Infectious Mononucleosis - Symptoms, Diagnosis, Treatment. Infectious mononucleosis (mononucleosis infectiosa)

INFECTIOUS MONONUCLEOSIS

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Amirmetova Elvira Shamil kyzy

Nalchik

Infectious mononucleosis (mononucleosis infectiosa, Filatov's disease, monocytic tonsillitis, benign lymphoblastosis)- acute viral disease, which is characterized by fever, lesions of the throat, lymph nodes, liver, spleen and peculiar changes in the composition of the blood.

Story

The infectious nature of this disease was pointed out by N. F. Filatov in 1887, who was the first to draw attention to a febrile disease with an increase in lymph nodes and called it an idiopathic inflammation of the lymph glands. The described disease for many years bore his name - Filatov's disease. In 1889, the German scientist Emil Pfeiffer (German Emil Pfeiffer) described a similar clinical picture of the disease and defined it as glandular fever with damage to the pharynx and lymphatic system. With the introduction of hematological research into practice, characteristic changes in the composition of the blood in this disease were studied, in accordance with which the American scientists T. Sprant and F. Evans called the disease infectious mononucleosis. In 1964, M. A. Epstein and I. Barr isolated a herpes-like virus from Burkitt's lymphoma cells, named after them the Epstein-Barr virus, which was later found with great constancy in infectious mononucleosis.

Epidemiology

The epidemiological picture of infectious mononucleosis is as follows: the disease is fixed everywhere, and, as a rule, these are episodic cases or individual outbreaks of infection. Heterogeneity clinical manifestations, the often occurring problems with the diagnosis suggest that the official incidence figures do not correspond to the real picture with the spread of infectious mononucleosis. Most often, adolescents suffer from this disease, and girls get sick earlier - at 14-16 years old, boys later - at 16-18. It is for this reason that another name for the disease has spread - “disease of students”. People who have crossed the forty-year milestone do not get sick often, but carriers of HIV infection are at risk of activating a dormant infection throughout their lives. If a person becomes infected with infectious mononucleosis at an early age, then the disease resembles a respiratory infection, but the older the patient, the more likely, what clinical symptoms will not. After thirty years, almost all people have antibodies to the causative agent of infectious mononucleosis, hence the rarity of obvious forms of the disease among adults. The incidence almost does not depend on the time of year, slightly fewer cases are recorded in the summer. Factors that increase the risk of infection are crowding, the use of common household items, household disorder.

Epidemiology

source of infection is a sick person and a virus carrier.

Transmission occurs by airborne droplets. Due to the fact that the infection is transmitted mainly through saliva (by kissing), the disease is called "kissing sickness". transmission mechanism infections - aerosol. Transmission of infection through blood transfusion is possible. The crowding of sick and healthy people causes a risk group in such places of residence as hostels, boarding schools, kindergartens, camps, etc.

The maximum incidence of MI in girls is observed at the age of 14-16 years, in boys 17-18 years. As a rule, by the age of 25-35, in most people, antibodies to the MI virus are detected in the blood during examination. It is worth noting that in HIV-infected people, the resumption of virus activity can occur at any age.

Etiology.

The causative agent of the infection is the DNA-containing Epstein-Barr virus. This virus is able to replicate in B-lymphocytes and, unlike other herpes viruses, it activates cell proliferation.

Epstein-Barr virus virions include specific antigens (AG):

Capsid AG (VCA)

Nuclear hypertension (EBNA)

Early AH (EA)

Membrane AG (MA)

In the blood of patients with infectious mononucleosis, antibodies to the capsid antigen (VCA) first appear. Antibodies in membrane (MA) and early (EA) antigens are produced later. The causative agent of infection is not resistant to the external environment and quickly dies when dried, under the influence of high temperature and disinfectants. Epstein-Barr virus can also cause Burkitt's lymphoma and nasopharyngeal carcinoma.

Pathogenesis.

Penetration of the virus into the upper respiratory tract leads to damage to the epithelium and lymphoid tissue of the oropharynx and nasopharynx. Note the swelling of the mucous membrane, an increase in the tonsils and regional lymph nodes. 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 the lymphoid and reticular tissues, in connection with which atypical mononuclear cells appear in the peripheral blood. Lymphadenopathy, edema of the mucous membrane of the turbinates and oropharynx develop, the liver and spleen increase. Histologically revealed hyperplasia of lymphoreticular tissue in all organs, lymphocytic periportal infiltration of the liver with minor dystrophic changes in hepatocytes.

Virus replication in B-lymphocytes stimulates their active proliferation and differentiation into plasma cells. The latter secrete immunoglobulins of low specificity. At the same time, in the acute period of the disease, the number and activity of T-lymphocytes increase. T-suppressors 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 with a decrease in immunity.

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

Clinic.

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, subfebrile body temperature, malaise, weakness, fatigue, catarrhal phenomena in the upper respiratory tract - nasal congestion, hyperemia of the oropharyngeal mucosa, enlargement and hyperemia of the tonsils are observed. With an acute onset of the disease body temperature quickly rises to high numbers. Patients complain about headache, sore throat when swallowing, chills, increased sweating, body aches. In the future, the temperature curve may be different; duration of fever varies from several days to 1 month or more. By the end of the first week of the disease, a period of the height of the disease develops. The appearance of all major clinical syndromes is characteristic: general toxic effects, tonsillitis, lymphadenopathy, hepatolienal syndrome. The patient's state of health worsens, high body temperature, chills, headache and body aches are noted. Nasal congestion with difficulty in nasal breathing, nasal voice may appear. Throat lesions are manifested by an increase in sore throat, development of angina in catarrhal, ulcerative-necrotic, follicular or membranous form. Hyperemia of the mucous membrane is not pronounced, loose yellowish, easily removable plaques appear on the tonsils. In some cases, raids may resemble diphtheria. On the mucous membrane soft palate the appearance of hemorrhagic elements is possible, the posterior wall of the pharynx is sharply hyperemic, loosened, granular, with hyperplastic follicles. Developing from the very first days lymphadenopathy. Enlarged lymph nodes can be found in all areas accessible to palpation; the symmetry of their lesions is characteristic. Most often, with mononucleosis, the occipital, submandibular, and especially the posterior cervical lymph nodes increase on both sides along the sternocleidomastoid muscles. Lymph nodes are compacted, mobile, painless or slightly painful on palpation. Their sizes vary from a pea to a walnut. The subcutaneous tissue around the lymph nodes in some cases may be edematous. In most patients during the height of the disease, an increase in the liver and spleen is noted. In some cases, icteric syndrome develops: dyspepsia (decreased appetite, nausea) intensifies, urine darkens, icterus of the sclera and skin appears, the content of bilirubin increases in the blood serum and the activity of aminotransferases increases. Sometimes there is a maculopapular exanthema. It does not have a 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, lasting an average of 2-3 weeks, comes convalescence period. The patient's state of health improves, body temperature normalizes, tonsillitis and hepatolienal syndrome gradually disappear. In the future, the size of the lymph nodes is normalized. The duration of the convalescence period is individual, sometimes subfebrile body temperature and lymphadenopathy persist for several weeks. The disease can proceed for a long time, with a change in periods of exacerbations and remissions, which is why it total duration may take up to 1.5 years. Clinical manifestations of infectious mononucleosis in adult patients differ in a number of features. The disease often begins with a gradual development of prodromal phenomena, fever often persists for more than 2 weeks, the severity of lymphadenopathy and hyperplasia of the tonsils is less than in children. At the same time, in adults, manifestations of the disease associated with involvement in the process of the liver and the development of icteric syndrome are more often observed. Complications.

