Mononucleosis differential diagnosis: Difference between revisions

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==Differentiating Mononucleosis from Other Diseases==
==Differentiating Mononucleosis from Other Diseases==
Other conditions to be differentiated from infectious mononucleosis include:  
The table below summarizes the findings that differentiate [[Mononucleosis]] from other conditions that cause [[fever]], [[fatigue]], [[abdominal pain]] and [[diarrhea]]:<ref>{{cite web | title = WHO Infection Control for Viral Haemorrhagic Fevers in the African Health Care Setting  | url = http://www.who.int/csr/resources/publications/ebola/whoemcesr982sec1-4.pdf }}</ref>


*[[Leukemia]] - [[cancer]] of the [[blood]] or [[bone marrow]] and is characterized by an abnormal proliferation (production by multiplication) of blood [[Cell (biology)|cells]], usually white blood cells ([[leukocytes]]). It is part of the broad group of diseases called [[Hematological malignancy|hematological neoplasms]].
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
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! style="background: #4479BA; width: 120px;" | {{fontcolor|#FFF|Disease}}
! style="background: #4479BA; width: 550px;" | {{fontcolor|#FFF|Findings}}
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| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Ebola]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Presents with [[fever]], [[chills]] [[vomiting]], [[diarrhea]], generalized [[pain]] or [[malaise]], and sometimes [[Internal bleeding|internal]] and external [[bleeding]], that follow an [[incubation period]] of 2-21 days.
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Typhoid fever]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Presents with [[fever]], [[headache]], [[rash]], gastrointestinal symptoms, with [[lymphadenopathy]], relative [[bradycardia]], [[cough]] and [[leucopenia]] and sometimes [[sore throat]]. [[Blood]] and [[stool culture]] can confirm the presence of the causative bacteria.
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''[[Malaria]]'''
| style="padding: 5px 5px; background: #F5F5F5;" |Presents with acute [[fever]], [[headache]] and sometimes [[diarrhea]] (children). A [[blood smear]]s must be examined for malaria parasites. The presence of [[parasites]] does not exclude a concurrent viral infection. An [[antimalarial]] should be prescribed as an [[empiric therapy]].
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Lassa fever]]'''
| style="padding: 5px 5px; background: #F5F5F5;" |Disease onset is usually gradual, with [[fever]], [[sore throat]], [[cough]], [[pharyngitis]], and [[facial edema]] in the later stages. [[Inflammation]] and exudation of the [[pharynx]] and [[conjunctiva]] are common.
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Yellow fever]] and other [[Flaviviridae]] '''
| style="padding: 5px 5px; background: #F5F5F5;" | Present with [[hemorrhage|hemorrhagic]] complications. [[Epidemiological]] investigation may reveal a pattern of disease [[transmission]] by an insect vector. Virus isolation and serological investigation serves to distinguish these [[viruses]]. Confirmed history of previous [[yellow fever]] [[vaccination]] will rule out [[yellow fever]].
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Shigellosis]] & other bacterial enteric infections'''
| style="padding: 5px 5px; background: #F5F5F5;" | Presents with [[diarrhea]], possibly [[Dysentery|bloody]], accompanied by [[fever]], [[nausea]], and sometimes [[toxemia]], [[vomiting]], [[cramps]], and [[tenesmus]]. [[Stool]]s contain [[blood]] and mucous in a typical case. A search for possible sites of bacterial infection, together with cultures and [[blood smear]]s, should be made. Presence of [[leucocytosis]] distinguishes bacterial infections from [[viral infections]].
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Leukemia]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | [[Cancer]] of the [[blood]] or [[bone marrow]] and is characterized by an abnormal proliferation (production by multiplication) of blood [[Cell (biology)|cells]], usually white blood cells ([[leukocytes]]). It is part of the broad group of diseases called [[Hematological malignancy|hematological neoplasms]].
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Tonsillitis]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Tonsillitis is characterized by signs of red, swollen [[tonsils]] which may have a [[exudate|purulent exudative]] coating of white patches (i.e. [[pus]]). In addition, there may be enlarged and tender neck [[cervical lymph nodes]].
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Pharyngitis]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Typically characterized by [[sore throat]], but commonly accompanied by [[fever]], [[headache]], [[joint pain]] and [[muscle aches]], [[skin rashes]], [[swollen lymph nodes]] in the [[neck]], [[diphtheria]] and [[common cold]].
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[adenovirus|Adenovirus infections]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Commonly presents by a [[cold]] syndrome, [[pneumonia]], [[croup]] and [[bronchitis]].
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Influenza]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | [[Symptoms]] of [[influenza]] can start quite suddenly one to two days after [[infection]]. Usually the first [[symptoms]] are [[chills]] or a chilly sensation but [[fever]] is also common early in the [[infection]], with body temperatures as high as 39 °C (approximately 103 °F). Many people are so ill that they are confined to bed for several days, with aches and pains throughout their bodies, which are worst in their backs and legs. Common [[symptoms]] of the [[flu]] such as [[fever]], [[headaches]], and [[fatigue]] come from the huge amounts of proinflammatory [[cytokine]]s and [[chemokine]]s (such as [[interferon]] or [[Tumor necrosis factor-alpha|tumor necrosis factor]]) produced from influenza-infected cells.<ref name="pmid15858027">{{cite journal| author=Schmitz N, Kurrer M, Bachmann MF, Kopf M| title=Interleukin-1 is responsible for acute lung immunopathology but increases survival of respiratory influenza virus infection. | journal=J Virol | year= 2005 | volume= 79 | issue= 10 | pages= 6441-8 | pmid=15858027 | doi=10.1128/JVI.79.10.6441-6448.2005 | pmc=PMC1091664 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15858027  }} </ref> In contrast to the [[rhinovirus]] that causes the [[common cold]], influenza does cause tissue damage, so symptoms are not entirely due to the inflammatory response.<ref>{{cite journal | author = Winther B, Gwaltney J, Mygind N, Hendley J | title = Viral-induced rhinitis. | journal = Am J Rhinol | volume = 12 | issue = 1 | pages = 17–20 | year = | id = PMID 9513654}}</ref>
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| style="padding: 5px 5px; background: #DCDCDC;" | '''Others'''
| style="padding: 5px 5px; background: #F5F5F5;" |[[Leptospirosis]], [[rheumatic fever]], [[typhus]], and [[mononucleosis]] can produce [[signs]] and [[symptoms]] that may be confused with [[Ebola]] in the early stages of [[infection]].
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|}


