Pfeiffer glandular fever
The mononucleosis ( glandular fever , Crohn's Pfeiffer ), and infectious mononucleosis ( infectious mononucleosis ), Monocytic or kiss disease ( students disease , students fever called), is a very common and usually harmless extending viral disease caused by the Epstein-Barr virus induced . An estimated 95 percent of all Europeans become infected with the virus by the age of 30 (98 percent by the age of 40), which can be detected by antibodies in the blood. In more than half of those affected, Pfeiffer glandular fever shows up with a triad of symptoms: fever (sometimes with chills ), swelling of the lymph nodes and inflammation of the tonsils ( tonsillitis ) in the throat area with typical changes in the blood count (monocyte angina). There is currently no special preparation against Pfeiffer glandular fever. Therapy treats the symptoms. Vaccines are still in development.
The name of the disease goes back to the pediatrician Emil Pfeiffer (1846–1921). He himself initially referred to the disease as idiopathic adenitis . Later names were also lymphaemoid glandular fever and lymphoid cell (s) angina .
The cause of the disease is the Epstein-Barr virus (EBV), an enveloped, double-stranded DNA virus (dsDNA). This virus is a gamma herpes virus and belongs to the Herpesviridae family . Like other representatives of this virus family, the EBV has two development phases : The first lytic phase is used for the production and release of the viruses and their spread. In the subsequent latent phase, the virus reaches a dormant state in which it largely eludes immunological control. In this way, a reservoir of EBV is created in the infected host , from which, after reactivation, infectious virus particles can be produced and released again.
The pathogen is mainly transmitted via saliva. The virus can be transmitted via this method even a few weeks after the symptoms of the disease have ceased. Droplet infection , contact infection and smear infection are suspected as further transmission routes . Young couples in particular very often transmit the disease from mouth to mouth, which is why it is popularly known as kissing disease , student disease or student fever . Studies on students and military personnel have shown that they are not exposed to an increased risk of infection just by living in the same room with the infected people.
Multiplication, Latency, and Reactivation
The pathogen initially infects the epithelial cells of the nose, mouth and throat as well as a group of white blood cells, the B lymphocytes , initially in regional lymph nodes and organs of the lymphatic pharyngeal ring , but also in the liver , spleen and heart . After that, the pathogen - like all herpes viruses - remains in the human body for life and latently persists in memory B-lymphocytes. Only 10 of the almost 100 viral genes are expressed there ; the virus thus undermines recognition by the immune system . However, there are always reactivations of the persistent viral disease. The affected person usually does not notice any of these, but then excretes fully replicable (infectious) viruses in the saliva. Such reactivations can also be detected in the blood (e.g. through an increase in IgG antibodies against the virus capsid antigen VCA and through EBV-PCR). People without immune protection against EBV can be infected by such asymptomatic virus shedders. The recurrence, i.e. the renewed illness of the virus carrier , must be distinguished from the reactivation of virus production and virus excretion .
A clear diagnosis consists in the detection of Epstein-Barr virus antibodies and often a noticeable increase in the number of leukocytes ( leukocytosis ) between 10,000 and 25,000 per mm³ with 60 to 80 percent lymphoid (mononuclear) cells, some of which are atypical lymphocytes . The liver values are increased in many cases. Serological are trend-setting:
- Detection of heterophile antibodies in the Paul-Bunnell reaction or tests derived from it
- IgM antibodies against early antigen (EA) and / or
- IgM antibodies against Viral Capsid Antigen (VCA) in the event of a negative EBNA-1 IgG test ( Epstein-Barr Nuclear Antigen-1 - IgG test).
High concentrations of EBNA-1-IgG (positive EBNA-1-IgG test) indicate an earlier infection and practically rule out a fresh infection, as these antibodies are only produced by the immune system several weeks to months after the symptoms appear .
In terms of differential diagnosis , infection with the cytomegalovirus (CMV) or the HIV virus must be excluded. At the beginning of the disease, an inflammation of the throat is often in the foreground, which is caused by a purulent angina , e.g. B. group A streptococci must be delineated. With the frequently occurring lymph node swelling, in addition to other infectious diseases (e.g. toxoplasmosis , cat scratch disease , tuberculosis ), an autoimmune disease and a malignant disease such as malignant lymphoma must be considered.
Course of the disease and symptoms
The Epstein-Barr infection is often very debilitating, but usually proceeds without complications. Latent, recurring or chronic courses are rare.