The most common complication is the addition of bacterial infections caused by Staphylococcus aureus, streptococci, etc. Meningoencephalitis and obstruction of the upper respiratory tract by enlarged tonsils are also possible. 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.

Diagnostics.

Infectious mononucleosis should be distinguished from lymphogranulomatosis and lymphocytic leukemia, coccal and other angina, oropharyngeal diphtheria, as well as viral hepatitis, pseudotuberculosis, rubella, toxoplasmosis, chlamydial pneumonia and ornithosis, some forms of adenovirus infection, CMV infection, primary manifestations HIV infections. 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, specific changes in the hemogram. In some cases, jaundice and (or) maculopapular exanthema may occur. Laboratory diagnostics

The most characteristic feature is changes in the cellular composition of the blood. The hemogram reveals moderate leukocytosis, relative neutropenia with a shift of the leukocyte formula to the left, a significant increase in the number of lymphocytes and monocytes (more than 60% in total). In the blood there are atypical mononuclear cells - cells with a wide basophilic cytoplasm, having a different shape. Their presence in the blood determined modern name illness. Diagnostic value has an increase in the number atypical mononuclear cells with a 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 with characteristic clinical manifestations of the disease does not contradict the proposed 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. PCR 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; in the future, they are detected in all patients (this serves as a reliable confirmation of the diagnosis). IgM to VCA antigens disappear only 2-3 months after recovery. After the disease, IgG to VCA antigens are stored for life. In the absence of the possibility of determining anti-VCA-IgM, serological methods for the detection of heterophilic antibodies are still used. They are formed as a result of polyclonal activation of B-lymphocytes. The most popular are the Paul-Bunnel reaction with ram 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 it is suspected should be given 3 times (in the acute period, then after 3 and 6 months) laboratory examination for antibodies to HIV antigens, since a mononucleosis-like syndrome is also possible at the stage of primary manifestations of HIV infection.

differential diagnosis.

With a typical course of infectious mononucleosis, its diagnosis does not cause great difficulties and is based on a clinical examination and analysis results, taking into account epidemiological data and the results of a serological study. Often there is a need to distinguish it from diseases in which there is damage to the tonsils, lymphadenitis, fever.

Quite often at the beginning of the disease with infectious mononucleosis, a diagnosis of angina is established. An acute onset with fever and reaction of the lymph nodes gives rise to this. But unlike infectious mononucleosis in patients with angina, the leading complaint is sore throat, inflammatory changes in the palatine tonsils are pronounced from the 1st day, regional lymphadenitis develops, and not widespread lymphadenopathy. Diagnostic doubts are resolved by detectable neutrophilic leukocytosis.

Throat diphtheria may be erroneously suspected in cases of infectious mononucleosis. Severe consequences occur when diphtheria of the pharynx is taken for infectious mononucleosis and, therefore, appropriate treatment is not carried out. The combination of angina with general intoxication, fever and lymphadenitis is characteristic of both infections. But with diphtheria of the pharynx, by the end of the 1st day, on enlarged, moderately hyperemic tonsils, a gray-white or dirty gray fibrinous plaque protruding above the surface of the mucous membrane is found. When you try to remove it, bleeding occurs. The temperature is subfebrile or high, general intoxication, increasing, with the transition of a localized form to a widespread one or expressed from the very beginning with toxic diphtheria. Regional lymph nodes are slightly enlarged, painful, they are surrounded by soft, painless swelling of the subcutaneous tissue. In patients with infectious mononucleosis in the first days of the disease, only slight redness and swelling of the tonsils and the mucous membrane of the pharynx surrounding them are noted. Tonsillitis develops at different times, but more often at later times, plaque can also spread beyond the tonsils, but it is easily removed, and its color is yellowish. Not only regional, but also more distant lymph nodes increase, often there are generalized lymphadenitis, hepato- and splenomegaly. General intoxication is moderate. Lymphocytes and monocytes predominate in the blood, and the number of mononuclear cells increases. ESR is normal in contrast to accelerated in diphtheria.

Of great importance for the final diagnosis are the results of a bacteriological study of the films for the presence of the causative agent of diphtheria, the data of the Paul-Bunnel reaction and the study of the epidemiological situation.

Adenovirus infection, which occurs with tonsillitis syndrome, is in many ways similar to infectious mononucleosis. In both nosological forms, polyadenitis, hepatolienal syndrome, mild intoxication, prolonged fever and signs of damage are possible. respiratory tract. The latter are more pronounced in adenoviral infection, the exudative component is significant, in the swabs from the nasal part of the pharynx, the adenoviral antigen is detected by immunofluorescence. Sometimes a typical combination of symptoms and epidemiological anamnesis data on the spread of infection in a child or youth group with a significant number of conjunctivitis among patients help to establish a diagnosis. In patients with adenovirus infection, a complete blood count without significant changes, in contrast to the typical hemogram pattern in infectious mononucleosis;

Rubella can be mistaken for infectious mononucleosis with severe lymphadenopathy and scanty exanthema. In such cases, one should take into account the predominant increase in the occipital and posterior cervical lymph nodes, a slight increase in temperature, the absence of pathological changes in the pharynx, the short duration of the disease, the presence of leukopenia, lymphocytosis, plasma cells, as well as the negative Paul-Bunnel-Davidson reaction.