*[[Tonsillitis]] - tonsillitis is characterized by signs of red, swollen [[tonsils]] which may have a [[exudate|purulent exudative]] coating of white patches (i.e. [[pus]]). In addition, there may be enlarged and tender neck [[cervical lymph nodes]].


*[[Pharyngitis]] - typically characterized by [[sore throat]], but commonly accompanied by [[fever]], [[headache]], [[joint pain]] and [[muscle aches]], [[skin rashes]], [[swollen lymph nodes]] in the [[neck]], [[diphtheria]] and [[common cold]].
The table below summarizes the findings that differentiate the [[rash]] in [[Mononucleosis]] from other conditions, such as:<ref name="MooreSeward2006">{{cite journal|last1=Moore|first1=Zack S|last2=Seward|first2=Jane F|last3=Lane|first3=J Michael|title=Smallpox|journal=The Lancet|volume=367|issue=9508|year=2006|pages=425–435|issn=01406736|doi=10.1016/S0140-6736(06)68143-9}}</ref>
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
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! style="background: #4479BA; width: 120px;" | {{fontcolor|#FFF|Disease}}
! style="background: #4479BA; width: 550px;" | {{fontcolor|#FFF|Findings}}
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| style="padding: 5px 5px; background: #DCDCDC;" | '''[[[[Insect bite]]]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | In an [[insect bite]], the insect injects [[formic acid]], which can cause an immediate [[skin]] reaction often resulting in a [[rash]] and swelling in the injured area, often with formation of [[vesicles]].
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Kawasaki disease]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Commonly presents with high and persistent [[fever]], red [[mucous membranes]] in mouth, "[[strawberry tongue]]", [[swollen lymph nodes]] and [[skin rash]] in early disease, with peeling off of the [[skin]] of the [[hands]], [[feet]] and [[genital area]].
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Measles]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Commonly presents with high [[fever]], [[coryza]] and [[conjunctivitis]], with observation of [[oral mucosa|oral mucosal]] lesions ([[Koplik's spots]]), followed by widespread [[skin rash]].
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Monkeypox]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Presentation is similar to [[smallpox]], although it is often a milder form, with [[fever]], [[headache]], [[myalgia]], [[back pain]], [[swollen lymph nodes]], a general feeling of discomfort, and exhaustion. Within 1 to 3 days (sometimes longer) after the appearance of [[fever]], the patient develops a papular [[rash]], often first on the face. The lesions usually develop through several stages before crusting and falling off.
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Rubella]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Commonly presents with a facial [[rash]] which then spreads to the [[trunk]] and [[limbs]], fading after 3 days, low grade [[fever]], swollen [[glands]], [[joint pain]]s, [[headache]] and [[conjunctivitis]]. The [[rash]] disappears after a few days with no staining or peeling of the [[skin]]. ''[[Forchheimer's sign]]'' occurs in 20% of cases, and is characterized by small, red [[papules]] on the area of the [[soft palate]].
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Atypical [[measles]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Symptoms commonly begin about 7-14 days after infection and present as [[fever]], [[cough]], [[coryza]] and [[conjunctivitis]]. Observation of [[Koplik's spots]] is also a characteristic finding in measles.
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Coxsackievirus]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | The most commonly caused disease is the [[Coxsackie A]] disease, presenting as ''hand, foot and mouth disease''. It may be [[asymptomatic]] or cause mild [[symptoms]], or it may produce [[fever]] and painful [[blisters]] in the mouth ([[herpangina]]), on the palms and fingers of the hand, or on the soles of the feet. There can also be [[blisters]] in the [[throat]]  or above the [[tonsils]]. Adults can also be affected. The [[rash]], which can appear several days after high temperature and painful sore throat, can be itchy and painful, especially on the hands/fingers and bottom of feet.
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Acne]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Typical of teenagers, usually appears on the [[face]] and upper neck, but the [[chest]], [[human back|back]] and [[shoulder]]s may have [[acne]] as well. The upper [[arm]]s can also have [[acne]], but lesions found there are often [[keratosis pilaris]], not [[acne]]. The typical [[acne]] lesions are [[comedones]] and [[inflammatory]] [[papules]], [[pustules]], and [[nodules]]. Some of the large [[nodules]] were previously called "[[cyst]]s"
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Syphilis]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Commonly presents with generalized systemic [[symptoms]] such as [[malaise]], [[fatigue]], [[headache]] and [[fever]]. [[Skin]] eruptions may be subtle and [[asymptomatic]]. It is classically described as 1) non-pruritic bilateral symmetrical mucocutaneous [[rash]]; 2) non-tender regional [[lymphadenopathy]]; 3) condylomata lata; and 4) patchy [[alopecia]].
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Molluscum contagiosum]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Lesions are commonly flesh-colored, dome-shaped, and pearly in appearance. They are often 1-5 millimeters in diameter, with a dimpled center. Generally not painful, but they may itch or become irritated. Picking or scratching the lesions may lead to further [[infection]] or scarring. In about 10% of the cases, [[eczema]] develops around the lesions. They may occasionally be complicated by secondary [[bacterial infections]].
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Mononucleosis]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Common [[symptoms]] include low-grade [[fever]] without [[chills]], [[sore throat]], white patches on [[tonsils]] and back of the throat, [[muscle weakness]] and sometime extreme [[fatigue]], tender [[lymphadenopathy]], [[petechial hemorrhage]] and [[skin rash]].
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Toxic [[erythema]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Common [[rash]] in infants, with clustered and [[vesicular]] appearance.
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Rat-bite fever]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Commonly presents with [[fever]], [[chills]], open sore at the site of the bite and [[rash]], which may show red or purple plaques.
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Parvovirus B19]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | The [[rash]] of fifth disease is typically described as "slapped cheeks," with [[erythema]] across the cheeks and sparing the nasolabial folds, forehead, and mouth.
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Cytomegalovirus]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Common [[symptoms]] include [[sore throat]], swollen [[lymph nodes]], [[fever]], [[headache]], [[fatigue]], [[weakness]], [[muscle pain]]  and [[loss of appetite]].
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Scarlet fever]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Commonly includes [[fever]], punctate red [[macules]] on the hard and soft [[palate]] and [[uvula]] ([[Forchheimer's spots]]), bright red [[tongue]] with a "strawberry" appearance, [[sore throat]] and [[headache]] and [[lymphadenopathy]].
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Rocky Mountain spotted fever]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | [[Symptoms]] may include [[maculopapular rash]], [[petechial rash]], [[abdominal pain]] and [[joint pain]].
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Stevens-Johnson syndrome]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | [[Symptoms]] may include [[fever]], [[sore throat]]  and [[fatigue]]. Commonly presents [[ulcers]] and other lesions in the [[mucous membranes]], almost always in the [[mouth]] and lips but also in the genital and anal regions. Those in the mouth are usually extremely painful and reduce the patient's ability to eat or drink. [[Conjunctivitis]] of the eyes occurs in about 30% of children. A [[rash]] of round lesions about an inch across, may arise on the face, trunk, arms and legs, and soles of the feet, but usually not on the scalp.
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Varicella-zoster virus]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Commonly starts as a painful [[rash]] on one side of the face or body. The [[rash]] forms blisters that typically scab over in 7-10 days and clears up within 2-4 weeks.
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Chickenpox]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Commonly starts with [[conjunctival]] and catarrhal [[symptoms]] and then characteristic spots appearing in two or three waves, mainly on the body and head, rather than the hands, becoming itchy raw pox (small open sores which heal mostly without scarring). Touching the fluid from a [[chickenpox]] blister can also spread the disease.
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Meningococcemia]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Commonly presents with [[rash]], [[petechiae]], [[headache]], [[confusion]], and [[stiff neck]], high [[fever]], mental status changes, [[nausea]] and [[vomiting]].
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Rickettsialpox]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | First [[symptom]] is commonly a bump formed by a mite-bite, eventually resulting in a black, crusty scab. Many of the [[symptoms]] are [[flu]]-like including [[fever]], [[chills]], [[weakness]] and [[muscle pain]] but the most distinctive [[symptom]] is the [[rash]] that breaks out, spanning the person's entire body.
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Meningitis]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Commonly presents with [[headache]], [[nuchal rigidity]], [[fever]], [[petechiae]] and [[altered mental status]].
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Impetigo]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Commonly presents with pimple-like lesions surrounded by [[erythematous]] [[skin]]. Lesions are [[pustules]], filled with [[pus]], which then break down over 4-6 days and form a thick crust. It's often associated with insect bites, cuts, and other forms of [[trauma]] to the [[skin]].
|-
|}