The role of the immune system
Whether a disease occurs after contact with a person suffering from Pfeiffer glandular fever depends on the amount and virulence of the pathogen and on the state of the immune system of the person who has not yet been infected. For example, the virus dose or virulence may be too low for an infection or the immune system may be able to prevent symptoms of illness despite infection (inapparent infection or silent celebration ).
The incubation period in children is 7 to 30 days. In adolescents and young adults, it is significantly longer at four to seven weeks. The disease often begins with the triad of fever (38–39 ° C), swelling of the lymph nodes on the neck and neck (sometimes up to the size of a chicken egg, rarely also under the armpits and on the groin) and tonsillitis (angina tonsillaris) The result is a dirty gray rather than white coating on the almonds that does not encroach on the area around the almonds. A putrid halitosis (foetor ex ore) is quite noticeable in many patients. Under flu- like symptoms may occur with increasing temperature chills, fever can with night sweats associated, hoarseness with dry cough ( "cough") or speech problems can be added. In addition, striking persistent fatigue, splenomegaly (may splenomegaly ), or liver enlargement ( hepatomegaly ) occur also rash ( rash ), eyelid edema of the eyes with nasal congestion (Hoagland's syndrome) , abdominal , muscle or headache , depression , mood swings , Dizziness or disorientation, loss of appetite (sometimes with nausea ). Those affected suffer most from fatigue during the second and third weeks of the illness. During this phase the fever can fall and rise again and again. The illness usually lasts a few weeks, but it can last for a month or two.
On the one hand, asymptomatic courses are possible, especially in small children. On the other hand, the disease can also be chronic (more than six months). Then extremely high amounts of antibodies against the pathogen can be found. Subjectively, those affected then suffer from symptoms such as fever, fatigue, exhaustion, depressive moods, feelings of lack of drive and swelling of the lymph nodes. In patients with AIDS or otherwise severely immunocompromised patients, particularly severe forms can occur. They can also develop very fine, white, hair-like extensions on the edges of the tongue (hairy leukoplakia ).
Progressive forms and percentages
- Glandular form: generalized lymph node swelling in 50% of cases , often with spleen swelling and / or tonsillitis .
- Exanthematic form: in 3% of cases a point-like (petachial) enanthem on the hard palate
- Hepatic form: hepatitis with a good prognosis in 5% of cases
Rare complications are Reye's syndrome and other types of inflammation of the brain ( encephalitis ), infectious anemia ( autoimmune hemolytic anemia ), low blood platelets ( thrombocytopenia ), severe reduction in granulocytes ( agranulocytosis ), pneumonia ( nephritis ) , inflammation of the lungs (inflammation of the kidneys ) , myocarditis ( inflammation of the myocardium) Jaundice ). Hospitalization may be necessary if these symptoms occur. As long as there is swelling of the spleen, physical exertion should be avoided because of the risk of a ruptured spleen .
Relationship to other diseases
It is believed that the Epstein-Barr virus plays a role in the development of chronic fatigue syndrome , rare tumors of the throat, rare lymphomas ( Burkitt's lymphoma ) and multiple sclerosis . Pfeiffer glandular fever does not cause infertility (in contrast to some cases of mumps ) .
There is currently no special preparation against Pfeiffer glandular fever. If you have a fever without major symptoms, it is sufficient to drink enough. Antipyretic drugs are only indicated if additional cooling compresses are not sufficient . Especially in children, no derivatives of salicylic acid such as aspirin should be used to reduce fever , as this increases the risk of life-threatening Reye's syndrome . In about 10 percent of the cases there is a bacterial infection that has to be treated with antibiotics if necessary . In the case of an EBV infection, however, certain antibiotics cause skin rashes with itching all over the body, in severe forms up to the dangerous Lyell syndrome . Aminopenicillins , especially the broad spectrum antibiotics ampicillin and amoxicillin, cause such rashes in up to 90 percent of cases. They can occur even after you stop taking the antibiotic and usually take about three days to completely spread throughout your body. They then subside very slowly until they completely disappear after about two weeks. This rash is not an allergy , but an interaction between aminopenicillin and lymphocytes with a disruption of the arachidonic acid metabolism . Aminopenicillins can therefore continue to be used against other pathogens in these patients.
Post-infectious immunity and relapse
Since antibodies against the virus are formed during the infection, there is usually lifelong immunity after the first infection. However, in severely immunodeficient patients, such as after organ transplantation , bone marrow transplantation or in the case of leukemia or AIDS, a relapse , i.e. an illness of the virus carrier with symptoms like those after the first infection, is possible. This is to be distinguished from the mere reactivation of virus production and virus excretion , which is not noticed by the virus carrier because it does not lead to symptoms in himself.