At mumps, usually accompanied by a temperature reaction, phenomena general intoxication and deformation in the parotid and submandibular regions, sometimes at first there is a need for differential diagnosis with infectious mononucleosis. Important distinguishing features are localization, the nature of local changes and general reaction. Manifest sign in mumps is the defeat of the salivary glands, mainly parotid, sometimes submandibular and sublingual with a typical deformity between the earlobe and the ascending branch of the lower jaw, more often from two, less often from one side. At the same time, edema of the surrounding subcutaneous base is always noted, its boundaries are indistinct, the consistency is doughy, it is painful on palpation. When opening the mouth, talking and chewing, pain occurs with irradiation to the ear, it is combined with dry mouth. Lymph nodes in this area are unremarkable or slightly enlarged. Intoxication is expressed from the first days, meningeal syndrome is often determined. positive symptoms Filatov (pain behind the earlobe) and Murson (infiltration and hyperemia of the parotid duct). With infectious mononucleosis; enlarged lymph nodes are determined, mainly generalized lymphadenopathy. Pain when swallowing is not combined with dry mouth, Murson's symptom is negative. The presence of atypical for infectious mononucleosis changes in the leukocyte blood count and epidemiological data resolve diagnostic doubts.

Serum sickness is manifested by some clinical symptoms that are also observed in infectious mononucleosis: rash, fever, polyadenitis, leukocytosis or leukopenia with lymphomonocytosis. Important in resolving the issue are information about the administration of serum preparations to the patient; the rash is often urticarial, itchy, often there is pain and swelling in the joints, eosinophilia in the absence of mononuclear cells in the blood. Since in serum sickness, as in infectious mononucleosis, the Paul-Bunnel reaction can detect heterophile antibodies, for the purpose of differential diagnosis, the Paul-Bunnel-Davidson reaction should be used.

Sometimes it becomes necessary to distinguish between lymphogranulomatosis in the initial period and infectious mononucleosis, especially in the case of the primary localization of the process in the neck. In contrast to infectious mononucleosis in lymphogranulomatosis, the lymph nodes reach large sizes, are painless, elastic at first, subsequently become dense, merge with each other, forming tumor-like conglomerates that are not soldered to the skin. Over time, all new lymph nodes are involved in the process. There are changes in internal organs. The defeat of the lymph nodes against the background of fever is combined with excessive sweating and skin itching, making up a triad of symptoms characteristic of Hodgkin's disease. In the blood, more often against the background of leukocytosis, in contrast to infectious mononucleosis, lymphopenia and a shift of the leukocyte formula to the left to stab neutrophilic granulocytes are determined; sometimes young and myelocytes. In the initial stage and during exacerbation, eosinophilia is often determined. A characteristic hematological sign of lymphogranulomatosis is a significant increase in ESR, in contrast to moderate in infectious mononucleosis; In difficult cases, the final diagnosis is decided taking into account serological data and the results of a histological examination of the lymph nodes or punctates.

Infectious low-symptomatic lymphocytosis is a little-known, rare disease. Unlike infectious mononucleosis, it is detected in children, less often in adults during preventive examinations, it is characterized by a slight change in well-being, the absence of enlargement of the lymph nodes, liver and spleen, is not accompanied by fever, short-term subfebrile condition is rarely noted. Diagnostic doubts are solved by a blood picture. In infectious lymphocytosis, an increase in the number of lymphocytes with a monomorphic composition in combination with hyperleukocytosis and eosinophilia is determined. The content of small and medium lymphocytes reaches 0.8-0.95, while in infectious mononucleosis; cellular polymorphism comes to the fore, an increased content of all types of mononuclear cells is recorded, the number of small lymphocytes is reduced.

The severe course of infectious mononucleosis sometimes clinically resembles leukemia. The similarity lies in the presence of tonsillitis, fever, leukocytosis, enlarged lymph nodes and spleen. Leukemic mononuclear cells can be mistaken for atypical. The absence of cyclicity in the development of the disease, the progressive deterioration of the general condition, the pallor of the mucous membranes and skin, the moderation of the febrile reaction, and hemorrhages indicate leukemia. At the same time, an increase in lymph nodes does not prevail in the clinical picture of the disease. Leukocytosis, as a rule, is significant (up to 100 * 109 / l or more), anemia and thrombocytopenia are noted. Data of a sternal puncture solve a question of the diagnosis.

With visceral forms of infectious mononucleosis, diagnostic difficulties often arise. Respiratory forms of the disease that occur like influenza or in the form of pneumonia, only on the basis of anamnesis and objective data, it is difficult to distinguish from influenza, other acute respiratory infections and forms complicated by acute pneumonia. With infectious mononucleosis; with the development of syndromes of eado-, myo- or pericarditis, digestive forms (mesoadenitis, appendicular syndrome, pancreatitis, etc.), as in cases with a predominant lesion nervous system(meningitis, meningoencephalitis, etc.), clinical manifestations are identical to the named syndromes of another etiology. Hepatic forms, manifested by jaundice, can be difficult to distinguish from viral hepatitis.

An important feature in the clinical recognition of visceral forms of infectious mononucleosis is generalized lymphadenopathy, which is not characteristic of the listed syndromes of another etiology, especially its combination with tonsil damage. But the decisive importance in this case belongs to the characteristic hematological parameters (an increase in the number of mononuclear cellular elements) and the results of serological studies. It is important to remember that in patients with viral hepatitis, as in infectious mononucleosis, it is possible to detect heterophile antibodies in the blood serum. Therefore, in cases that are difficult for differential diagnosis, the Paul-Bunnel-Davidson reaction should be used from serological reactions, which makes it possible to clarify the origin of the detected heterophile antibodies.

Treatment.

To date, there is no specific treatment for infectious mononucleosis in children, there is no single therapy regimen, and there is no antiviral drug that would effectively suppress the activity of the virus. Usually the disease is treated in a hospital, in severe cases only bed rest is recommended. There are several directions for the treatment of mononucleosis in children:

Therapy is mainly aimed at relieving the symptoms of infectious mononucleosis.

Pathogenetic therapy in the form of antipyretics for children (Ibuprofen, Paracetamol in syrup)

Antiseptic local preparations for the relief of angina, as well as local non-specific immunotherapy, are prescribed drugs Imudon and IRS 19.

Desensitizing agents

General strengthening therapy - vitamin therapy, including vitamins of groups B, C and P.

If changes in liver function are detected, a special diet, choleretic drugs, hepatoprotectors are prescribed

Immunomodulators together with antiviral drugs have the greatest effect. Imudon, Children's Anaferon, Viferon, as well as Cycloferon at a dose of 6-10 mg / kg can be prescribed. Sometimes metronidazole (Trichopolum, Flagyl) has a positive effect.

Since the secondary microbial flora often joins, antibiotics are indicated, which are prescribed only in case of complications and an intense inflammatory process in the oropharynx (except for penicillin antibiotics, which cause severe allergic reactions in infectious mononucleosis in 70% of cases)

With antibiotic therapy, probiotics are simultaneously prescribed (Acipol, Narine, Primadophilus for Children, etc. see the entire list of probiotic preparations with prices and composition)

In severe hypertoxic course, a short-term course of prednisolone is indicated (20-60 mg per day for 5-7 days), it is used at the risk of asphyxia

Installation of a tracheostomy and transfer to artificial ventilation of the lungs is carried out with severe swelling of the larynx and with breathing difficulties in children

If the spleen is at risk of rupture, an emergency splenectomy is performed.

