Detection and virulence potential of a phospholipase D-negative Corynebacterium ulcerans from a concurrent diphtheria and infectious mononucleosis case.

Diphtheria by Corynebacterium ulcerans is increasingly occurring in children, adolescents and adults. In addition to diphtheria toxin (DT), phospholipase D (PLD) is considered a virulence factor of C. ulcerans. In the present study, a first case of concurrent diphtheria by a PLD-negative C. ulcerans and infectious mononucleosis (IM) was verified. Clinical and microbiological profiles and binding properties to human Fibrinogen (Fbg), Fibronectin (Fn) and type I collagen (col I) biotinylated proteins and virulence to Caenorhabditis elegans were investigated for C. ulcerans strain 2590 (clinical isolate) and two control strains, including PLD-positive BR-AD22 wild type and PLD-negative ELHA-1 PLD mutant strains. MALDI-TOF assays and a multiplex PCR of genes coding for potentially toxigenic corynebacteria identified strain 2590 as non-DT producing. Interestingly, strain 2590 did not express PLD activity in the CAMP test although the presence of the pld gene was verified. PLD-negative 2590 and a PLD-positive 210932 strains showed similar affinity to Fbg, Fn and type I collagen. C. elegans were able to escape from C. ulcerans strains, independent of PLD and DT production. Higher mortality of nematodes was verified for PLD-negative strains. Additional studies concerning multifactorial virulence potential of C. ulcerans, including environmental conditions remain necessary.

An infant with concurrent serotype 6C invasive pneumococcal disease and infectious mononucleosis.

Streptococcus pneumoniae is a main causative agent of serious invasive bacterial infections. However, concurrent infection with invasive pneumococcal disease (IPD) and viral infectious mononucleosis (IM) is rare. We report an infant with serotype 6C infection causing IPD occurring simultaneously with IM. A previously healthy 11-month-old girl referred to our hospital because of fever, leukopenia, and elevated C-reactive protein presented to us with disturbance of consciousness, tachycardia, tachypnea and agranulocytosis. Other findings included tonsillitis with purulent exudates and white spots, bilateral cervical adenopathy, and hepatosplenomegaly. We diagnosed her illness as sepsis and administered a broad-spectrum antibiotic, an antiviral agent, and granulocyte transfusions. After treatment was initiated, fever gradually decreased and general condition improved. IPD was diagnosed based upon isolation of S. pneumoniae of serotype 6C from blood cultures obtained on admission. Concurrently the girl had IM, based upon quantitation of Epstein-Barr viral DNA copies in blood and fluctuating serum antibody titers. Although simultaneous IPD and IM is a rare occurrence, this possibility is important to keep in mind.

[THE DIAGNOSTIC APPROACHES TO VERIFICATION OF STREPTOCOCCUS INFECTION IN PATIENTS WITH INFECTIOUS MONONUCLEOSIS].

The Rostovskii state medical university of Minzdrav of Russia, 344022 Rostov-on-Don, Russia The analysis is applied concerning significance of laboratory techniques of verification of streptococcus infection (bacteriological analysis, detection of anti-streptolysin O in pair serums) in 148 patients with infectious mononucleosis aged from 3 to 15 years. The content of anti-streptolysin O exceeded standard in 41 ± 4.8% of patients with concomitant in acute period and in 49.5 ± 4.9% during period of re-convalescence. This data differed from analogous indicator in patients with negative result of examination on streptococcus infection independently of period of disease (9.3 ± 2.8%). The exceeding of standard of anti-streptolysin O was detected more frequently (t ≥ 2, P ≥ 95%) in patients with isolation of Streptococcus pyogenes (56.9 ± 5.8%) than in patients with Streptococcus viridans (31.2 ± 6.5%). The concentration of anti-streptolysin 0 in patients with concomitant streptococcus infection varied within limits 200-1800 IE/ml. The minimal level of anti-streptolysin O (C = 200 IE/mI) was detected independently of type of isolated Streptococcus and period of disease. The high levels of anti-streptolysin O were observed exclusively in patients with isolation of Streptococcus pyogenes. In blood serum ofpatient with concomitant streptococcus infection (Streptococcus pyogenes + Streptococcus viridans) increasing of level of anti-streptolysin O was detected in dynamics of diseases from minimal (C = 200 IE/ ml) to moderately high (200 < C < 400 IE/mI). It is demonstrated that to identify streptococcus infection in patients with infectious mononucleosis the anamnesis data is to be considered. The complex bacteriological and serological examination ofpatients is to be implemented This is necessary for early detection ofpatients with streptococcus infection and decreasing risk of formation of streptococcus carrier state.

