Communicable Disease Chain: Mononucleosis/ Epstein Barr Virus
LaTasha R. Uszakiewicz
Grand Canyon University
Author Note
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Communicable Disease Chain: Mononucleosis/ Epstein Barr Virus
Mononucleosis is a contagious disease caused by a virus. The most common virus causing mononucleosis is the Epstein-Barr virus (EBV), but it can be caused by others. The Epstein-Barr virus or (EBV) is also known as human herpesvirus 4, is categorized as a gamma herpes virus that occurs only in humans. Infectious mononucleosis is also called “Mono” or “the kissing disease” because it is most often seen among teenagers or young adults between the ages of 15 to 17.” EBV infectious mononucleosis has also been linked to the cause of viral pharyngitis. According to the CDC, “at least 25% of teenagers and young adults who get infected with EBV will develop infectious mononucleosis” with approximately 12% of susceptible college-aged young adults converting each year and half of whom will develop acute infectious mononucleosis.
Mononucleosis/EBV Pathophysiology
There are more than 3 million US cases per year of mononucleosis. The virus is most often spread by saliva or close intimate contact, semen during sexual contact, in some rare cases via blood transfusion and is linked to the Epstein-Barr virus. It is rare that mononucleosis will be caused by any other virus such as the cytomegalovirus (CMV), Hepatitis A, B, or C, HIV, Toxoplasmosis Streptococcal pharyngitis or Rubella. EBV infects the B cells in the oropharyngeal epithelium and also from the uterine cervix, which has implicated the role of genital transmission in some cases. B cells are a type of white blood cell or lymphocyte that mature into either plasma cells or memory cells, it is the plasma cells that produce antibodies that are needed by the body to fight off infections. These circulating B cells will spread the infection throughout the entire reticular endothelial system, i.e., the liver, spleen, and peripheral lymph nodes. Via the B lymphocytes, the EBV will spread and this will result in a humoral and cellular response to the virus from the body.
Epidemiology/Symptoms1
With the incubation period of EBV infectious mononucleosis being around 30 to 60 days with any symptoms of the disease appearing within 4 to 6 weeks after the patient has been infected with the Epstein-Barr virus. The first most common symptom of mononucleosis being fatigue, “which may be profound initially but usually resolves gradually in 3 months.”(2015, Medscape). Some patients will experience a prolonged episode of fatigue, after initial recovery, then exhibit a state of prolonged fatigue without the following symptoms of infectious mononucleosis. These symptoms will include, but are not excluded to headache, sore throat, drowsiness, fever is usually low grade, cough, nosebleed, sensitivity to light, shortness of breath, loss of appetite, muscle aches or neck stiffness, swollen tonsils with development of a whitish-yellow covering upon assessment and a pink, measles-like rash. The Wholistic Therapy Centre states “A skin rash in the early, acute stage of mono can be a viral rash which normally resolves itself within a couple of days.” This skin rash is commonly seen in children. This measles-like skin rash can appear anywhere on the face or body and is more commonly related to taking amoxicillin for the treatment of the sore throat pain or discomfort.
Complications. Patients with a compromised immune systems are more prone to the development of symptoms from the EBV infection and with more severity than healthier individuals. The nervous system may effected via the nerves, brain and spinal cord and cause conditions such as Guillain-Barre syndrome, encephalitis, viral meningitis, hemiplegia, facial nerve paralysis, psychosis, and difficulties in sleep. The hematological system can be effected from the EBV by way of the blood and bone marrow. The EBV can cause the body to overproduce the number of white blood cells and it can also suppress the immune system, which would make the patient more susceptible to infections such as pneumonia or interstitial lung disease, peritonsillar abscesses, acute bacterial sinusitis and mastoiditis.
Assessment and Laboratory Testing. Upon assessment by a health care provider, swollen lymph nodes will be detected with palpation in the front and back of the neck, swollen tonsils with a whitish-yellowish covering can be observed, skin rash to chest or torso area and swollen liver or spleen. If patient is left untreated from previous assessment findings, possible physical findings could include hepatomegaly, palatal petechiae, jaundice, uvular edema, splenomegaly, and, rarely (1-2%), findings associated with splenic rupture. Laboratory testing is aimed at detecting antibodies to the following EBV-associated antigens. Viral capsid antigen (VCA), the anti-VCA IgM can be detected early in EBV infection and usually disappears within 4 to 6 weeks. Early antigen (EA), the anti-EA IgG can be detected in the acute phase of illness and generally falls to undetectable levels after 3 to 6 months. In many people, detection of antibody to EA is a sign of active infection. However, 20% of healthy people may have antibodies against EA for years. The immunofluorescent test, can detect the antibody to Epstein-Barr nuclear antigen or (EBNA) testing, it is not seen in the acute phase of EBV infection but slowly appears 2 to 4 months after onset of symptoms and persists for the rest of a person’s life. The Monospot test is not recommended for general use because the antibodies detected by testing can be caused by conditions other than infectious mononucleosis and have also shown to produce both false positive and false negative results. At best, the Monospot test may indicate that a person has a typical case of infectious mononucleosis, but does not confirm the presence of EBV infection. Complete Blood Count Testing will show that white blood cell count results are higher than normal and Antibody titer will tell the difference between current and past infection.
