Thursday, July 15, 1999

Pathophysiology week 3

I'm Just Tired
You have to love the our immune system. “ You must remember this. A kiss is not just a kiss..., ” is a partial lyrics in a song sung in the classic movie “Casablanca”. The above lyrics is a clue how infectious mononucleosis can be spread. Unknown to any one person, the saliva in the mouth may harbor the Epstein-Barr ( EBV) virus. In part, this may be what happened in the following scenario.
Karen is a 17 y.o. Female basketball player who has been suffering from fatigue. It is beginning to interfere with her playing, and her team is expected to go to the playoffs this year. She also has a sore throat. Karen believes she is just not getting enough sleep due to games and being out with her boyfriend. However, her mother insists she visit the doctor.
Infectious mononucleosis is a common illness caused by Epstein-Barr virus(EBV). EBV is categorize in the herpes virus group. The primary transmission source of EBV is a person-to-person contact with saliva; however in a few cases transmission may occur through air ( droplet in sneezing or coughing) or blood. The EBV exposure eventually leads to the infection of the B lymphocytes in the epithelial cells of the nasopharynx and oropharynx In the United States, 95 % of adults between the ages of 30-45 years of age have already been exposed to the EBV and have antibodies (immunity) that can target the virus. Thus, sometime during their life span, these people have been infected with EBV. Thanks to the immune system, the antibodies that targets the EBV cells, produces a life long immunity. However, the EBV can become dormant and remain in a few epithelial cells in the throat and blood. In some healthy people, this stealth-like nature of the EBV reactivates in the person's saliva, causes no symptoms and , the person then becomes a carrier, shedding the EBV without his/hers knowledge of its existence. According to the Center of Disease and Control (CDC), this may be one reason why EBV is world wide and difficult to prevent. These same people can secrete the EBV through out their life time due to the periods of reactivation. Most children who have been exposed to EBV do not have any symptoms or are treated for having other mild childhood illnesses. In teenagers and young adults, symptomatic conditions and signs of mononucleosis, usually occurs in 35-50% of the cases per National Center of Infectious Disease. Incubation period (time from the initial infection to the appearance of symptoms) for mononucleosis is approximately 4 -8 weeks. Contagious period is usually
during the infection period and weeks after ward. (pg 164-165)(, 2011)(aafp, 2004)
The physician finds Karen has swollen lymph nodes; an enlarged spleen; and tonsillitis. The lab test come back with the following findings: CBC: Increased WBC; normal RBC. Liver Function Test: Increase liver enzymes. Heterophil antibody test : positive.
Clinical symptoms and signs of mononucleosis involve sore throat (80-90%), fever, headache, malaise (lack of energy), fatigue, temporary rash on trunk, enlarged (swollen) lymph nodes/glands (lymphadenopathy), enlarged spleen (splenomegly) and the age factor. Diagnostic measures are also taken to confirm or rule out other illnesses/causes. Lab test that narrow in on certain symptoms or signs such as culture for sore throat or fever, blood chemistry test to reveal infection or abnormal liver functions, and a heterophil antibody test (Monospot test), which is sensitive to specific antibodies made in the immune system. An elevated white count( increase in lymphacytes and monocytes ), an increase or presence of atypical T-lymphacytes, and a positive heterophil test confirms the diagnosis. (, 2012)( Gould, B. E, pg 165, 2011)(aafp, 2004)(labtestonline, 2012)
Karen's physician likely suspected Karen's diagnosis as mononucleosis due to Karen's symptoms, signs and physical exam. Karen was in the right age group, suffered fatigue, malaise, and had a sore throat. Her exposure to saliva could have come from any one she was close to. Number one, it could have come from her boy friend. Number two, one or more of her family members or friends, where she may shared a bite of cake or another food item where the utensil or food may have saliva on it. It could be any number of situations where saliva maybe exchanged.
Karen's physical exam noted swollen lymph nodes, an enlarge spleen, and tonsillitis. Karen's lab results showed an increase in WBCs and normal RBCs, an increase liver enzymes obtained from the liver function test, and a positive Heterophil Antibody Test. The increase liver enzymes only indicates that there is some liver inflammation, with mono the liver enzymes usually return to normal without treatment. The lab results along with the Heterophil Antibody Test confirmed Karen's diagnosis. Karen had to have mono for a period of time in order to obtain an acceptable amount antibodies made by the immune system for the Heterophil Antibody Test to become positive, approximately 1-4 weeks. ( immunity cycle).
Karen's doctors prescribes a treatment regimen and tells her she may not play basketball for at least one month and she needs an exam before she resumes playing. Karen is disappointed she cannot play basketball, but is happy that the doctor says she will never get this disease again.
Since mononucleosis is viral, Karen's physician more than likely prescribed comfort and supportive measures that would help in relieving her symptoms, such as plenty of rest, or an over-the-counter analgesic like tylenol or motrin for temporary relief from discomfort (no aspirin in her age group due to Reyes syndrome), and fluid hydration. It also might be possible that Karen's tonsillitis is a bacterial infection, secondary affect of mono. An antibacterial drug would be prescribed ( ampicillin and amoxicillin should be avoided due body rash potential in people with mono, thus mistaken as an allergy) . If not, gargling with salt water is one home-made treatment that could be used to soothe the soreness in her throat along with others temporary remedies , such sucking on a Popsicle or warm drinks etc. (medicinenet, 2010)
The spleen is fragile and important part of the immune system. It filters blood, stores iron from recycle RBCs, removes abnormal blood cells, and initiates response of B cells and T cells in the blood. Splenomegaly (enlarged spleen) caused by mono, makes it vulnerable to injury. Karen's physician requested no basketball for a month most likely due to the spleen's vulnerability to injury. A follow up clinic visit was needed in order to evaluate the spleen before Karen resumes basketball. (webmd,
As mentioned earlier, Karen does not have to worry about getting the disease again; she has life time immunity. At the present, she only needs to concern herself in getting better with lots of hugs with no kisses from her family, friends, and boyfriend.

Anonymous. (2012). Epstein-Barr Virus and Infectious Mononucleosis
Retrieved January 20, 2012, from website
Ebell, M.H.. (2004, October, 1). Epstein-Barr Virus Infectious Mononucleosis
Retrieved January 20, 2012, from website
Anonymous. (2012). Epstein-Barr Virus Antibodies
Retrieved January 20, 2012, from website
Anonymous. (2010, April 19). Spleen
Retrieved January 20, 2012, from website
Stöppler, M.C. (2012). Infectious Mononucleosis
Retrieved January 20, 2012, from medicinenet website

Gould, B. E.. (2011) Chapter 10
(pp. 165), Path physiology for the Health Professions, 4th Edition. Saunders Learning, printed in United States.

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