash in infectious mononucleosis is usually diffusely macular. A 15-year-old boy presented to us with high grade fever, sore throat, malaise, body aches, and polyarthralgia. He developed annular, erythematous, and non-scaly eruptions on chest and right arm. Blanching erythema was noted on his trunk. He had bilateral tender cervical lymph nodes, severe pharyngeal congestion, petechiae on soft palate, uvular edema, infraorbital edema, and marginal tender hepatomegaly. Investigations revealed lymphocytosis and activated atypical lymphocytes in the peripheral smear, and positive monospot test. The boy subsequently recovered in one week with total disappearance of his rash. Epstein-Barr virus-related infectious mononucleosis was considered the most likely diagnosis for our patient. To our knowledge, this atypical case is the third reported case of annular lesions in infectious mononucleosis. Dermatologists and other clinicians should be alerted to this special presentation of primary EBV infection.

Fra tonsillitt til koksitt

We present a 19-year-old woman with a throat infection, increased temperature, a positive mononucleosis monospot test and clinical signs of a lower respiratory tract infection. The diagnosis was thought to be mononucleosis complicated by bacterial pneumonia, but she was later found to have Fusobacterium necrophorum in blood cultures. She subsequently developed metastatic abscesses in her lungs and hip joint and was diagnosed with Lemierre's Syndrome. This case report highlights the importance of close links between clinicians and microbiologists in order to prevent morbidity and mortality in patients with an infectious disease.

Treatment of Severe Infectious Mononucleosis with Famciclovir

We report a patient with severe acute infectious mononucleosis who was successfully treated with famciclovir. A 15-year-old male was admitted with a 6-week history of fever, malaise, generalized lymphadenopathy, and hepatosplenomegaly, the patient was acutely ill with a temperature of 39.0 degrees C. Oropharingeal examination revealed enlarged tonsils partially obstructing the airways. EBV serology obtained during admission showed a positive Monospot test, virus capsid antigen IgM, 1:320, Epstein-Barr nuclear and early antigen, negative. After 72 hours of treatment with famciclovir (500 mg t.i.d.), the patient was afebrile with important regression of the lymphadenopathy, enlarged tonsils and hepatosplenomegaly. Because acute infectious mononucleosis may be associated with extensive and prolonged disease, the potential therapeutic role of famciclovir in the treatment of severe forms of the disease deserves further studies.

Predictions and associations of fatigue syndromes and mood disorders that occur after infectious mononucleosis

Certain infections can trigger chronic fatigue syndromes (CFS) in a minority of people infected, but the reason is unknown. We describe some factors that predict or are associated with prolonged fatigue after infectious mononucleosis and contrast these factors with those that predicted mood disorders after the same infection. We prospectively studied a cohort of 250 primary-care patients with infectious mononucleosis or ordinary upper-respiratory-tract infections until 6 months after clinical onset. We sought predictors of both acute and chronic fatigue syndromes and mood disorders from clinical, laboratory, and psychosocial measures. An empirically defined fatigue syndrome 6 months after onset, which excluded comorbid psychiatric disorders, was most reliably predicted by a positive Monospot test at onset (odds ratio 2.1 [95% CI 1.4-3.3]) and lower physical fitness (0.35 [0.15-0.8]). Cervical lymphadenopathy and initial bed rest were associated with, or predicted, a fatigue syndrome up to 2 months after onset. By contrast, mood disorders were predicted by a premorbid psychiatric history (2.3 [1.4-3.9]), an emotional personality score (1.21 [1.11-1.35]), and social adversity (1.7 [1.0-2.9]). Definitions of CFS that included comorbid mood disorders were predicted by a mixture of those factors that predicted either the empirically defined fatigue syndrome or mood disorders. The predictors of a prolonged fatigue syndrome after an infection differ with both definition and time, depending particularly on the presence or absence of comorbid mood disorders. The particular infection and its consequent immune reaction may have an early role, but physical deconditioning may also be important. By contrast, mood disorders are predicted by factors that predict mood disorders in general.

Incidence and pathogenicity of Arcanobacterium haemolyticum during a 2-year study in Ottawa.

Arcanobacterium haemolyticum has been described as a rare cause of systemic invasive disease and is occasionally isolated from throat swabs. We describe a 2-year study of the incidence and clinical features of A. haemolyticus infection in a pediatric and adolescent population. A total of 11,620 throat swabs were examined for A. haemolyticum with use of a locally developed selective medium. Controls (2,241) were healthy students who were recruited from a separate study. A. haemolyticum was isolated from 42 patients, with the maximum incidence in the 15 to 18-year-old age group; in this subset the incidence was 2.5%. There were no isolates of A. haemolyticum found in the healthy controls, and the difference in incidence between patients and controls in the 15 to 18-year-old age group was highly significant (P < .01). Approximately half of the patients infected with A. haemolyticum had a rash. In 5 patients, A. haemolyticum was associated with a positive monospot test. The organism was highly susceptible to erythromycin and less susceptible to penicillin. The evidence from this study suggests that A. haemolyticum may be a pathogen with maximum incidence in the 15 to 18-year-old age group.

Burkitt Lymphoma Presenting as a Conjunctival Mass

Purpose: A sporadic Burkitt lymphoma, which presented as a primary Conjunctival mass, demonstrates the approach to clinical diagnosis, staging, and current management of this rapidly growing malignant tumor, as well as newer concepts of its pathogenesis.Patient and Methods: A 16-year-old girl had rapid development of a conjunctiva) mass 6 weeks after an infectious mononucleosis-like illness, associated with a positive monospot test. A biopsy of the tumor was immunostained for lymphocyte markers. Additional clinical workup included computed tomographic scanning, nasopharyngeal biopsy, and studies of blood, bone marrow, and spinal fluid. In situ hybridization for Epstein-Barr virus (EBV)-encoded nuclear RNA was performed on the tumor and adenoidal tissue.Results: The conjunctival biopsy showed a typical Burkitt lymphoma with markers positive for predominantly B lymphocytes. Computed tomographic scans indicated residual tumor in the anterior orbit. Biopsy of thickened adenoidal tissue showed only benign lymphoid hyperplasia. Evidence of EBV infection was found in the adenoidal tissue but not in the tumor cells. The patient was treated with combined chemotherapy on a Pediatric Oncology Group Study protocol for localized non-Hodgkin lymphoma, and is disease-free 4 1/2 years after diagnosis.Conclusions: A sporadic Burkitt lymphoma arising in the conjunctiva appears to be the first reported in this site. The lymphoma responded well to chemotherapy, which is now the usual course in stage 1 disease. A direct role for EBV in the oncogenesis of this sporadic tumor, similar to that in the endemic form, could not be supported because EBV-encoded nuclear RNA was absent in the tumor cells.

Encephalitis due to Epstein-Barr virus

Acute encephalitis due to Epstein-Barr virus is described. The initial diagnosis was based on clinical features and a positive Monospot test. Early treatment with intravenous acyclovir was given; steroids were not used. The patient made a rapid and complete recovery from a comatose state. The effectiveness of acyclovir in this condition remains unproven but early treatment is recommended in severely ill patients whose prognosis is uncertain.