[A young man with mononucleosis and swelling of the right eye]. / En ung mann med mononukleose og hevelse over høyre øye.

Treatment of acute infections in the upper airways comprises a significant part of direct healthcare expenditure and is a challenge for healthcare professionals. In Norway, 11,495 hospitalized days were recorded for acute infections (influenza and pneumonia excluded) in the upper airways in 2008. Acute bacterial rhinosinusitis (ABRS) is defined as inflammation of the nose and the paranasal sinuses characterized by both 1): symptoms of nasal blockage/obstruction/congestion or nasal discharge, and/or facial pain/pressure and 2): endoscopic signs of mucopurulent discharge from middle meatus and/or CT changes within the osteomeatal complex/sinuses. After 12 weeks of symptoms the definition changes to chronic rhinosinusitis. With antibiotic treatment of complicated ABRS we see fewer severe complications, but they still occur. Due to anatomical proximity of the orbit and intracranial structures a localized spread of the infection is especially unfortunate and potentially dangerous. We present a case report (with pan sinusitis and grave local complications) from the ear, nose and throat department in St. Olav's University Hospital in Trondheim, Norway.

The uptake and use of the Monospot test in patients with tonsillitis.

The objective of the study was to ascertain the uptake of the Monospot test in St. James's hospital in Dublin over the five years 2002-2006 and to determine the percentage of Monospot tests which had a positive result. Using the HIPE, Electronic Patient Record (EPR) and Patient Access System (PAS) databases in St. James's Hospital, a cohort of 593 patients with a diagnosis of tonsillitis or infectious mononucleosis was identified. Fourteen patients met the exclusion criteria as outlined below leaving a valid pool of 579 patients. It was ascertained whether each patient had a Monospot performed and if so, whether the result was positive or negative. In total, 249 (43.0%) of the included patients had a Monospot test. Of these, 197 (79.1%) were negative and 29 (11.6%) were positive. In 23 (9.2%) cases, no result was available. The uptake of the Monospot increased over the five years studied. A positive Monospot impacts on treatment and follow up. We therefore recommend that one is carried out in all patients presenting with acute tonsillitis.

Cervical necrotising fasciitis: a rare complication of infectious mononucleosis.

Cervical necrotising fasciitis (NF) is an aggressive polymicrobial infection of the subcutaneous tissues in the head and neck. We present a case of a healthy 19-year-old man who developed cervical and upper mediastinal NF after an initial presentation of infectious mononucleosis (IM). He was treated with broad-spectrum antibiotics in addition to incision and drainage of an anterior neck and upper mediastinal abscess. He progressed favourably after ten days of hospitalisation and was discharged home on intravenous antibiotics. This is a unique case of cervical NF as a sequelae of IM in a previously healthy paediatric patient.

Pharyngitis of infectious mononucleosis: computed tomography findings.

Two women presented with sore throat and fever. Their symptoms were not alleviated by antibiotics. Cervical computed tomography (CT) with contrast enhancement demonstrated enlargement of predominant posterior cervical lymph nodes and streaky heterogeneous tonsils with interspersed low attenuation. They were diagnosed as having infectious mononucleosis by their laboratory data. Thus, when radiologists encounter these CT findings of pharyngitis that is not alleviated by antibiotic therapy, infectious mononucleosis should be considered in the differential diagnosis.

Screening for glandular fever in patients with Quinsy: is it necessary?

Quinsy (peritonsillar abscess) is a common emergency seen in otolaryngology practice. These patients are often screened for glandular fever in addition to routine haematological tests. In our unit, we have screened 66 patients with quinsy for glandular fever over a period of 12 months. All these patients were screened for glandular fever by rapid immunoassay. Only one out of 66 patients was tested positive for glandular fever. Due to the extremely low incidence of glandular fever in quinsy patients, we do not see any relevance in screening for glandular fever in quinsy patients. Hence we recommend that routine screening for glandular fever in quinsy patients is an unnecessary invasive investigation for the patients and not cost effective for the hospital.

Activation of Epstein-Barr virus in hybrid cells.

Human-primate hybrid cell lines were established by fusion of African green monkey kidney cells (VERO) with lymphoblastoid cells from patients with infectious mononucleosis (IM)(IMK101) and from Burkitt's lymphoma culture (HR1K). Both Epstein-Barr virus (EBV)-specific antigens and EBV particle-containing cells increased in the hybrid lines (IMK1-1/VERO,HR1K/VERO). Treatment of the hybrids with 5-bromodeoxyuridine induced more antigen-positive and more virus-containing cells. EBV could be activated from IM lymphoblastoid cells by fusion of the lymphoblastoid cells with the VERO cells. The increase of viral antigens and virus particles may have been due to the cellular interaction between VERO cells and the lymphoblastoid cells or to a possible derepressor supplied by the VERO component of the hybrid. Virus derived from the HR1K cell line was replicated in the human-primate hybrid, but further investigation may be necessary to determine if it was identical to the EBV derived from the human cell line.