*[[adenovirus|Adenovirus infections]]
====Pharyngitis vs EBV====
*[[EBV|EBV infection]] may cause either exudative or non-exudative pharyngitis and both of which is colonized by [[streptococcus pyogens]] present in the oropharynx


*[[Influenza]]
*[[Petechiae|Petechial hemorrhages]] present in the posterior oropharynx are characteristic of infectious mononucleosis
 
Different [[rash]]-like conditions may be misdiagnosed with [[mononucleosis]], including:<ref name="MooreSeward2006">{{cite journal|last1=Moore|first1=Zack S|last2=Seward|first2=Jane F|last3=Lane|first3=J Michael|title=Smallpox|journal=The Lancet|volume=367|issue=9508|year=2006|pages=425–435|issn=01406736|doi=10.1016/S0140-6736(06)68143-9}}</ref>
*[[Insect bite]]s - In an [[insect bite]], the insect injects [[formic acid]], which can cause an immediate [[skin]] reaction often resulting in a [[rash]] and swelling in the injured area, often with formation of [[vesicles]].
 
*[[Kawasaki disease]] - commonly presents with high and persistent [[fever]], red [[mucous membranes]] in mouth, "[[strawberry tongue]]", [[swollen lymph nodes]] and [[skin rash]] in early disease, with peeling off of the [[skin]] of the [[hands]], [[feet]] and [[genital area]].
 