Prevention.

Specific immunoprophylaxis against infectious mononucleosis (vaccination) does not exist. Since the route of infection is airborne, all preventive measures are similar to preventive measures for acute respiratory diseases. It is important to remember that the virus will not be able to “thrive” in an organism with strong immunity, so you need to direct your efforts to strengthen the defenses. It is necessary to observe the rules of personal hygiene, to avoid entering into casual sexual relations.

After contact of the child with the patient, it is necessary to carry out emergency prophylaxis in the form of the appointment of immunoglobulin. Where there are patients, constant wet cleaning and disinfection of the patient's personal belongings are carried out.

Infectious mononucleosis is an infectious disease caused by the herpesvirus type IV (Epstein-Barr virus). It is customary to distinguish between acute and chronic forms.

This disease is characterized by specific changes in the blood, lymphadenitis (), as well as damage to the pharynx (manifested by sore throat), involvement in the process of the liver and spleen, as well as hyperthermia (increased general temperature bodies).

The infectious nature of pathology was first pointed out by N. F. Filatov, an outstanding Russian doctor who became the founder of the Russian pediatric school. For a long time infectious mononucleosis was called "Filatov's disease". It is also known as "kissing disease" (the infectious mononucleosis virus is often transmitted to a healthy person from a carrier with saliva when kissing), monocytic angina and benign lymphoblastosis.

The DNA genomic herpes-like virus was first isolated in 1964.

Infectious mononucleosis in children early age usually goes almost unnoticed. Clinical symptoms in babies are usually "blurred".

The main route of transmission of an infectious agent is airborne. There is a possibility of infection through hemotransfusion (blood transfusion), as well as through household contact(for example - through a common dish).

The disease most often develops in young people (at 14-16 years old in girls and at 16-18 years old in boys). AT age group from 25 to 35 years of age, antibodies to the Epstein-Barr virus are determined in the blood in almost 100% of the subjects. The source of the infectious agent is a patient (including with an "erased" form) or a virus carrier.

note: the disease is characterized by low contagiousness; for the transmission of the pathogen requires a sufficiently long contact with the carrier.

The "entrance gate" for the herpes virus type IV is the mucous membranes of the nasopharynx. The infectious agent is introduced into the cells of the epidermis of the mucosa, and then with the blood flow penetrates into B-lymphocytes, where it actively multiplies. The characteristic clinical manifestations of infectious mononucleosis are due precisely to the defeat of lymphocytes.

note: replication of this virus in lymphocytes does not cause cell death (unlike other herpes-like pathogens), but activates their proliferation (division).

Duration incubation period can be different - from 4 days to 2 months (on average, it is from 1 to 2 weeks).

The main clinical manifestations of benign lymphoblastosis are:

• increased fatigue;
• lymphadenopathy (enlargement of regional lymph nodes);
• hyperthermia;

The following clinical manifestations may also occur (individually or in various combinations):

• myalgia;
• arthralgia ( joint pain due to stagnation of the lymph);
• (including migraine);
• catarrhal tracheitis;
• catarrhal;
• reduction in total.

As a rule, the first symptom is a general malaise without any other manifestations of pathology. Initial period lasts an average of about a week. As the disease develops, an increase (up to 2-3 cm) and soreness are added. cervical lymph nodes and an increase in the overall temperature to febrile values ​​​​(38-39 ° C).

Infectious mononucleosis is accompanied by liver damage, and therefore, symptoms such as a feeling of heaviness in the right hypochondrium and a change in the color of urine (it becomes dark) are often noted.

The spleen is also involved in the pathological process, so the patient has splenomegaly (an increase in this body in size).

Important:if the patient was treated with ampicillin or amoxicillin, then in most cases with infectious mononucleosis, the appearance of skin rashes is noted.

The total duration of the disease averages 1-2 weeks, after which a period of convalescence begins. The patient's condition is gradually improving, but general weakness and increase cervical nodes may continue for up to 3 weeks.

Possible Complications

At severe course diseases can develop various complications from the nervous system.

To the number possible complications also include:

• (outer and middle);
• inflammation paranasal sinuses nose
• acute;
• follicular angina;
• hemolytic anemia.

Some patients have seizures and behavioral disturbances. Cases of the development of inflammation of the soft meninges () and brain tissues () have been recorded.

Important:rupture of the spleen is not excluded, which is an indication for urgent operation. This complication is extremely rare.

Diagnosis of infectious mononucleosis

The basis for the diagnosis is the presence of characteristic clinical symptoms, but it cannot be called strictly specific. Very similar manifestations are observed, for example, with, as well as some other acute infectious diseases.

Confirm the diagnosis of infectious mononucleosis. When examining a smear, lymphocytosis and monocytosis are determined. Also, the appearance of characteristic modified blood cells- mononuclear cells (“monolymphocytes” or “wide-plasma lymphocytes”), which are produced instead of B-lymphocytes affected by the Epstein-Barr virus. In addition, antibodies to the pathogen are detected in the blood.

For differential diagnosis with infectious diseases bacterial origin (in particular - streptococcal tonsillitis, tularemia and listeriosis) is cultured. The material for the study is the discharge of the tonsils.

At differential diagnosis in children should be excluded first of all (jaundice or Botkin's disease), Hodgkin's disease and acute leukemia.

In the vast majority of cases, a complete recovery occurs. Serious (including life threatening) complications are recorded in less than 1% of diagnosed cases. persistent after infectious mononucleosis. At sharp decline resistance of the organism (in particular, against the background of HIV infection), reactivation of the virus is possible.

Important: It has been established that the Epstein-Barr virus, in addition to infectious mononucleosis, can cause such serious diseases as nasopharyngeal carcinoma and Burkitt's lymphoma.

Infectious mononucleosis requires bed rest until it subsides acute symptoms. specific therapy not developed. Held symptomatic treatment, and measures are taken to strengthen the body in general.
After recovery, it is recommended to avoid physical activity to avoid such a serious complication as rupture of the spleen. It is strictly forbidden to lift weights, even if the organ is enlarged in acute period disease was not observed.

note: high temperature if necessary, you can knock down drugs containing paracetamol. Application acetylsalicylic acid in this case can lead to the development of a life-threatening disease - acute hepatic encephalopathy (Reye's syndrome).

How to treat infectious mononucleosis in children?

