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COMMENTARY
Year : 2017  |  Volume : 10  |  Issue : 5  |  Page : 445-446  

Is infectious mononucleosis a pediatric disease?


Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis, USA

Date of Web Publication14-Nov-2017

Correspondence Address:
Jennifer Grimm
Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Mississippi National River and Recreation Area, 420 Delaware St SE, Minneapolis, MN 55455
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/MJDRDYPU.MJDRDYPU_66_17

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How to cite this article:
Grimm J. Is infectious mononucleosis a pediatric disease?. Med J DY Patil Univ 2017;10:445-6

How to cite this URL:
Grimm J. Is infectious mononucleosis a pediatric disease?. Med J DY Patil Univ [serial online] 2017 [cited 2019 May 19];10:445-6. Available from: http://www.mjdrdypu.org/text.asp?2017/10/5/445/218200



Primary Epstein–Barr virus (EBV) infection was first recognized as a major cause of infectious mononucleosis in 1967 and has since been established as a common illness among adolescents and young adults.[1] Indeed, though varying by age of acquisition geographically, its classical triad of sore throat, fatigue, and cervical lymphadenopathy are telltale signs of the “kissing disease” in clinical settings.[2] However, the majority of primary EBV infections in preadolescent children go undiagnosed. In addition, little is known about the route of transmission in children, making suspicion of mono difficult to perceive.[3]

Few studies have addressed the presentation of infectious mononucleosis in early childhood; however, this article presents a multicenter look-back of children between the ages of 1 month and 12 years diagnosed with infectious mononucleosis in Kolkata, India. This study presents valuable information about the clinical manifestations of primary EBV infection in young children, as most studies to date have focused on disease in adolescents and young adults.

Using case records of children admitted over a 1-year period to three Kolkata teaching hospitals, the authors identified 53 children positive for antibodies against EBV viral capsid antigen (VCA) IgM, indicating recent primary infection. The most interesting finding is that the most common presentations in children included fever, splenomegaly, and cervical lymphadenopathy. As compared to studies in adolescents and young adults, signs and symptoms in children are different. In a prospective study conducted in the United States that followed university-aged students, the most common manifestations of infectious mononucleosis were sore throat (93%), cervical lymphadenopathy (76%), and fatigue (66%). Fever and general abdominal pain were experienced less frequently, in 47% and 8%, respectively.[4] In the study conducted by Grotto et al., which was used as a measure of comparison by the authors, this same phenomenon was also observed.[5] Therefore, there is striking evidence that the clinical manifestations vary by age.

In addition, the authors' laboratory findings were also remarkable. They found lymphocytosis to be present in, on average, 26% of children. However, young adults experience severe lymphocytosis, which is a hallmark of primary infection.[6] The authors also reported elevated alanine aminotransferase (ALT) levels in 28.3% of children, which is much lower than in symptomatic university-aged individuals, of whom 100% experienced elevated ALT levels indicating more derangements of liver function in older individuals.[7]

While the findings in this report are unique, there are a number of limitations. The authors make the comparison of their data with studies that include adolescents. All of these other studies report sore throat as a common symptom, which may be attributed to this increased age range. However, the authors followed hospitalized children, so signs and symptoms may not be representative of the general population or comparable to these other studies.

In addition, although VCA IgM is useful as a diagnostic marker of recent primary EBV infections in young adults, the diagnostic tests are fraught with cross-reactivity. Moreover, VCA IgM responses in children are not well documented. In fact, it is difficult to make the comparisons between the kinetics of antibodies in children and adolescents, as many young children do not produce heterophile antibodies, a nonspecific indicator of acute EBV infection, which indicates differences in immune responses between young children and adolescents.[8]

Nevertheless, these results provide an excellent step for a larger study to be conducted and have shown us that primary EBV infection is a true pediatric disease that may be easily overlooked, as signs and symptoms are not consistent with “classic mono” as we have thought previously. Furthermore, this study highlights the need for a prophylactic vaccine in children, which is currently in development.



 
  References Top

1.
Balfour HH Jr., Dunmire SK, Hogquist KA. Infectious mononucleosis. Clin Transl Immunology 2015;4:e33.  Back to cited text no. 1
    
2.
Dunmire SK, Hogquist KA, Balfour HH. Infectious mononucleosis. Curr Top Microbiol Immunol 2015;390(Pt 1):211-40.  Back to cited text no. 2
    
3.
Sumaya CV, Ench Y. Epstein-Barr virus infectious mononucleosis in children. I. Clinical and general laboratory findings. Pediatrics 1985;75:1003-10.  Back to cited text no. 3
    
4.
Balfour HH Jr., Odumade OA, Schmeling DO, Mullan BD, Ed JA, Knight JA, et al. Behavioral, virologic, and immunologic factors associated with acquisition and severity of primary Epstein-Barr virus infection in university students. J Infect Dis 2013;207:80-8.  Back to cited text no. 4
    
5.
Grotto I, Mimouni D, Huerta M, Mimouni M, Cohen D, Robin G, et al. Clinical and laboratory presentation of EBV positive infectious mononucleosis in young adults. Epidemiol Infect 2003;131:683-9.  Back to cited text no. 5
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6.
Dunmire SK, Grimm JM, Schmeling DO, Balfour HH Jr., Hogquist KA. The incubation period of primary Epstein-Barr virus infection: Viral dynamics and immunologic events. PLoS Pathog 2015;11:e1005286.  Back to cited text no. 6
    
7.
Grimm JM, Schmeling DO, Dunmire SK, Knight JA, Mullan BD, Ed JA, et al. Prospective studies of infectious mononucleosis in university students. Clin Transl Immunology 2016;5:e94.  Back to cited text no. 7
[PUBMED]    
8.
Schaller RJ, Counselman FL. Infectious mononucleosis in young children. Am J Emerg Med 1995;13:438-40.  Back to cited text no. 8
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