*[[Measles]] - commonly presents with high [[fever]], [[coryza]] and [[conjunctivitis]], with observation of [[oral mucosa|oral mucosal]] lesions ([[Koplik's spots]]), followed by widespread [[skin rash]].
 
*[[Monkeypox]] - presentation is similar to [[smallpox]], although it is often a milder form, with [[fever]], [[headache]], [[myalgia]], [[back pain]], [[swollen lymph nodes]], a general feeling of discomfort, and exhaustion. Within 1 to 3 days (sometimes longer) after the appearance of [[fever]], the patient develops a papular [[rash]], often first on the face. The lesions usually develop through several stages before crusting and falling off.
 
*[[Rubella]] - commonly presents with a facial [[rash]] which then spreads to the [[trunk]] and [[limbs]], fading after 3 days, low grade [[fever]], swollen [[glands]], [[joint pain]]s, [[headache]] and [[conjunctivitis]]. The [[rash]] disappears after a few days with no staining or peeling of the [[skin]]. ''[[Forchheimer's sign]]'' occurs in 20% of cases, and is characterized by small, red [[papules]] on the area of the [[soft palate]].
 
*Atypical [[measles]] - symptoms commonly begin about 7-14 days after infection and present as [[fever]], [[cough]], [[coryza]] and [[conjunctivitis]]. Observation of [[Koplik's spots]] is also a characteristic finding in measles.
 
*[[Coxsackievirus]] - the most commonly caused disease is the [[Coxsackie A]] disease, presenting as ''hand, foot and mouth disease''. It may be [[asymptomatic]] or cause mild [[symptoms]], or it may produce [[fever]] and painful [[blisters]] in the mouth ([[herpangina]]), on the palms and fingers of the hand, or on the soles of the feet. There can also be [[blisters]] in the [[throat]]  or above the [[tonsils]]. Adults can also be affected. The [[rash]], which can appear several days after high temperature and painful sore throat, can be itchy and painful, especially on the hands/fingers and bottom of feet.
 
*[[Acne]] - typical of teenagers, usually appears on the [[face]] and upper neck, but the [[chest]], [[human back|back]] and [[shoulder]]s may have [[acne]] as well. The upper [[arm]]s can also have [[acne]], but lesions found there are often [[keratosis pilaris]], not [[acne]]. The typical [[acne]] lesions are [[comedones]] and [[inflammatory]] [[papules]], [[pustules]], and [[nodules]]. Some of the large [[nodules]] were previously called "[[cyst]]s"
 
*[[Syphilis]] - commonly presents with gneralized systemic [[symptoms]] such as [[malaise]], [[fatigue]], [[headache]] and [[fever]]. [[Skin]] eruptions may be subtle and [[asymptomatic]] Classically described as 1) non-pruritic bilateral symmetrical mucocutaneous [[rash]]; 2) non-tender regional [[lymphadenopathy]]; 3) condylomata lata; and 4) patchy [[alopecia]].
 
*[[Molluscum contagiosum]] -  lesions are commonly flesh-colored, dome-shaped, and pearly in appearance. They are often 1-5 millimeters in diameter, with a dimpled center. Generally not painful, but they may itch or become irritated. Picking or scratching the lesions may lead to further [[infection]] or scarring. In about 10% of the cases, [[eczema]] develops around the lesions. They may occasionally be complicated by secondary [[bacterial infections]].
 
*[[Mononucleosis]] - Common [[symptoms]] include low-grade [[fever]] without [[chills]], [[sore throat]], white patches on [[tonsils]] and back of the throat, [[muscle weakness]] and sometime extreme [[fatigue]], tender [[lymphadenopathy]], [[petechial hemorrhage]] and [[skin rash]].
 
*Toxic [[erythema]] - common [[rash]] in infants, with clustered and [[vesicular]] appearance.
 
*[[Rat-bite fever]] - commonly presents with [[fever]], [[chills]], open sore at the site of the bite and [[rash]], which may show red or purple plaques.
 
*[[Parvovirus B19]] - the [[rash]] of fifth disease is typically described as "slapped cheeks," with [[erythema]] across the cheeks and sparing the nasolabial folds, forehead, and mouth.
 
*[[Cytomegalovirus]] - common [[symptoms]] include [[sore throat]], swollen [[lymph nodes]], [[fever]], [[headache]], [[fatigue]], [[weakness]], [[muscle pain]]  and [[loss of appetite]].
 
*[[Scarlet fever]] - commonly includes [[fever]], punctate red [[macules]] on the hard and soft [[palate]] and [[uvula]] ([[Forchheimer's spots]]), bright red [[tongue]] with a "strawberry" appearance, [[sore throat]] and [[headache]] and [[lymphadenopathy]].
 
*[[Rocky Mountain spotted fever]] - [[symptoms]] may include [[maculopapular rash]], [[petechial rash]], [[abdominal pain]] and [[joint pain]].
 
*[[Stevens-Johnson syndrome]] - [[symptoms]] may include [[fever]], [[sore throat]]  and [[fatigue]]. Commonly presents [[ulcers]] and other lesions in the [[mucous membranes]], almost always in the [[mouth]] and lips but also in the genital and anal regions. Those in the mouth are usually extremely painful and reduce the patient's ability to eat or drink. [[Conjunctivitis]] of the eyes occurs in about 30% of children. A [[rash]] of round lesions about an inch across, may arise on the face, trunk, arms and legs, and soles of the feet, but usually not on the scalp.
 
*[[Varicella-zoster virus]] - commonly starts as a painful [[rash]] on one side of the face or body. The [[rash]] forms blisters that typically scab over in 7-10 days and clears up within 2-4 weeks.


