Four similar clinical presentations

The four infections (EMB, primary HIV, CMV and toxoplasmosis) produce almost identical clinical presentations and tend to be diagnosed as glandular fever or pseudoglandular fever. It is important for the first contact practitioner to consider all four possibilities, especially keeping in mind the possibility of HIV infection.

A worthwhile approach is to make a provisional diagnosis based on the clinical variations as presented in Table 25.1 . Screening tests are:

• Full blood count, especially WCC

• Paul Bunnell test (for heterophil antibodies)

• Serological test for cytomegalovirus (specific antibodies)

• Serological test for toxoplasmosis (specific antibodies)

Table 25.1 Clinical features differentiating HIV, EBV, CMV and toxoplasmosis infections (all can present with a similar illness)

Feature

EBV infection HIV infection CMV infection Toxoplasmosis

Onset

Insidious

Acute

Insidious

Insidious or acute

Fever

A feature Intermittent

(afternoon spikes)

Low grade

Fatigue/malaise

Common

Common, severe

Common

Common

Tonsillar hypertrophy

Common

Mild enlargement

Uncommon

Uncommon

Exudative pharyngitis

Common

Rare

Rare

Occurs

Mucocutaneous ulcers

Rare

Common

Unknown

Unknown

Skin rash

About 5%

Common

About 5%

About 10%

Jaundice

About 8%

Rare

Uncommon

Uncommon

Diarrhoea

Unknown

Occurs

Unknown

Unknown

Cervical lymphadenopathy

Common

Common

Uncommon

Common (a feature)

Hepatomegaly

About 8%

Rare

Common

Occasional

Splenomegaly

About 50%

Rare

About 50%

Up to 30%

Atypical lymphocytes

In 80-90%

In < 50%

Common

Uncommon

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