Since the pathogen is usually only transmitted through direct contact, an infection can be avoided by avoiding such contact with sick people. However, isolation of children with infectious mononucleosis is not required. A vaccine against the pathogen would also be of interest because of its suspected cause for later malignant diseases, but so far (as of 2020) it is only in development, see Epstein-Barr virus vaccine .
- Infectious mononucleosis, details, pictures and literature references
- Society for Virology: A little guide for patients on Epstein-Barr virus ( Memento from June 21, 2008 in the Internet Archive )
- Matthias Godt: The Wiesbaden doctor and discoverer of glandular fever Dr. Emil Pfeiffer (1846-1921). Life and work. Publishing house for science and culture (WiKu-Verlag), Duisburg / Cologne 2010, ISBN 978-3-86553-366-1 (also dissertation, University of Würzburg 2010).
- Karl Wurm, AM Walter: Infectious Diseases. In: Ludwig Heilmeyer (ed.): Textbook of internal medicine. Springer-Verlag, Berlin / Göttingen / Heidelberg 1955; 2nd edition, ibid. 1961, pp. 9-223, here: pp. 206 f.
- Ludwig Heilmeyer, Herbert Begemann: Blood and blood diseases. In: Ludwig Heilmeyer (ed.): Textbook of internal medicine. Springer-Verlag, Berlin / Göttingen / Heidelberg 1955; 2nd edition ibid. 1961, pp. 376–449, here: pp. 421–423: The infectious mononucleosis (Pfeiffer's glandular fever, monocyte angina, lymphoid cell angina ).
- Sabine Cepok: Characterization of the humoral immune response in multiple sclerosis. Dissertation in the Department of Biology at the Philipps University of Marburg, Marburg (Lahn) 2004 ( PDF file p. 85. )
- JA McSherry: Myths about infectious mononucleosis. In: Canadian Medical Association journal. (Can. Med. Assoc. J.) March 15, 1983, Vol. 128, No. 6, pp. 645-646, PMID 6825028 , PMC 1875234 (free full text).
- RN Sawyer, AS Evans, JC Niederman, RW McCollum: Prospective studies of a group of Yale University freshmen. I. Occurrence of infectious mononucleosis. In: The Journal of Infectious Diseases. Volume 123, Number 3, March 1971, pp. 263-270, PMID 4329526 .
- TJ Hallee, AS Evans, JC Niederman, CM Brooks, j. H. Voegtly: Infectious mononucleosis at the United States Military Academy. A prospective study of a single class over four years. In: The Yale journal of biology and medicine. Volume 47, Number 3, September 1974, pp. 182-195, PMID 4374836 , PMC 2595096 (free full text).
- RJ Hoagland: Etiology and epidemiology. In: RJ Hoagland: Infectious Mononucleosis. Grune & Stratton, New York 1967, pp. 24-50.
- Sangeeta Priyadarshi Sawant: Hoagland Sign: An early manifestation of acute infectious mononucleosis. Current Pediatric Research, Volume 21, Issue 3, May 25, 2017, pp. 400–402 , accessed October 26, 2019 .
- German professional association of ear, nose and throat doctors eV (ed.): Pfeiffersches Drüsenfieber - signs and course . On: hno-aerzte-im-netz.de ; last accessed on March 7, 2019.
- Gerd Herold: Internal Medicine. A lecture-oriented presentation taking into account the subject catalog for the medical examination with ICD 10 code in the text and index. Herold, Cologne 2015, ISBN 978-3-9814660-4-1 , pp. 854 ff.
- Johannes Forster, Ralf Bialek, Michael Borte: DGPI Handbook: Infections in Children and Adolescents. Edited by the German Society for Pediatric Infectious Diseases (DGPI), 6th, completely revised edition, Thieme, Stuttgart 2013, ISBN 978-3-13-175716-6 ( at Google-books ).
- Konrad Bork: drug side effects on the skin: Clinic - diagnostics to identify the triggering drugs - pathogenesis - therapy. 2nd, revised and expanded edition, Schattauer, Stuttgart 1999, ISBN 3-7945-1860-8 , p. 18 ( on Google books ).
- Ulf Reineke, Randolf Riemann: Specialist examination ear, nose and throat medicine: 1000 commented examination questions. Thieme, Stuttgart / New York 2007, ISBN 3-13-143821-5 , p. 64 ( at Google-books ).