Different clinical presentation of infectious mononucleosis in children: a retrospective analysis of 369 cases

Year 2012, , 189 - 192, 01.09.2012

Ayşe Kılıç İsmail Yıldız Hayati Beka Ali Ağaçfidan Ayşegül Ünüvar Özlem Yanar Emin Ünüvar Fatma Oğuz

https://doi.org/10.4274/tpa.1664

Abstract

Aim: The aim of this study was to investigate the clinical findings and serologic test results of the patients diagnosed with Epstein Barr virus EBV induced infectious mononucleosis Material and Method: This retrospective study was performed among 369 serologically proven positive EBV VCA IgM infectious mononucleosis subjects out of 845 patients who were tested for EBV VCA IgM and IgG antibodies because of their suspicious clinical findings between January 2004 and December 2009 EBV VCA IgM and IgG antibodies were detected by enzyme linked immunosorbent assay ELISA Clinical findings of the subjects and any other diseases related to EBV in differential diagnosis were evaluated Results: The mean age of 369 subjects diagnosed with EBV infection was 94 5 plusmn;58 4 months range: 6 months 14 years One hundred and seventy one patients 46 4 out of 369 were female Symptoms and findings at the time of the first evaluation were as follows: fever longer than seven days and malaise 43 1 ; fever sore throat and cervical lymphadenopathy 33 1 ; fever with maculopapulary rash 10 3 ; anemia and thrombocytopenia 7 1 ; elevated liver function enzymes 4 1 and arthralgia 1 6 The classical clinical findings of infectious mononucleosis such as fever cervical lymphadenoathy pharyngitis and splenomegaly were observed in 357 155 152 and 177 subjects respectively 96 7 42 41 2 47 9 and 21 4 respectively while hepatomegaly and edema of the eyelids were observed in 79 and 65 subjects respectively 21 4 and 17 6 respectively The mean hemoglobin level was 8 2 plusmn;2 3 g dL The mean leukocyte count was 10 8 plusmn;4 6 103 mu;L The mean thrombocyte count was 168 plusmn;87 103 mu;L The mean C reactive protein level was 56 6 plusmn;42 5 mg L EBV VCA IgM and IgG antibodies were simultaneously positive in 248 subjects 67 2 at the time of the first evaluation while in 121 subjects 32 8 EVB VCA Ig G antibody was detected 18 3 plusmn;4 6 days after the initial diagnosis During the follow up 12 3 2 subjects were diagnosed with EBV related hematologic malignancies including leukemia one acute myeloid and 3 lymphoblastic leukemia cases 1 1 lymphoma five cases 1 3 and hemophagocytic syndrome three cases 0 8 Conclusions: In children infectious mononucleosis can present with a wide range of clinical symptoms besides its classical presentation In addition to clinical findings serologic tests are required for definitive diagnosis In addition EBV VCA IgG seroconversion is necessary to rule out false positivity In 3 2 of the cases with unexpected clinical course EBV related hematologic malignancies may develop Turk Arch Ped 2012; 47: 189 92

Keywords

-

Çocuklarda farklı klinik tablolarla enfeksiyöz mononükleoz: 369 olgunun geriye dönük incelenmesi

Abstract

Amaç: Kliniğimize farklı yakınmalar ile başvurup Epstein Barr virüsüne EBV bağlı enfeksiyöz mononükleoz tanısı alan olguların klinik bulguları ve serolojik test sonuçlarının araştırılması amaçlandı

Gereç ve Yöntem: Ocak 2004 ile Aralık 2009 tarihleri arasında başvuran ve klinik bulguları ile enfeksiyöz mononükleoz olabileceği düşünülerek EBV VCA IgM ve IgG antikorları istenilen 845 olgu arasında IgM antikorları pozitif serolojiye sahip enfeksiyöz mononükleoz kesin tanısı alan 369 olgunun dosyaları geriye dönük olarak incelendi Epstein Barr virüsü VCA IgM ve IgG antikorları ELISA yöntemi ile belirlenmişti Olguların klinik bulguları ve EBV ile ilişkili olabilecek ayırıcı tanıdaki diğer hastalıklar irdelendi.

Bulgular: Epstein Barr virüs enfeksiyonu saptanan 369 olgunun yaş ortalaması 94 5 plusmn;58 4 ay 6 ay 14 yaş idi ve 171 rsquo;i 46 4 kızdı Başvuru bulgularında 159 43 1 olguda bir haftadan uzun süren ateş ve halsizlik 122 rsquo;sinde 33 1 boğaz ağrısı ateş ve boyunda şişlik 38 rsquo;inde 10 3 makülopapüler döküntü ve ateş 26 rsquo;sında 7 1 anemi ve trombositopeni 15 rsquo;inde 4 1 transaminaz yüksekliği altısında 1 6 artralji saptandı Klasik enfeksiyöz mononükleoz bulgularından ateş 357 96 7 olguda servikal lenfadenopati 155 rsquo;inde 42 farenjit 152 rsquo;sinde 41 2 ve dalak büyüklüğü 177 47 9 olguda saptanırken karaciğer büyüklüğü 79 21 4 gözlerde ödem 65 17 6 olguda görüldü Laboratuvar bulgularında ortalama hemoglobin 8 2 plusmn;2 3 g dL lökosit sayısı 10 8 plusmn;4 6 103 mu;L trombosit sayısı 168 plusmn;87 103 mu;L bulundu Transaminaz yüksekliği 15 4 1 olguda vardı Ortalama CRP değeri 56 6 plusmn;42 5 mg L idi Epstein Barr virüs VCA IgM ve IgG antikorları 248 67 2 olguda başvuruda birlikte pozitifken diğer 121 32 8 olguda ise ortalama 18 3 plusmn;4 6 gün sonra EBV VCA IgG antikoru pozitifleşti Olguların izleminde 12 tanesinde 3 2 EBV ile ilişkili olabilecek hematolojik malin hastalıklar görüldü Bunlardan dört 1 1 olguda lösemi 1 AML 3 ALL beş 1 3 olguda lenfoma üç 0 8 olguda hemofagositik sendrom tanıları konuldu.