Documentation of Epstein-Barr virus infection in immunodeficient patients with life-threatening lymphoproliferative diseases by Epstein-Barr virus complementary RNA/DNA and viral DNA/DNA hybridization.

Tissues from patients thought to have Epstein-Barr virus (EBV)-induced lymphoproliferative diseases were probed for EBV genomes using 2 independent hybridization techniques. Tissues from six patients with the X-linked lymphoproliferative syndrome, all five renal allograft recipients with immunoblastic sarcoma, and eight patients with diverse types of immunodeficiency and lymphoproliferative diseases such as fatal infectious mononucleosis or malignant lymphoma associated with antecedent immunodeficiency contained significant numbers of EBV genome equivalents per cell. The use of 2 hybridization probes is recommended to confirm the presence of EBV genomes. The finding of significant numbers of EBV genomes in tissues from patients with immunodeficiency suggests that EBV is the etiological agent of the associated lymphoproliferative diseases.

Benign and malignant disease caused by EBV.

Epstein-Barr virus (EBV) causes infectious mononucleosis as a primary disease. The virus infects more than 90% of the average population and persists lifelong in peripheral B-lymphocytes. The virus is produced in the parotid gland and spread via the oral route. Serology suggests that the Epstein-Barr virus might be involved in the causation of two neoplastic diseases of humans: African Burkitt's lymphoma and nasopharyngeal carcinoma. Whereas the development of the lymphoma has an even better linkage with chromosomal rearrangements, nasopharyngeal carcinoma shows a unique association with Epstein-Barr virus. Environmental factors, including traditional Chinese medicine, may be responsible for the enhanced risk of nasopharyngeal carcinoma in certain, predominantly Chinese, populations of southern Asia. Possible mechanisms leading to the establishment of the neoplastic manifestations will be discussed.

Clinical and laboratory evaluation of cytomegalovirus-induced mononucleosis in previously healthy individuals. Report of 82 cases.

The present report describes the clinical and laboratory profile of 82 previously healthy individuals who developed cytomegalovirus (CMV)-induced mononucleosis. Many of these patients posed initial diagnostic problems and were hospitalized with diagnoses such as fever of undetermined origin, active viral hepatitis, acute leukemia, probable systemic lupus erythematosus, autoimmune hemolytic anemia, and severe pancytopenia. These patients underwent a variety of diagnostic biopsies, including liver biopsies (6) and bone marrow aspirations (9). Four patients had exploratory laparotomies, 1 for a ruptured spleen, and another had a splenectomy following an erroneous initial diagnosis of agnogenic myeloid metaplasia. There was no apparent clinical response to a short course of steroid therapy in 3 of 5 cases and acyclovir in another. The vast majority of these patients demonstrated infectious mononucleosis-type reactive blood smears, negative heterophil antibody studies, mildly or moderately elevated aspartate aminotransferase activity, and evidence for subclinical hemolysis on serial specimens. The peak serum bilirubin levels were above 2.0 mg/dl in only 2 of 71 cases tested, both of the latter patients having significant hemolysis (hemoglobin values 8.6-9.3 g/dl). The CMV-IgM test had a high sensitivity for detection of CMV macroglobulins (positive in 81 of 82 cases). In contrast, complement-fixing antibodies to CMV showed diagnostic four-fold titer changes in only 39/82 cases (47.6%). Despite its great sensitivity, the CMV-IgM test is limited by a one-way crossreaction of acute Epstein-Barr virus (EBV)-IM sera and spurious positive reactions in some sera due to the presence of rheumatoid factors. Based on EBV-specific serologic studies, the 82 patients with CMV-IM could be divided into 4 groups: 3 patients without antibodies to EBV; 2) 69 patients with uncomplicated serologic data indicative of long-past EBV infections; (3) 6 patients with unusual antibody profiles, e.g., anti-D responses; and (4) 5 patients, including 1 originally susceptible to EBV, with apparent dual CMV/EBV infections. At the conclusion of our study, final diagnoses and initial hematologic data were correlated in 750 cases in which CMV macroglobulins were searched for. The vast majority of patients with active CMV infections initially demonstrated either markedly or moderately reactive peripheral blood smears. These data support our impression that diagnostic tests for CMV, as well as for EBV, are seldom indicated in symptomatic previously healthy patients whose blood smears during the acute phase (first several weeks) of their illnesses are either nonreactive or minimally reactive.