*[[Chickenpox]] - commonly starts with [[conjunctival]] and catarrhal [[symptoms]] and then characteristic spots appearing in two or three waves, mainly on the body and head, rather than the hands, becoming itchy raw pox (small open sores which heal mostly without scarring). Touching the fluid from a [[chickenpox]] blister can also spread the disease.
*[[Edema|Edema of the uvula]] is rare but if present differentiates mononucleosis from all other types of pharyngitis


*[[Meningococcemia]] - commonly presents with [[rash]], [[petechiae]], [[headache]], [[confusion]], and [[stiff neck]], high [[fever]], mental status changes, [[nausea]] and [[vomiting]].
Infectious mononucleosis should be differentiated from other diseases that cause [[runny nose]], [[cough]], and constitutional symptoms.


*[[Rickettsialpox]] - first [[symptom]] is commonly a bump formed by a mite-bite, eventually resulting in a black, crusty scab. Many of the [[symptoms]] are [[flu]]-like including [[fever]], [[chills]], [[weakness]] and [[muscle pain]] but the most distinctive [[symptom]] is the [[rash]] that breaks out, spanning the person's entire body.
{| style="border: 0px; font-size: 85%; margin: 7px; width:1000px;" align="center"


*[[Meningitis]] - commonly presents with [[headache]], [[nuchal rigidity]], [[fever]], [[petechiae]] and [[altered mental status]].
|+
 
! style="background: #4479BA; color:#FFF;  width: 150px;" | Disease
*[[Impetigo]] - commonly presents with pimple-like lesions surrounded by [[erythematous]] [[skin]]. Lesions are [[pustules]], filled with [[pus]], which then break down over 4-6 days and form a thick crust. It's often associated with insect bites, cuts, and other forms of [[trauma]] to the [[skin]].
! style="background: #4479BA; color:#FFF;  width: 200px;" | History
 
! style="background: #4479BA; color:#FFF;  width: 200px;" | Physical examination
====Pharyngitis vs EBV====
! style="background: #4479BA; color:#FFF;  width: 200px;" | Laboratory or radiological findings
*[[EBV|EBV infection]] may cause either exudative or non-exudative pharyngitis and both of which is colonized by [[streptococcus pyogens]] present in the oropharynx
|-
 
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |  Acute viral nasopharyngitis<ref name="pmid12517470">{{cite journal |vauthors=Heikkinen T, Järvinen A |title=The common cold |journal=Lancet |volume=361 |issue=9351 |pages=51–9 |year=2003 |pmid=12517470 |doi=10.1016/S0140-6736(03)12162-9 |url=}}</ref>
*[[Petechiae|Petechial hemorrhages]] present in the posterior oropharynx are characteristic of infectious mononucleosis
| style="padding: 5px 5px; background: #F5F5F5;" |
 
* Symptoms start with [[sore throat]], [[nasal congestion]], and [[runny nose]].
*[[Edema|Edema of the uvula]] is rare but if present differentiates mononucleosis from all other types of pharyngitis 
* [[Cough]] that may persist after resolution of the other symptoms.
* [[Fever]] is not common.
| style="padding: 5px 5px; background: #F5F5F5;" |
* [[Nasal mucosa]] is [[congested]] and [[Hyperaemia|hyperemic]].
* [[Pharynx]] is typically normal.
| style="padding: 5px 5px; background: #F5F5F5;" |
* Diagnosis is usually clinical; lab tests are rarely needed.
* The virus can be [[Culture medium|cultured]] on human lung cells, but it takes time.
* [[PCR]] is rapid and accurate, but is done only when the infecting [[virus]] strain in [[immunocompromised]] patients needs to be known.
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |  [[Allergic rhinitis]]<ref name="pmid20232579">{{cite journal |vauthors=Pawankar R, Bunnag C, Chen Y, Fukuda T, Kim YY, Le LT, Huong le TT, O'Hehir RE, Ohta K, Vichyanond P, Wang DY, Zhong N, Khaltaev N, Bousquet J |title=Allergic rhinitis and its impact on asthma update (ARIA 2008)--western and Asian-Pacific perspective |journal=Asian Pac. J. Allergy Immunol. |volume=27 |issue=4 |pages=237–43 |year=2009 |pmid=20232579 |doi= |url=}}</ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
* Characterized by repeated paroxysms of [[rhinorrhea]], [[sneezing]], and [[cough]].
* Symptoms may be related to a specific season of the year, hence the name “seasonal [[allergies]].”
| style="padding: 5px 5px; background: #F5F5F5;" |
* [[Rhinorrhea]] discharge is usually clear and watery.
* Examination of the nose reveals a crease below the [[nasal bridge]], formed from repeated pulling of the nose secondary to [[irritation]].
* [[Edema]] in the area below the eye, if associated [[conjunctivitis]] is present.<ref name="pmid11449200">{{cite journal |vauthors=Skoner DP |title=Allergic rhinitis: definition, epidemiology, pathophysiology, detection, and diagnosis |journal=J. Allergy Clin. Immunol. |volume=108 |issue=1 Suppl |pages=S2–8 |year=2001 |pmid=11449200 |doi= |url=}}</ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
* Skin testing using intradermal skin prick tests to determine the specific [[allergens]] causing [[allergic rhinitis]].
* Serum immune assays to determine [[IgE|IgE levels]] in the [[serum]].
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |  [[Acute sinusitis]]<ref name="pmid9347786">{{cite journal |vauthors=Low DE, Desrosiers M, McSherry J, Garber G, Williams JW, Remy H, Fenton RS, Forte V, Balter M, Rotstein C, Craft C, Dubois J, Harding G, Schloss M, Miller M, McIvor RA, Davidson RJ |title=A practical guide for the diagnosis and treatment of acute sinusitis |journal=CMAJ |volume=156 Suppl 6 |issue= |pages=S1–14 |year=1997 |pmid=9347786 |doi= |url=}}</ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
* Presents with symptoms similar to [[URTI|URTIs]] ([[sneezing]], [[cough]], and [[runny nose]]).
* Symptoms last for a longer time (about 10 days), with a peak between the 4th and 6th days.
* Usually, [[acute sinusitis]] is not associated with [[fever]].<ref name="pmid7242607">{{cite journal |vauthors= |title=Acute maxillary sinusitis |journal=N. Engl. J. Med. |volume=305 |issue=4 |pages=226–7 |year=1981 |pmid=7242607 |doi=10.1056/NEJM198107233050419 |url=}}</ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
* Inspection may show [[erythema]] and [[edema]] over the involved [[sinus]].
* Palpation of [[sinuses]] shows [[tenderness]].
* [[Transillumination]] of the [[sinuses]] may show opacity.
| style="padding: 5px 5px; background: #F5F5F5;" |
* [[X ray|X-ray]] and [[CT]] may show air fluid level or bubbles in the affected [[sinuses]].
* [[Culture medium|Culture]] of the nasal secretions is of limited use in [[acute sinusitis]], as may be contaminated by [[Flora|nasal flora]].
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" | [[Infectious mononucleosis]]<ref name="pmid4864269">{{cite journal |vauthors=Niederman JC, McCollum RW, Henle G, Henle W |title=Infectious mononucleosis. Clinical manifestations in relation to EB virus antibodies |journal=JAMA |volume=203 |issue=3 |pages=205–9 |year=1968 |pmid=4864269 |doi= |url=}}</ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
* Symptoms are like the symptoms of [[pharyngitis]], which include:
** [[Sore throat]] and [[Dysphagia|difficulty swallowing]]
** [[Fever]]
** [[Fatigue]]
** [[Lymphadenopathy]] (especially in the posterior cervical region)
| style="padding: 5px 5px; background: #F5F5F5;" |
* Abdominal examination reveals [[splenomegaly]].
* [[Maculopapular rash]] may be present.
| style="padding: 5px 5px; background: #F5F5F5;" |
* Positive monospot test.
* Elevated [[liver enzymes]].
|}