Çıkarımlar: Çocuklarda enfeksiyöz mononükleoz klasik bulguların dışında farklı klinik bulgular gösterebilir Klinik bulgular yanında serolojik testler kesin tanı için değerlidir ancak yalancı pozitifliği dışlamak için IgG rsquo;nin pozitifleşmesi önem taşır İzlemde beklenmeyen bir seyir gösteren olgularda EBV ile ilişkili hematolojik malin hastalıklar 3 2 oranında gelişebilir.

Keywords

Çocuk, EBV, mononükleoz

References

• Katz BZ, Miller G. Epstein-Barr virus infections. In: Katz SL, Gers-hon AA, Hotez PJ, (eds). Krugman's infectious diseases of chilıdren. 10th. edit. London: Mosby, 1998: 98-115.
• Fidan I, Yüksel S, İmir T. Değişik yaş gruplarında Epstein-Barr viırus antikorlarının araştırılması. J Infect 2005; 19: 453-6.
• Cohen JI. Epstein-Barr virus infection. N Engl J Med 2000; 343: 481-92.
• Jenson HB. Epstein-Barr virus. In: Behrman RE, Kliegman RM, Jenson HB (eds). Nelson textbook of pediatrics. 19thedt. Philadelphia: Elsevier Saunders, 2011: 1110-4.
• Lawrence DW. Herpesviruses. In: Walter RW, Merle AS (eds). Current diagnosis and treatment in infectious diseases. New York: Lange Medical Books/Mc Graw Hill, 2001: 401.
• Baumgarten E, Herbst H, Schmitt M, Seeger KH, Schulte-Over-Berg U,
• Henze G. Life-threatening infectious mononucleosis: is it correlated with virus-induced T cell proliferation? Clin Infect Dis 1994; 19: 152-6.
• Barranco M, Vidal J, Quintero L, Vives-Corrons JL, Jiménez de Anta
• MT. Relationship between Epstein-Barr virus and lymphoproliferative syndromes in patients without immunodeficiency. Sangre 1995; 40: 383-7.
• Sehgal S, Mujtaba S, Gupta D, Aggarwal R, Marwaha RK. High
• incidence of Epstein Barr virus infection in childhood acute lymphocytic leukemia: a preliminary study. Indian J Pathol Microbiol 2010; 53: 63-7.
• Uemura K, Otani H, Sakamoto K, et al. Hand-mirror cells acute
• lymphoblastic leukemia (L3). Rinsho Byori 1995; 43: 1173-7.
• Zorbala-Mallios H, Sutton RN, Emond RT. EB-virus-specific IgM and IgG antibodies in first-degree relatives of children with acute lymphoblastic leukaemia. Arch Dis Child 1975; 50: 137-41.
• Schooley RT. Epstein-Barr virus (Infectious mononucleosis). In: Mandell GL, Bennet JE, Dolin R, (eds). Mandell Douglas and Bennet's principles and practice of infectious diseases. 5th ed. New York: Churchill Livingstone, 2000; 1364.
• Risdall R J, Mc Kenna RW. Virus associated hemophagocytic syndrome: a benign histiocytic proliferation distinct from malignant histiocytosis. Cancer 1979; 44: 993-1002.
• Cwiklińska M, Czogała M, Balwierz W, et al. Hemophagocytic syndrome in children with different underlying conditions. Przegl Lek 2010; 67:430-5.
• Jin YK, Xie ZD, Yang S, Lu G, Shen KL. Epstein-Barr virus-associated hemophagocytic lymphohistiocytosis: a retrospective study of 78 pediatric cases in mainland of China. Chin Med J 2010; 123: 1426-30.
• Sevilla DW, El-Mallawany NK, Emmons FN, et al. Spectrum of childhood Epstein-Barr virus-associated T-cell proliferations and bone marrow findings. Pediatr Dev Pathol 2011; 14: 28-37.
• Kofteridis DP, Koulentaki M, Valachis A, et al. Epstein Barr virus hepatitis. Eur J Intern Med 2011 ; 22:73-6.
• Shaw NJ, Evans JH. Short reports. Liver failure and Epstein-Barr virus infection. Arch Dis Child 1988; 63: 432-3.
• Arslan N, Akman H, Sayan M, Öztürk Y, Büyükgebiz B. Epstein-Barr virüs enfeksiyonuna ikincil gelişen hepatik yetmezlik. Çocuk Sağlığı ve Hastalıkları Dergisi 2003; 46: 47-9.
• Cengiz AB, Cultu-Kantaroğlu O, Seçmeer G, Ceyhan M, Kara A, Gürgey A. Infectious mononucleosis in Turkish children. Turk J Pediatr 2010; 52: 245-54.
• deOry F, Guisasola ME, Sanz JC, García-Bermejo I. Evaluation of four commercial systems for the diagnosis of Epstein-Barr virus primary infections. Clin Vaccine Immunol 2011; 18: 444-8.