Mortality and Morbidity. Mortality and morbidity rates related to mononucleosis or Epstein-Barr virus are very low and if death occurs it is most often caused by rare cases of spontaneous splenic rupture, underlying immune disorders or previous underlying conditions.
Treatment, Follow-up care and Prognosis. Nurses can educate the patient about the importance of not kissing, sharing drinks, straws or food, personal items, such as toothbrushes, with people who might possibly have infectious mononucleosis. Patients should be made aware of the avoidance of exposing others to their body secretions because EBV remains viable in patients with EBV infectious mononucleosis for months after the initial infection. There are no known vaccines offered to protect against infectious mononucleosis and antibiotics have shown to have no effect on the EBV, so as a nurse or health care provider, it is our duty to be focused on treatment of infectious mononucleosis as it relates to relieving the symptoms of the disease. Patient should be encouraged to increase fluid intake, educated on the importance of gargling with warm salt water to ease sore throat pain or discomfort, encouraged to rest and decreasing physical activity for 3 about weeks, throat lozenges and taking over-the-counter pain relievers for fever or pain. Steroid therapy has been prescribed for severe symptoms. Emphasis has been placed on monitoring patients with extreme tonsillar enlargement closely for airway obstruction and the use of steroids for impending or established airway obstruction. Follow-up care should include referrals for the appropriate consultation for indicated specialists such as an infectious disease specialist, a hematologist, neurologist, cardiologist, and or gastroenterologist. Patients that have suffered from a splenic rupture that was recognized in time and expeditiously treated surgically, the prognosis is good. Most people get better in 2 to 4 weeks; however, some people may feel fatigued for several more weeks. Occasionally, the symptoms of infectious mononucleosis can last for 6 months or longer.
National Agency/ Organizations for Mononucleosis:
Centers for Disease Control and Prevention (CDC) http://www.cdc.gov 1600 Clifton Road Atlanta, GA 30329-4027 USA
800-CDC-INFO (800-232-4636), TTY: 888-232-6348
Email CDC-INFO
The CDC (the national public health institute of the United States) promotes health and quality of life by preventing and controlling disease, injury, and disability. CDC works 24/7 to protect America from health, safety and security threats, both foreign and in the U.S. Whether diseases start at home or abroad, are chronic or acute, curable or preventable, human error or deliberate attack, CDC fights disease and supports communities and citizens to do the same.

American Academy of Pediatrics (AAP) http://www.aap.org National Headquarters: The American Academy of Pediatrics
141 Northwest Point Boulevard Elk Grove Village, IL 60007-1098
USA 847/434-4000 (tel) 800/433-9016 (toll-free tel) 847/434-8000 (fax)
The AAP is committed to the health and well-being of infants, adolescents, and young adults. The website offers news articles and tips on health for families. The AAP was founded in 1930 by 35 pediatricians to serve as an independent forum to address children’s health needs. At that time, the idea that children had unique developmental and health needs was new. Practices that are now standard preventive care (i.e., immunization, regular health exams) were only just beginning to change the custom of treating children as “miniature adults.” The Academy also maintains the Pediatric History Center, which collects and archives materials related to the history of pediatrics in the United States and Canada and the history of the Academy itself.

References
Burke A Cunha, M., & Chief Editor: Michael Stuart Bronze, M. (2015, October 06). Medscape. Retrieved from emedicine.medscape.com: http://emedicine.medscape.com/article/222040-overview#a4
Center for Disease Control and Prevention. (n.d.). Retrieved from www.cdc.gov: http://www.cdc.gov/epstein-barr/about-mono.html
Noble, E. (2009, June 30). The Mono Blog. Retrieved from epsteinbarrvirus.com: http://www-epsteinbarrvirus.com/blog/treating-mononucleosis-skin-rash/