Cytomegalovirus infection in the normal host.

CMV mononucleosis often resembles EBV infectious mononucleosis; however, certain features of the history and physical may help to distinguish CMV from EBV. While CMV mononucleosis is usually self-limited, certain laboratory abnormalities may persist for months or years after the patient has recovered. Previous reports on CMV in the non-immunocompromised host have rarely described systemic complications. We have reviewed 10 cases of CMV with systemic manifestations at one institution over a 15-year period. These patients had prolonged fevers (often greater than three weeks) and the diagnosis was often unsuspected during the early part of the illness. While two patients required mechanical ventilation, all patients had self-limiting disease and survived. When CMV is suspected and diagnosed early in the course, numerous diagnostic (and potentially dangerous) tests can be avoided in a viral illness in which prolonged fever is common.

Cytomegalovirus mononucleosis in a healthy adult: association with hepatitis, secondary Epstein-Barr Virus antibody response and immunosuppression.

A 35 year old previously healthy physician had clinical manifestations of a mononucleosis illness complicated by arthralgia, vesicular pharyngitis and hepatitis. Initially, the patient had cytomegalovirus (CMV) viremia (predominantly in polymorphonuclear leukocytes) followed by the presence of CMV in the urine, throat and semen. He also had an antibody response to the Epstein-Barr virus which appeared to be a secondary type. During the acute phase of illness, only 7 per cent of the patient's lymphocytes formed spontaneous T cell rosettes as compared to a normal value of 65 to 70 per cent. Concurrently, evidence of abnormal delayed hypersensitivity was manifested by the loss of reactivity to mumps skin test antigen. All clinical and laboratory abnormalities except for the persistence of CMV in the pharynx, urine and semen returned to normal after resolution of the clinical illness.

Epstein-Barr virus DNA in peripheral blood leukocytes of patients with posttransplant lymphoproliferative disease.

We tested the hypotheses that Epstein-Barr virus (EBV) DNA levels in peripheral blood leukocytes (PBL) of transplant recipients with posttransplant lymphoproliferative disease (PTLD) (1) exceed those of patients without PTLD, (2) rise with or before clinical detection of the disease, and (3) fall with effective therapy. Using the polymerase chain reaction (PCR) and an endpoint dilution technique, we compared EBV DNA levels in sequential specimens from 5 patients with PTLD, 16 solid organ transplant recipients without PTLD, and 5 young adults with primary infectious mononucleosis (IM), and in single specimens from 21 healthy seropositive subjects. EBV DNA levels in the first two groups rose with induction of immunosuppression despite prophylactic acyclovir. Markedly elevated levels of EBV DNA were seen in 4 of 5 patients with PTLD at or before clinical diagnosis. The peak levels in these patients exceeded those of transplant recipients without PTLD (P = 0.02) and healthy adults with IM (P = 0.02). EBV DNA levels fell dramatically with effective therapy. Four of 21 healthy seropositive subjects demonstrated low levels of EBV DNA, similar to levels seen late in the course of patients with IM. We conclude that a semiquantitative PCR assay for EBV DNA in PBL can assist in the detection of PTLD and in monitoring the effect of therapy.

Primary Epstein-Barr virus infections in children.

During a serioepidemiologic survey of a community, 13 (6.2%) of 209 children were found to be experiencing a current or recent primary Epstein-Barr virus (EBV) infection. The sera contained elevated antibody titers to viral capsid antigen of EBV, antibodies to early antigen (EA) of EBV, and specific IgM. The frequency of primary infections was highest in the first decade of life. The primary EBV infections were usually asymptomatic. The antibody to EA was directed predominantly to the R component. A heterophil antibody response was not detected.

Epstein-Barr virus-carrying B cells in the blood during acute infectious mononucleosis give rise to lymphoblastoid lines in vitro by release of transforming virus and by proliferation.