Possible symptoms of infectious mononucleosis in children include:

• subfebrile or febrile temperature;
• nasal congestion;
• sore throat;
• general weakness;
• drowsiness;
• symptoms of general intoxication;
• redness of the mucous membrane of the oropharynx;
• grain rear wall pharynx;
• hemorrhages in the mucous membrane of the pharynx;
• marked enlargement of the tonsils;
• lymphadenopathy;
• hepatosplenomegaly.

note: the severity of clinical manifestations depends on the severity of the disease. Various combinations of symptoms are possible.

Most significant symptom, which with a high degree of probability indicates infectious mononucleosis in a child, is polyadenitis due to pathological proliferation of lymphoid tissue. During the inspection, characteristic overlays are found on the tonsils in the form of islands of a light yellow or grayish hue.

The defeat of regional lymph nodes, as a rule, is bilateral.

Up to 50% of toddlers become infected with Epstein-Barr virus before the age of 5, but the disease is usually mild at an early age. Maintenance therapy is indicated, which implies adequate hydration (consumption enough liquids), rinsing with antiseptic solutions (with severe sore throat, 2% lidocaine hydrochloride solution is added to them).

To reduce the temperature during a febrile reaction, as well as reduce the severity or relief of symptoms of inflammation, it is recommended to use NSAIDs (Paracetamol, Ibuprofen).

To stimulate general immunity, the drug Imudon is indicated, and for overall strengthening the body requires vitamin therapy (with vitamins C, P and group B). Diagnosed decline functional activity liver is an indication for a strict diet and prescription medicines from the groups of hepatoprotectors and biliary tract. Also shown antiviral drugs(Viferon, Cycloferon, Anaferon). Their dosages are determined at the rate of 6-10 mg per 1 kg of the child's body weight.

Connecting a secondary bacterial infection may require use (penicillin preparations are not prescribed to avoid the development of hypersensitivity reactions). In parallel with antibiotics, children are prescribed probiotics (Acipol, Narine).

Children are shown strict bed rest. In some cases, treatment is required stationary conditions. Severe toxicity is an indication for hormone therapy(a weekly course of prednisolone is prescribed). With severe swelling of the larynx, a tracheostomy is performed, after which the child is connected to a ventilator.

You will learn more about the symptoms and methods of treating infectious mononucleosis in children by watching this video review with the participation of a pediatrician, Dr. Komarovsky:

Konev Alexander, therapist

Infectious mononucleosis is divided by type, severity and course. Typical cases include cases of the disease, accompanied by the main symptoms (enlarged lymph nodes, liver, spleen, tonsillitis, lymphomonocytosis and / or atypical mononuclear cells in the blood test). Atypical include erased, asymptomatic and visceral forms of the disease. Typical forms are divided according to severity into mild, moderate and severe. Indicators of severity are the severity of intoxication, the degree of enlargement of the lymph nodes, liver and spleen, lesions of the oropharynx and nasopharynx, 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, rupture of the spleen).

Scheme of examination of a patient with infectious mononucleosis.

When collecting an anamnesis, you need to find out the source of infection. To this end, it is necessary to find out if the child was 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, which ones, when and in connection with what? Whether the child suffers from any somatic disease (especially 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, lesions of the oropharynx, enlargement of the liver and spleen, skin rash.

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 with age norm, the color of the skin and visible mucous membranes, the condition of the lymph nodes, subcutaneous fat, oropharynx.

Detect changes in the digestive of cardio-vascular system, respiratory organs, liver, spleen, kidneys. Determine the nature of the stool, urination. Conduct an examination of the state of the central nervous system.

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

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 type DNA (qualitative and quantitative) and / or their AG in blood lymphocytes in RIF with monoclonal antibodies , serological examination for the presence of antibodies of the IgM and IgG class (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 testing for HIV, hepatitis B and C, G and TTV, bacteriological examination of the microflora of the oropharynx, ultrasound examination of the abdominal organs, general analyzes blood and urine.

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

Check your self-preparation by answering the questions of test control 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. What family do the causative agents of infectious mononucleosis belong to:

a) picornaviruses

b) herpetic 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

e) affects only the salivary glands

f) in myocardial infarction affects T-lymphocytes

g) in MI affects B-lymphocytes.

6. Epstein-Barr virus causes:

a) infectious mononucleosis

b) sarcoidosis

c) Burkitt's lymphoma

d) DiGiorgi's syndrome

e) nasopharyngeal carcinoma

e) cystic fibrosis

g) hairy leukoplakia of the tongue

h) Duncan's syndrome.

7) Associated with cytomegalovirus:

a) sepsis

b) perinatal infection

c) infectious mononucleosis

d) parotitis

e) complications of organ and tissue transplantation

e) retinitis

g) pneumonia

h) hepatitis

i) encephalitis.

8) Human herpesvirus type 6 (HHV-6 type) 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 IV, V and VI types 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 type 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) airborne

b) air-dust way

c) by contact-household way

d) sexually

e) by blood transfusion

f) by 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) defeat by viruses of the epithelium of the gastrointestinal tract

in) scattered foci of demyelination in the head and spinal

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

e) damage by viruses to the epithelium of the upper respiratory tract.

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 in infectious mononucleosis, there may be:

a) exanthema

b) encephalitis

c) nasal congestion and snoring

e) thyroiditis

e) puffiness of the face

g) encopresis

h) pastosity of the eyelids

i) catarrhal manifestations from the upper respiratory

j) intermittent claudication

k) gastrointestinal disorders.

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

a) posterior

b) axillary

c) cubital

d) inguinal.

17. Suppuration of lymph nodes in infectious mononucleosis occurs:

a) in 80-90% of cases

b) does not 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 in infectious mononucleosis is associated with:

a) profuse mucous discharge from the nose

b) an increase in the nasopharyngeal tonsil

c) sinusitis.

20. Infectious mononucleosis is characterized by:

a) leukocytosis

b) neutrophilia

c) thrombocytopenia

d) ESR acceleration

e) lymphomonocytosis

f) the appearance of atypical mononuclear cells

g) anemia

h) increased activity of transaminases

i) increased activity of alkaline phosphatase.

21. Among the atypical forms of infectious mononucleosis, there are:

a) erase

b) subclinical

c) visceral

d) fulminant.

22. For the diagnosis of infectious mononucleosis, the following reactions with heterophile antibodies are used:

a) Horner

b) Paul-Bunnel-Davidson

c) Belsky-Filatov-Koplik

d) Tomchik

e) Waterhouse-Frederiksen

e) Hoff-Bauer.

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

a) EBV-etiology of MI

b) CMV-etiology of MI

c) HHV-6 - the etiology of MI

d) EBV + CMV - MI etiology

e) EBV + HHV-6 – MI etiologies

f) CMV + HHV-6 - MI etiology

g) EBV + CMV + HHV-6 - the etiology of MI.