====Cytomegalovirus vs EBV====
====Cytomegalovirus vs EBV====
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[[Category:Disease]]
[[Category:Disease]]
[[Category:Infectious disease]]
 
[[Category:Pediatrics]]
[[Category:Pediatrics]]
[[Category:Medicine]]
[[Category:Medicine]]

Latest revision as of 18:06, 18 September 2017

Mononucleosis Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2]

Overview

Acute mononucleosis, acute cytomegalovirus infection and toxoplasma gondii infection have similar clinical presentations. In addition, since their management is much the same, it is not always helpful, or possible, to distinguish between infectious mononucleosis and cytomegalovirus infection. However, in pregnant women, it is imperative to differentiate mononucleosis from toxoplasmosis as toxo is associated with significant consequences in the fetus. Acute HIV infection can also mimic signs similar to those of infectious mononucleosis, and tests should be performed in pregnant women for the same reason as toxoplasmosis.[1]

Differentiating Mononucleosis from Other Diseases

The table below summarizes the findings that differentiate Mononucleosis from other conditions that cause fever, fatigue, abdominal pain and diarrhea:[2]

Disease Findings
Ebola Presents with fever, chills vomiting, diarrhea, generalized pain or malaise, and sometimes internal and external bleeding, that follow an incubation period of 2-21 days.
Typhoid fever Presents with fever, headache, rash, gastrointestinal symptoms, with lymphadenopathy, relative bradycardia, cough and leucopenia and sometimes sore throat. Blood and stool culture can confirm the presence of the causative bacteria.
Malaria Presents with acute fever, headache and sometimes diarrhea (children). A blood smears must be examined for malaria parasites. The presence of parasites does not exclude a concurrent viral infection. An antimalarial should be prescribed as an empiric therapy.
Lassa fever Disease onset is usually gradual, with fever, sore throat, cough, pharyngitis, and facial edema in the later stages. Inflammation and exudation of the pharynx and conjunctiva are common.
Yellow fever and other Flaviviridae Present with hemorrhagic complications. Epidemiological investigation may reveal a pattern of disease transmission by an insect vector. Virus isolation and serological investigation serves to distinguish these viruses. Confirmed history of previous yellow fever vaccination will rule out yellow fever.
Shigellosis & other bacterial enteric infections Presents with diarrhea, possibly bloody, accompanied by fever, nausea, and sometimes toxemia, vomiting, cramps, and tenesmus. Stools contain blood and mucous in a typical case. A search for possible sites of bacterial infection, together with cultures and blood smears, should be made. Presence of leucocytosis distinguishes bacterial infections from viral infections.
Leukemia Cancer of the blood or bone marrow and is characterized by an abnormal proliferation (production by multiplication) of blood cells, usually white blood cells (leukocytes). It is part of the broad group of diseases called hematological neoplasms.
Tonsillitis Tonsillitis is characterized by signs of red, swollen tonsils which may have a purulent exudative coating of white patches (i.e. pus). In addition, there may be enlarged and tender neck cervical lymph nodes.
Pharyngitis Typically characterized by sore throat, but commonly accompanied by fever, headache, joint pain and muscle aches, skin rashes, swollen lymph nodes in the neck, diphtheria and common cold.
Adenovirus infections Commonly presents by a cold syndrome, pneumonia, croup and bronchitis.
Influenza Symptoms of influenza can start quite suddenly one to two days after infection. Usually the first symptoms are chills or a chilly sensation but fever is also common early in the infection, with body temperatures as high as 39 °C (approximately 103 °F). Many people are so ill that they are confined to bed for several days, with aches and pains throughout their bodies, which are worst in their backs and legs. Common symptoms of the flu such as fever, headaches, and fatigue come from the huge amounts of proinflammatory cytokines and chemokines (such as interferon or tumor necrosis factor) produced from influenza-infected cells.[3] In contrast to the rhinovirus that causes the common cold, influenza does cause tissue damage, so symptoms are not entirely due to the inflammatory response.[4]
Others Leptospirosis, rheumatic fever, typhus, and mononucleosis can produce signs and symptoms that may be confused with Ebola in the early stages of infection.