In accordance with earlier studies, we detected higher numbers of Epstein-Barr virus (EBV)-carrying lymphocytes (B-EBV) in the blood of acute infectious mononucleosis (IM) patients and higher amounts of transforming EBV particles in the saliva compared to healthy seropositive individuals. B cells grew in cultures seeded with the low and high density IM lymphocytes. The majority of B cells which grew acquired the infection in vitro (2-step outgrowth), because addition of virus neutralizing antibodies considerably reduced the emergence of lymphoblastoid cell lines (LCLs). Only the minority of the explanted B-EBV cells proliferated. The antiviral drug phosphonoformate (PFA) did not influence the frequency of 2-step LCLs in the IM cultures. This may indicate that a large proportion of EBV carrying B cells have already entered the viral productive cycle in vivo and passed the PFA-sensitive stage at the time of explantation. Earlier experiments with blood of healthy seropositive individuals showed an inhibitory effect of PFA on the generation of LCLs. One healthy individual who entered this study as a control, probably had a reactivated EBV infection as judged by the anti-EA activity in his serum and the high level of virus in his saliva. He had antibodies against EBV nuclear antigens (EBNA), and therefore he did not have a primary infection at the time of the test. Judged by the number of wells with B cell growth, the frequency of virus-carrying B cells in his blood was low. It seems that anti-EBV immunity can control the number of infected B cells in the blood, but does not influence the virus load in the epithelial cells.

Detection of an idiotope on a human monoclonal autoantibody by monoclonal anti-idiotypic antibody and its relationship to Epstein-Barr virus-induced autoimmunity.

We have recently described a human IgM monoclonal antibody (mAb), reactive with both self antigens, i.e., cytoskeleton filaments and smooth muscle, and Epstein-Barr virus (EBV)-induced nuclear antigen (EBNA), produced by EBV-transformed B lymphocytes isolated from a patient with infectious mononucleosis (IM). In order to achieve higher antibody secretion in culture supernatant, the mAb-producer cells were fused with ouabain-resistant mouse myeloma cells and a stable human-mouse heterohybrid, coded HY 5488, producing up to 80 micrograms/ml IgM mAb, was isolated after 4 cloning procedures. Purified HY 5844 mAb was used to immunize mice for the production of a murine anti-idiotypic mAb, which was used to probe the expression of the idiotope of HY 5488 mAb (Id 5488) in sera of IM patients and normal controls by ELISA. It was found that Id 5488 is expressed both in IM patients and normal controls, and that Id 5488 expression is significantly higher in IM patients' sera; furthermore, in IM sera a statistically significant correlation between Id 5488 expression and anti-cytoskeleton and anti-smooth muscle autoantibodies was found. It is suggested that at least part of EBV-induced IgM autoantibodies appearing during IM are secreted by B lymphocytes programmed to the production of "natural antibodies" bearing Id 5488-like idiotopes.

Epstein-Barr virus infections and Hodgkin's disease: a study of fixed tissues using the polymerase chain reaction.

Epstein-Barr viral (EBV) infections are associated with Hodgkin's disease (HD). To better characterize this relationship, fixed tissues of infectious mononucleosis, normal and reactive lymph nodes, lymph nodes with progressively transformed germinal centers, and biopsy specimens with the different subtypes of HD were analyzed by polymerase chain reaction (PCR). The presence or absence of EBV, the relative amounts of EBV, and the presence of multiple EBV genotypes as defined by amplification of a polymorphic EBV locus were determined for each specimen. Epstein-Barr virus could be detected from all specimens with infectious mononucleosis (eight of eight cases), generally in relatively large amounts, with multiple EBV genotypes evident in two cases. Epstein-Barr virus could not be detected from normal or reactive lymph nodes (none of 39 cases). Small amounts of EBV could be detected from a minority of cases with progressively transformed germinal centers (two of 16 cases), with multiple EBV genotypes evident in one case. Variable amounts of EBV could be detected from approximately half of the specimens with HD (26 of 50 cases). Epstein-Barr virus was most often detected in the subtypes of mixed cellularity (12 of 15 cases), nodular sclerosis (seven of 14 cases), and lymphocyte depletion (five of seven cases) compared with nodular lymphocyte predominance HD (two of 14 cases). In contrast to specimens with infectious mononucleosis and progressively transformed germinal centers, only one EBV genotype was evident in the specimens with HD. These findings are consistent with the hypothesis that some cases of HD may be directly associated with EBV.

Mononucleosis caused by Epstein-Barr virus and cytomegalovirus in children: a comparative study of 124 cases.

We present 124 children who had mononucleosis. The patients were selected according to strict clinical features. Twenty (16.1%) of the 124 children were proved to have cytomegalovirus mononucleosis and 104 (83.8%) children had Epstein-Barr virus mononucleosis. The symptoms were similar in both groups. Significant differences were found only for the presence of cervical lymphadenopathy, which was more frequent in the Epstein-Barr group (83.2%) compared with the cytomegalovirus group (75%). Fever was the most frequent symptom in both groups. Cytomegalovirus mononucleosis was significantly more frequent in children younger than 4 years.