It is a reactivation of chickenpox. Herpes zoster rashes form painful blisters, which can cause long-term pain known as post-herpetic neuralgia and vision loss if the condition affects the eyes. Chronic infections are conditions we see frequently in our office. This is because they often produce perplexing, multisystem symptoms. Chronic infections often cause the worsening of other illnesses and conditions as well. Sometimes these infections are triggered by some other condition, and sometimes they are the trigger themselves.
Interestingly, treating chronic infections like the Epstein-Barr virus is sometimes not about wiping out the microorganism altogether. Instead, when it comes to chronic infections, treatment is often about management and rebalancing other microbes while supporting a healthy immune system response so that we can get the harmful pathogen under control.
We regularly see patients who have reactivated or chronic infections in our office. In fact, we suspect many people who have recurring low-level symptoms are suffering because they have undiagnosed chronic, reactivated infections. We will also assess the function of your immune system to see if an abnormality here is making you susceptible to chronic infections. Ellen and Scott Antoine have many years of experience in treating both acute and chronic infections. Cervical lymphadenopathy is a hallmark in IM and involves the nasopharyngeal and palatal tonsils.
Swelling has been estimated to cause airway compromise in 1—3. Symptoms include stridor, cyanosis and tachypnea and should lead to immediate admittance and treatment. Early treatment with systemic corticosteroids may therefore limit the need for surgical intervention in severe cases [ 29 ]. Tracheotomy has only been used in extremely severe and exceptionally described cases, where treatment with systemic corticosteroids have failed [ 29 ].
Selected use of acute tonsillectomy in patients who have not responded satisfactorily to systemic corticosteroids has been proposed by some groups [ 30 , 31 ], but has been a topic of debate, due to the conflicting data on the risk of bleeding. These results were not supported by those advocating for selected use of acute tonsillectomy [ 30 , 31 ] and it seems that more research on this topic is warranted. Of importance, treatment with systemic corticosteroids is only warranted in an emergency setting, in the case of acute complications such as impending airway compromise.
Systemic corticosteroids should not be instituted for symptomatic relief as it does not affect the incidence of complications nor rates of admission or length of hospitalization [ 32 ]. Lymphoproliferative cancers are the most well-established late-onset complication to IM and have been investigated in several different cohorts since the s. A British study from found similar results in two different cohorts. Both showed elevated risk of HL with rate ratios of 3. An Italian multicenter case-control study from also observed an increased risk, with an age-adjusted OR of 4.
Overall, published data seem to agree on a strong correlation between IM and HL where results concerning NHL in general are more conflicting. On the other hand, for certain NHL subtypes a strong correlation seems to exist. This highly aggressive type of B-cell lymphoma has since been strongly correlated to EBV. There are three subtypes of BL; endemic, sporadic and immunodeficiency-associated, where the endemic subtype has shown the strongest correlation with EBV [ 35 ].
This condition has shown to impair prognosis as these patients tend to respond poorly to conventional therapy [ 36 ]. As previously discussed, IM may lead to airway compromise as the mentioned lymphoproliferative cancers may themselves cause airway obstruction. However, this is not within the scope of this review nor relevant to a GP.
It seems clear, however, that there is an association. Furthermore, the risk of MS was 2. A large umbrella review published in , studying 44 different proposed risk factors for MS found similar results, with strong epidemiological evidence for IM as a risk factor for MS [ 38 ].
A study of the correlation of IM and initial symptoms of MS from supports a causative relationship between IM and MS and state that the rate of which MS develops could depend on genetically susceptibility to EBV infection as well as time of infection, with postpubescent infection being critical for the initiation and rapid development of MS [ 39 ]. Despite the published data, it is a challenge to prove underlying mechanisms.
Humanized mouse models have been studied, but graft-versus-host reactions have been major confounders in these studies [ 40 ]. A study from on this controversy summarized the key issues in the debate: There is currently no consensus as to whether patients with MS has EBV-infected B-cells in the CNS [ 41 ].
If there indeed exits a causal link between EBV and MS, this would support that vaccination against EBV could have the potential to eliminate MS as one study suggests or, that insuring early life exposure to EBV could decrease the risk of developing MS, as individuals with a history of symptomatic IM exhibit a 2. A causal link between RA and IM has been proposed alongside several other autoimmune diseases. However, a large systematic review and meta-analysis from found no significant association.
The authors concluded, however, that several of the included studies had limitations and that more data on the subject was needed [ 45 ].