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

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 blood and/or CMV AG in blood lymphocytes

b) anti HBc Ig M

c) anti-CMV Ig G

d) anti-CMV Ig M

e) anti-CMV Ig A

f) CMV DNA in saliva, urine

g) anti-HAV Ig M.

26. HHV-6 - 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) adenovirus 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

k) mumps infection.

28. Complications of infectious mononucleosis are:

a) encephalitis

b) paresis of the facial nerve

c) bacterial infection of the oropharynx

d) osteomyelitis

e) rupture of the spleen

f) immune: anemia, thrombocytopenia, neutropenia

g) respiratory arrest

h) myocarditis.

29. For the etiological treatment of MI, use:

a) fluoroquinolones

b) preparations of recombinant interferon - alpha

c) inhibitors of proteolysis

d) interferon inducers

e) intravenous immunoglobulins

e) ganciclovir

g) acyclovir

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

a) oxygen therapy

b) antibiotics course for 5-7 days

c) prednisolone short course.

Check the correctness of the 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, e, f, g, h, i; 8 - b, c, e, f, g, h; 9 - G; 10 - b, c;

11 - a, c, d, e, f, g; 12 - in; 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, k; 28) - a, c, e, f, g, h; 29 - b, d, e, g; 30 - in.

The sum of the reference answers is 99

Calculation of student response score:

A (sum of correct answers)

K (coefficient of assimilation) \u003d --------------

B (sum of reference answers)

When 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 questions of the tasks

I. A 6-month-old child fell ill acutely with an increase in body temperature to febrile numbers, rhinitis and cough were noted. On the fourth day of illness, puffiness of the face, pastosity of the eyelids, and snoring breath appeared. By the end of the week, a sore throat and a maculopapular rash appeared without a staging of rashes and preferential localization sites.

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

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

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

6. What are the features 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. Against the background of the therapy, the bleeding was stopped, the condition returned to normal, and the patient was discharged home.

One 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, sore throat when swallowing, enlarged peripheral lymph nodes, as well as the liver and spleen, darkened urine and discolored feces. Headaches, anorexia, abdominal pain, feeling of weakness and malaise were noted. The mucous membrane of the oropharynx was moderately hyperemic, edematous, the palatine tonsils were enlarged, they were noted overlays.

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

1. Indicate the presumptive clinical diagnosis.

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

5. With what diseases is it necessary to carry out a differential diagnosis?

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

Upon admission, the patient was in a state of moderate severity, temperature 37.9ºC, complaints of sore throat when swallowing. The skin is pale, clean. Anterior and posterior cervical lymph nodes are palpable, enlarged up 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, sonorous. The pharynx is brightly hyperemic, edematous, hypertrophy of the left lateral column of the posterior pharyngeal wall and yellowish overlays on it are determined. The tonsils are enlarged to the II degree, hyperemic, without impositions. 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-Bunnel test on the 13th day of illness is negative.

PCR revealed 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 IgM; anti-CMV IgG.

1. Indicate the presumptive clinical diagnosis.

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

3. What tests should be done to confirm the diagnosis?

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

5. With what diseases is it necessary to carry out a differential diagnosis?

TEST-TASK.

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

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

In the peripheral blood, 52% of atypical mononuclear cells were found. In the biochemical analysis of blood - an increase in the activity of AlAT up to 483 U / l and AsAT up to 467 U / l. The reaction of Paul-Bunnel-Davidson is positive. Anti-EBV EA IgM, anti-EA EBV Ig G, anti-VCA EBV Ig M were found in blood serum; anti-VCA EBV Ig G.

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

Answer the questions posed:

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.

On the basis of what data can one judge the timing of infection?

What are the leading symptoms determined the severity of the disease?

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

Is liver damage characteristic of this disease?

What is the effect of herpetic viruses types IV, V and VI on the immune system?

What is 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 agents can be used in this case?

What methods specific prevention Epstein-Barr virus infections exist now?

Sample 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: a significant increase in 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%), the detection of anti-EBV EA IgM, anti-EA EBV Ig G, anti-VCA EBV Ig M in the blood serum; anti- VCA EBV Ig G. Detection of EBV DNA in blood, saliva, urine, positive result of the Paul-Bunnel-Davidson reaction, increased activity of hepatocellular (AlAT, AsAT).

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, oropharyngeal lesions, hepatosplenomegaly, hemorrhagic syndrome, jaundice, the appearance of 52% of atypical mononuclear cells in 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. Epstein-Barr virus has now been convincingly proven to be 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. A positive result of the Paul-Bunnel-Davidson reaction in this patient is associated with the production of heterophilic IgM antibodies to the EBV antigen, which agglutinate ram erythrocytes.

10. Tomczyk reaction - agglutination reaction of trypsinized bovine erythrocytes with patient serum treated with kidney extract guinea pig. The Goff-Bauer reaction is an agglutination reaction of equine erythrocytes with the patient's serum on glass.