The table below summarizes the findings that differentiate the rash in Mononucleosis from other conditions, such as:[5]

Disease Findings
[[Insect bite]] In an insect bite, the insect injects formic acid, which can cause an immediate skin reaction often resulting in a rash and swelling in the injured area, often with formation of vesicles.
Kawasaki disease Commonly presents with high and persistent fever, red mucous membranes in mouth, "strawberry tongue", swollen lymph nodes and skin rash in early disease, with peeling off of the skin of the hands, feet and genital area.
Measles Commonly presents with high fever, coryza and conjunctivitis, with observation of oral mucosal lesions (Koplik's spots), followed by widespread skin rash.
Monkeypox Presentation is similar to smallpox, although it is often a milder form, with fever, headache, myalgia, back pain, swollen lymph nodes, a general feeling of discomfort, and exhaustion. Within 1 to 3 days (sometimes longer) after the appearance of fever, the patient develops a papular rash, often first on the face. The lesions usually develop through several stages before crusting and falling off.
Rubella Commonly presents with a facial rash which then spreads to the trunk and limbs, fading after 3 days, low grade fever, swollen glands, joint pains, headache and conjunctivitis. The rash disappears after a few days with no staining or peeling of the skin. Forchheimer's sign occurs in 20% of cases, and is characterized by small, red papules on the area of the soft palate.
Atypical measles Symptoms commonly begin about 7-14 days after infection and present as fever, cough, coryza and conjunctivitis. Observation of Koplik's spots is also a characteristic finding in measles.
Coxsackievirus The most commonly caused disease is the Coxsackie A disease, presenting as hand, foot and mouth disease. It may be asymptomatic or cause mild symptoms, or it may produce fever and painful blisters in the mouth (herpangina), on the palms and fingers of the hand, or on the soles of the feet. There can also be blisters in the throat or above the tonsils. Adults can also be affected. The rash, which can appear several days after high temperature and painful sore throat, can be itchy and painful, especially on the hands/fingers and bottom of feet.
Acne Typical of teenagers, usually appears on the face and upper neck, but the chest, back and shoulders may have acne as well. The upper arms can also have acne, but lesions found there are often keratosis pilaris, not acne. The typical acne lesions are comedones and inflammatory papules, pustules, and nodules. Some of the large nodules were previously called "cysts"
Syphilis Commonly presents with generalized systemic symptoms such as malaise, fatigue, headache and fever. Skin eruptions may be subtle and asymptomatic. It is classically described as 1) non-pruritic bilateral symmetrical mucocutaneous rash; 2) non-tender regional lymphadenopathy; 3) condylomata lata; and 4) patchy alopecia.
Molluscum contagiosum Lesions are commonly flesh-colored, dome-shaped, and pearly in appearance. They are often 1-5 millimeters in diameter, with a dimpled center. Generally not painful, but they may itch or become irritated. Picking or scratching the lesions may lead to further infection or scarring. In about 10% of the cases, eczema develops around the lesions. They may occasionally be complicated by secondary bacterial infections.
Mononucleosis Common symptoms include low-grade fever without chills, sore throat, white patches on tonsils and back of the throat, muscle weakness and sometime extreme fatigue, tender lymphadenopathy, petechial hemorrhage and skin rash.
Toxic erythema Common rash in infants, with clustered and vesicular appearance.
Rat-bite fever Commonly presents with fever, chills, open sore at the site of the bite and rash, which may show red or purple plaques.
Parvovirus B19 The rash of fifth disease is typically described as "slapped cheeks," with erythema across the cheeks and sparing the nasolabial folds, forehead, and mouth.
Cytomegalovirus Common symptoms include sore throat, swollen lymph nodes, fever, headache, fatigue, weakness, muscle pain and loss of appetite.
Scarlet fever Commonly includes fever, punctate red macules on the hard and soft palate and uvula (Forchheimer's spots), bright red tongue with a "strawberry" appearance, sore throat and headache and lymphadenopathy.
Rocky Mountain spotted fever Symptoms may include maculopapular rash, petechial rash, abdominal pain and joint pain.
Stevens-Johnson syndrome Symptoms may include fever, sore throat and fatigue. Commonly presents ulcers and other lesions in the mucous membranes, almost always in the mouth and lips but also in the genital and anal regions. Those in the mouth are usually extremely painful and reduce the patient's ability to eat or drink. Conjunctivitis of the eyes occurs in about 30% of children. A rash of round lesions about an inch across, may arise on the face, trunk, arms and legs, and soles of the feet, but usually not on the scalp.
Varicella-zoster virus Commonly starts as a painful rash on one side of the face or body. The rash forms blisters that typically scab over in 7-10 days and clears up within 2-4 weeks.
Chickenpox Commonly starts with conjunctival and catarrhal symptoms and then characteristic spots appearing in two or three waves, mainly on the body and head, rather than the hands, becoming itchy raw pox (small open sores which heal mostly without scarring). Touching the fluid from a chickenpox blister can also spread the disease.
Meningococcemia Commonly presents with rash, petechiae, headache, confusion, and stiff neck, high fever, mental status changes, nausea and vomiting.
Rickettsialpox First symptom is commonly a bump formed by a mite-bite, eventually resulting in a black, crusty scab. Many of the symptoms are flu-like including fever, chills, weakness and muscle pain but the most distinctive symptom is the rash that breaks out, spanning the person's entire body.
Meningitis Commonly presents with headache, nuchal rigidity, fever, petechiae and altered mental status.
Impetigo Commonly presents with pimple-like lesions surrounded by erythematous skin. Lesions are pustules, filled with pus, which then break down over 4-6 days and form a thick crust. It's often associated with insect bites, cuts, and other forms of trauma to the skin.

