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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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*[[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]].
! style="background: #4479BA; width: 120px;" | {{fontcolor|#FFF|Disease}}
 
! style="background: #4479BA; width: 550px;" | {{fontcolor|#FFF|Findings}}
*[[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]].
|-
 
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Ebola]]'''
*[[adenovirus|Adenovirus infections]] - commonly characterized by common [[cold]] syndrome, [[pneumonia]], [[croup]] and [[bronchitis]].
| 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.
 
|-
*[[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 [[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>
| 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>
|-
| 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]].
|-
|}


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>
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>

Revision as of 17:41, 14 July 2014

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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.

Different rash-like conditions may be misdiagnosed with mononucleosis, including:[5]

  • 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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

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.


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