11. A 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 virus infection have not yet been developed.

The share of infectious mononucleosis in the structure infectious pathology in last years significantly increased due to a decrease in the incidence of other infections. The danger of the spread of AIDS, in which a mononucleosis-like syndrome develops a few weeks or months after infection, makes us especially attentive to each case of this infection.
Infectious mononucleosis (Filatov's disease), acute viral infection characterized by fever inflammatory phenomena in the pharynx, an increase in the cervical lymph nodes, spleen and liver, hematological changes and an increase in the titer of heterophilic antibodies. This disease was first described by N.F. Filatov in 18895 under the name "idiopathic inflammation of the cervical glands". In 1920, Sprint and Evans, having discovered hematological changes, called this disease infectious mononucleosis. In 1932, Paul and Bunnell applied the heterohemagglutination test for serological diagnosis.
In Latin American countries, Central Africa, South Asia, the infection rate in children of the first 4 years of life is 80-90%, while in the USA, Australia, and Western European countries, the same percentage is recorded in the group of preschool and younger age. In the European part of the USSR, the highest titers of antibodies to the causative agent of this disease are found in preschool children.
Most researchers believe that the Epstein-Barr virus is the causative agent of mononucleosis, although it has not been isolated directly from patients. This is a DNA-containing virus from the herpes group, a spherical shape with 4 antigens. It is sensitive to ether. Reproduces only in cultures of lymphoblasts of Burkitt's tumor, in the blood of patients with infectious mononucleosis, leukemic cells and brain cell culture healthy person. Its ability to cause lymphoid neoplasia in marmosets (a type of monkey) and owl monkeys has been established. The Epstein-Barr virus has a tropism for lymphoid tissue and can persist for a long time in the host cells as a latent infection. Plays an etiological role in Burkitt's lymphoma and possibly in nasopharyngeal carcinoma. The entrance gates of infection are the mucous membrane of the nose and oropharynx and the region of the pharyngeal lymphatic ring. From here, already at the end of the incubation period, the virus spreads hematogenously and lymphogenously throughout the body. Settling in the lymphoid tissue, it causes hyperplastic processes in it with the formation of lymphocytic infiltrates and the release of the so-called atypical mononuclear cells into the peripheral bloodstream. Despite the absence of a direct damaging effect of viruses on organ cells, functional disorders liver, kidney, nervous, cardiovascular and other systems are possible. This is due to the formation of perivascular infiltrates, the accumulation of immune complexes, an increase in vascular permeability, which entails a metabolic disorder, lymph and blood circulation in the organs.
Specific cytological changes and a decrease in local immunological reactivity of the tonsils contribute to the attachment of a bacterial infection with the development of inflammation. The duration of the incubation period is on average 5-20 days. The disease often begins acutely, with fever to high numbers, weakness, headache. Much less likely to be identified prodrome. Fever with 37.5 ° C is noted at the beginning of the disease and by the end of the 1st week reaches a maximum (38.5 - 40 ° C), then it persists for several more days (up to 10-14). Temperature curve of the wrong type, with a tendency to lytic decrease at the end of the febrile period. In adult patients, the temperature is higher and is reached longer than in children, chills are often noted at the onset of the disease. In children under 1 year of age, subfebrile condition is more often observed. During the period of maximum temperature rise at the height of the disease, some patients may have a petechial rash on the skin and mucous membranes, nose and other bleeding, which is associated with an increase in vascular permeability and thrombocytopenia. In children from the first days of the disease, the defeat of the nasopharynx comes to the fore, which is manifested by difficulty in nasal breathing. The child breathes through a half-open mouth, the voice acquires a nasal tone, the face has an "adenoid" appearance. Discharge from the nose is minor. Children of the first years of life are especially affected, when a significant difficulty in nasal breathing and obstruction of the airways by a sharply enlarged lymphoid tissue lead to the development of false croup syndrome with respiratory failure. In all patients, when examining the oropharynx, hyperemia of the pharynx and posterior pharyngeal wall with a large amount of mucus is determined, often granular pharyngitis (bright, roughly expressed granularity of the posterior wall). Swelling and looseness of the tonsils - persistent symptoms diseases. Overlays on the tonsils in the form of islands, films, whitish-yellow or dirty gray stripes are not always found. They are loose, bumpy, easily removed and rubbed between glass slides. Appearing in the first 2 days, the sore throat symptom complex lasts an average of 7-13 days, and in children with necrotic changes in the tonsils - even longer. In adult patients, the timing of the onset of angina is usually shifted by 3-6 days of the disease. It is almost non-existent in older people. On the 2-3rd day of illness, one of the main clinical symptoms of infectious mononucleosis can be detected - an increase in one degree or another of all groups of lymph nodes. AT most the lymph nodes of the posterior cervical group increase, forming, as it were, a chain along the posterior edge of the sternocleidomastoid muscle and are clearly visible to the eye. Lymph nodes become dense, retain elasticity, are not soldered to each other and to the surrounding tissue, and are slightly sensitive to palpation. In younger children, the lymph nodes of the anterior cervical group often increase significantly, due to which the configuration of the neck changes. Enlargement of the post-mortem and lymph nodes of the abdominal cavity can lead to the development abdominal syndrome with abdominal pain, bloating, nausea, vomiting, loose stools. The sizes of lymph nodes vary from 0.5 to 3-4 cm in diameter, their reduction usually begins after 7-10 days and can be delayed for several weeks. The enlargement of the spleen is usually parallel to the enlargement of the liver and reaches its maximum by the 7-10th day of the disease. The spleen on palpation is smooth, elastic, protrudes 2-4 cm from under the edge of the costal arch. There have been cases of significant enlargement of the spleen with rupture of the organ, which is one of the specific complications of infectious mononucleosis and requires immediate surgical intervention. Normalization of the size of the spleen usually occurs by the end of the 3-4th week, less often - it drags on for several months. The enlargement of the liver in most cases is significant - its edge is dense, a slightly painful edge is palpated 3-5 cm below the costal arch. The severity of hepatomegaly (liver enlargement) is greatest in preschool children. A decrease in the size of the organ occurs only by the middle of the 2nd month of the disease. Sometimes hepatolienal syndrome persists for 6-8 months after suffering infectious mononucleosis. In some cases, at the height of the clinical picture, the disease is accompanied by jaundice - icterus (jaundice) of the skin and sclera, sometimes a change in the color of urine and feces. Hyperbilirubinemia (an increase in the content of bilirubin in the blood serum) is usually insignificant, the enzymatic and protein-synthetic functions of the liver are more disturbed, as evidenced by increased performance thymol test, hypergammaglobulinemia (increased levels of gamma globulins in blood serum), an increase in the activity of various enzymes. A change in the picture of peripheral blood is most often detected as early as the 1st week. In patients, the number of mononuclear elements of white blood (lymphocytes, monocytes, plasma cells) increases to 60-70%, which is especially often found when calculating their absolute number. Leukocytosis reaches 20-30 * 109 / l, ESR - 15-30 mm / hour, the number of atypical mononuclear cells increases. The diagnostic level is considered to be their content in the peripheral blood above 10%. Such blood changes can persist for up to 2-3 months. In middle-aged and elderly patients, the blood reaction comes later and lasts longer (up to 1-3 years), while normal ESR and leukopenia are more often observed. Rare symptoms of infectious mononucleosis include a polymorphic, esudative rash all over the body without specific localization (maculopapular, punctate, roseolous, urticarial). More often rashes occur in young children on the 2nd-3rd day of the disease, persist for 4-7 days and disappear without leaving pigmentation and flaking behind. In connection with the defeat of the lymphoid tissue of the nasopharynx and pharynx, the development of lymphostasis in children, puffiness of the face and pasty eyelids are often noticeable. Despite the usually benign course of the disease, in rare cases, symptoms of kidney damage in the form of interstitial nephritis are observed. With this disease, the nervous system is often affected with the development of meningitis, encephalitis or polyradiculoneuritis. To specific complications infectious mononucleosis is classified as acute hemolytic anemia, hemorrhagic syndrome, lesion thyroid gland.