At present, no data demonstrate a clear association between EBV and RA, but it is worth acknowledging the increasing amount of literature suggesting diverse roles of EBV in autoimmune disease. Although rare, a GP should be aware of this as a differential diagnosis in patients with IM-symptoms persisting for more than 3 months, after exclusion of IM, autoimmune disease and immunodeficiency disorders congenital or acquired [ 46 ].
Further diagnostic work should be performed by a specialist in haematology. The expanding roles of EBV in both benign and malignant disease bear witness of a viral species with diverse effects on the human body.
GPs of today therefore need to be aware of not only the classical early complications to IM, but also late complications and potential associated conditions as patients are entitled to evidence-based risk estimates of such outcomes. Upon initial evaluation of a patient with symptoms suggestive of IM an algorithmic approach is recommended to ensure correct diagnosis and proper risk stratification.
Treatment should focus on symptomatic relief and rest; however, prolonged bed-rest is discouraged as deconditioning may prolong symptoms and recovery time. Hospitalization can be necessary in severe cases of dehydration and impeding respiratory failure. Hepatitis is a common and self-limiting early complication to IM, but liver tests should be monitored in more symptomatic cases as fatal events have been reported.
Also, splenomegaly may be noticed upon physical examination and consequently increases the risk of splenic rupture. Currently, there is no consensus on the safe return to physical activities, and ultrasonic assessment of spleen size may provide the best estimate of risk. Airway compromise due to tonsil enlargement is encountered in a minority of patients 1—3. Such patients should be admitted to pediatric wards, where early intervention with systemic corticosteroids limits the need for surgical intervention and thereby the risk of post-operative bleeding, infection and prolonged hospitalization.
The level of evidence for the late complications varies, but the association between lymphoproliferative cancers, especially HL and BL, and IM are well-established. Due to the high prevalence of EBV-infected individuals throughout the world, and the known and proposed late complications to IM, preventive measures should be prioritized, ideally through vaccination.
Future research will hopefully shed light on costs, benefits, side-effects and target-groups as well as determining whether the prevention of EBV-infection in general - or the prevention of IM in particular - is the primary goal.
Furthermore, future research should focus on substantiating the known- and proposed associations and causations in order to contribute to the understanding of the pathogenic mechanisms of EBV.
AF co-designed the study, collected, analyzed and interpreted data and drafted the manuscript. CLA co-designed the study, analyzed and interpreted data. Both authors revised the manuscript critically for important intellectual content, and approved the final version to be submitted. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Anders Fugl, Email: kd. Christen Lykkegaard Andersen, Email: kd. National Center for Biotechnology Information , U. BMC Fam Pract. Published online May Anders Fugl 1 and Christen Lykkegaard Andersen 1, 2. Author information Article notes Copyright and License information Disclaimer.
Corresponding author. Received Aug 29; Accepted Apr This article has been cited by other articles in PMC. Abstract Background General practitioners encounter the vast majority of patients with Epstein-Barr virus-related disease, i. Purpose of review: We describe a patient in whom Epstein-Barr virus infection appears to have caused an unusual interstitial lung disease with multisystem involvement resembling sarcoidosis and interstitial lung disease.
We have reviewed the relevant literature about the relation of Epstein-Barr virus and interstitial lung disease. Recent findings: Epstein-Barr virus replication within type II alveolar cells was shown to occur in adult cryptogenic fibrosing alveolitis. A year-old female with a history of polymyositis was admitted with a four-week history of increasing dyspnoea. She had been treated with maintenance oral steroid therapy over the previous 4 years, augmented with oral cyclophosphamide over the preceding 4 weeks.
On examination there were fine crepitations to the mid-zones. The patient was hypoxic with a Pa0 2 of Echocardiogram was normal.
Initial chest X-ray was normal figure 1. Ground glass opacification describes the findings on HRCT of the lungs in which there is a hazy increased attenuation of lung with preservation of bronchial and vascular margins. This appearance can be caused by partial filling of air spaces, interstitial thickening, partial collapse of alveoli, normal expiration, or increased capillary blood volume 1.
The presence of numerous intra and interlobular septa almost always indicate the presence of an interstitial abnormality, only a few septa should be visible in normal patients.
Septal thickening can be seen in the presence of interstitial fluid, cellular infiltration or fibrosis 2. Diffuse alveolitis refers to the combination of these appearances throughout both lung fields suggestive of an acute inflammatory process of the pulmonary alveoli.
Coronal reformat reproduced from CTPA study demonstrating wide spread ground glass opacity white arrows. Transaxial HRCT image at level of the carina showing intralobular interstitial thickening black arrow , interlobular septal thickening grey arrow and ground glass opacity white arrow.
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