Pharyngitis vs EBV

  • Edema of the uvula is rare but if present differentiates mononucleosis from all other types of pharyngitis

Infectious mononucleosis should be differentiated from other diseases that cause runny nose, cough, and constitutional symptoms.

Disease History Physical examination Laboratory or radiological findings
Acute viral nasopharyngitis[6]
  • Diagnosis is usually clinical; lab tests are rarely needed.
  • The virus can be cultured on human lung cells, but it takes time.
  • PCR is rapid and accurate, but is done only when the infecting virus strain in immunocompromised patients needs to be known.
Allergic rhinitis[7]
  • Characterized by repeated paroxysms of rhinorrhea, sneezing, and cough.
  • Symptoms may be related to a specific season of the year, hence the name “seasonal allergies.”
Acute sinusitis[9]
Infectious mononucleosis[11]

Cytomegalovirus vs EBV

  • Although, due to the presence of the atypical lymphocytes on the blood smear in both conditions, some physicians confusingly used to include both infections under the diagnosis of "mononucleosis," though EBV is by definition the infection that must be present for this illness.

Toxoplasmosis vs EBV

  • In pregnant women, it is imperative to differentiate mononucleosis from toxoplasmosis as toxo is associated with significant consequences in the fetus.

Viral Hepatitis vs EBV

  • Liver function tests may show a moderate elevation of liver enzyme levels in nearly 90% of patients infected with mononucleosis. On the contrary, there is a significant increase in enzyme levels observed in patients with viral hepatitis.

References

  1. Ebell MH (2004). "Epstein-Barr virus infectious mononucleosis". American Family Physician. 70 (7): 1279–87. PMID 15508538. Retrieved 2012-02-23. Unknown parameter |month= ignored (help)
  2. "WHO Infection Control for Viral Haemorrhagic Fevers in the African Health Care Setting" (PDF).
  3. Schmitz N, Kurrer M, Bachmann MF, Kopf M (2005). "Interleukin-1 is responsible for acute lung immunopathology but increases survival of respiratory influenza virus infection". J Virol. 79 (10): 6441–8. doi:10.1128/JVI.79.10.6441-6448.2005. PMC 1091664. PMID 15858027.
  4. Winther B, Gwaltney J, Mygind N, Hendley J. "Viral-induced rhinitis". Am J Rhinol. 12 (1): 17–20. PMID 9513654.
  5. Moore, Zack S; Seward, Jane F; Lane, J Michael (2006). "Smallpox". The Lancet. 367 (9508): 425–435. doi:10.1016/S0140-6736(06)68143-9. ISSN 0140-6736.
  6. Heikkinen T, Järvinen A (2003). "The common cold". Lancet. 361 (9351): 51–9. doi:10.1016/S0140-6736(03)12162-9. PMID 12517470.
  7. Pawankar R, Bunnag C, Chen Y, Fukuda T, Kim YY, Le LT, Huong le TT, O'Hehir RE, Ohta K, Vichyanond P, Wang DY, Zhong N, Khaltaev N, Bousquet J (2009). "Allergic rhinitis and its impact on asthma update (ARIA 2008)--western and Asian-Pacific perspective". Asian Pac. J. Allergy Immunol. 27 (4): 237–43. PMID 20232579.
  8. Skoner DP (2001). "Allergic rhinitis: definition, epidemiology, pathophysiology, detection, and diagnosis". J. Allergy Clin. Immunol. 108 (1 Suppl): S2–8. PMID 11449200.
  9. Low DE, Desrosiers M, McSherry J, Garber G, Williams JW, Remy H, Fenton RS, Forte V, Balter M, Rotstein C, Craft C, Dubois J, Harding G, Schloss M, Miller M, McIvor RA, Davidson RJ (1997). "A practical guide for the diagnosis and treatment of acute sinusitis". CMAJ. 156 Suppl 6: S1–14. PMID 9347786.
  10. "Acute maxillary sinusitis". N. Engl. J. Med. 305 (4): 226–7. 1981. doi:10.1056/NEJM198107233050419. PMID 7242607.
  11. Niederman JC, McCollum RW, Henle G, Henle W (1968). "Infectious mononucleosis. Clinical manifestations in relation to EB virus antibodies". JAMA. 203 (3): 205–9. PMID 4864269.


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