When classifying clinical forms on the basis of the pathogenetic principle, typical and atypical forms of infectious mononucleosis of mild, moderate and severe degree with complicated and uncomplicated course are distinguished. To typical forms include those in which the main signs are clearly identified: fever, swollen lymph nodes, changes in the oropharynx and nasopharynx, hepatolienal syndrome and characteristic hematological changes. An indicator of severity is the severity of general intoxication and the main symptoms of the disease. To atypical forms infectious mononucleosis include erased, asymptomatic and forms with rare manifestations of the disease (i.e. with damage to the nervous, cardiovascular systems, kidneys and other organs). Erased forms are detected during a thorough examination with the definition of mild signs of the disease, serological and hematological changes, asymptomatic forms - only on the basis of epidemiological, serological and hematological data. Laboratory diagnosis is important. For more early detection and a reliable count of atypical mononuclear cells in peripheral blood, in addition to conventional smears, the microleukoconcentration method is used, followed by staining of a suspension of leukocytes.
Serological diagnosis based on the detection of heterophile antibodies in the patient's serum. The Paul-Bundell-Davidson agglutination reaction with sheep erythrocytes pretreated with guinea pig kidney extract is highly specific. The diagnosis can be made already at the end of the 1st, beginning of the 2nd week. The simplicity of the technique, quick results, high specificity of the Tomczyk reaction (agglutination of trypsinized bovine erythrocytes of the patient's serum) allow us to recommend it for wide application. This reaction gives high titers (1:192), more often it is positive in children under 3 years old, it is also determined by the end of the 1st week. As an express diagnostic method, the Hoff and Bauer reaction is used - agglutination on the glass of native or preserved horse erythrocytes with the patient's serum. It is convenient, easy to perform not only in hospitals, but also in a clinic. At cytological examination Imprint smears from the surface of the tonsils reveal cells similar to atypical blood mononuclear cells. The severity of the process can be judged by an increase in the titer of immunoglobulin M. To exclude acute respiratory disease or the establishment of mixed infection, virological reactions must be included in the examination complex. This is especially true for young children, because clinical picture acute respiratory disease against the background of their anatomical and physiological features (some enlargement of the liver and spleen, damage to the lymphoid tissue) may be similar to infectious mononucleosis. In addition to acute respiratory disease, mononucleosis must be differentiated from diphtheria, tonsillitis, infectious hepatitis, typhoid fever, tularemia, acute and chronic leukemia, lymphogranulomatosis, benign lymphoreticulosis, HIV infection. Diphtheritic lesions of the pharynx are accompanied by a rapid (in 1-2 days) fever, an increase in tonsils with widespread grayish-white, smooth, shiny, hard-to-remove deposits, and an increase in regional lymph nodes; edema captures not only tissues, but also extends to chest to collarbones and below. Biochemical changes blood are expressed considerably and keep for a long time. The basis of diagnosis in doubtful cases are hematological and serological studies. In the first 4-5 days, the picture of Filatov's disease may resemble typhoid fever especially in middle-aged and elderly patients. However, the nature of the temperature curve, severe symptoms intoxication with damage to the cardiovascular system (relative bradycardia, lowering blood pressure, roseolous rash, signs of intestinal damage) make it possible to exclude infectious mononucleosis. With tularemia, lymphadenitis is determined only in the zone of the entrance gate of infection (bubonic or anginal-bubonic form). Only one tonsil is affected, and lymphadenopathy is also unilateral. Painless nodes are further opened with the release of creamy pus. Skin allergy test with tularemia becomes positive from the 5-7th day of illness. in cases of high leukocytosis (30-60 * 109 / l) with lymphocytosis (up to 80-90%), it becomes necessary to differentiate infectious mononucleosis from acute leukemia. The peripheral blood picture and myelogram have specific changes. The presence of natural killer cells (LKL cells) among atypical mononuclear cells in infectious mononucleosis is an indicator of the benign process. chronic leukemia does not have an acute onset, proceeds against the background of uniform lymphadenopathy, the liver and spleen are enlarged, dense, painless. From infectious mononucleosis, lymphogranulomatosis mainly differs in the duration of the course of the disease (months), the undulating nature of the temperature curve, the absence of damage to the pharynx and nasopharynx, the density of the lymph nodes, and neutrophilic leukocytosis. The presence of Berezovsky-Steinberg cells in the punctates of the lymph nodes confirms this diagnosis. With benign lymphoreticulosis (disease " cat scratch"), in contrast to infectious mononucleosis, there is an isolated increase in lymph nodes regional in relation to the entrance gate of the infection, there is no tonsillitis, nasopharyngitis and an increase in the posterior cervical lymph nodes.
Infectious mononucleosis can occur in people of all ages. However, children from 3 to 10 years old are predominantly ill (according to various sources, from 39 to 73%). The incidence of mononucleosis in adolescents and individuals young age may also be high.
Infectious mononucleosis refers to anthroponotic infections. Its source is a sick person or a virus carrier. After the transfer of the disease, in some cases, the virus is periodically shed for 2-5 months. Especially in large quantities the causative agent is isolated from persons undergoing immunosuppressant therapy. It should be borne in mind the cases of infection of the medical personnel of infectious diseases hospitals with this disease. Quite often, a low incidence is apparently associated with a large percentage of immune individuals, the presence of erased and asymptomatic forms of the disease. The main route of transmission of the disease is airborne. The transfusion route of transmission is also recognized.
After an illness, a person develops a strong immunity. In children infancy maternal innate immunity is present, which explains the rarity of cases of infectious mononucleosis in this age group. In persons over 50 years of age, the extinction of immunity is noted.
basis symptomatic therapy infectious mononucleosis is the observance of bed rest until the disappearance of clinical symptoms, a full, sparing diet, plentiful drink. It is necessary to provide oral care, symptomatic treatment of lesions of the oropharynx and nasopharynx. Recently, specific drugs have been used in the treatment: amorphous pancreatic RNase (0.5 mg/kg/day intramuscularly for 1-2 injections for 10-14 days) and amorphous DNase (1.5 mg/kg/day intramuscularly for 7 days). Particularly tangible positive effect in combination with courses of desensitizing therapy was obtained with severe forms with damage to the nervous system.
The appointment of antibiotics (most often the penicillin series) is justified for young children with high risk bacterial complications, older children and adults - with developed complications. Levomycetin and are contraindicated sulfa drugs that inhibit hematopoiesis. Experience has shown that the use of ampicillin often causes a rough exudative rash and worsens the course of the disease. In severe cases, especially with pronounced local symptoms from the nasopharynx, it is advisable to use glucocorticoids in a short course. Preventive measures consist in isolating patients in a hospital setting. Hospitalization of such patients in a general somatic hospital is unacceptable. Disinfection in the hearth is not carried out. Contact persons should be observed for at least 2 weeks, especially for children and contacts in closed groups. Where available, serological testing of contacts' blood may be recommended in outbreaks.