The rash of EBM is almost always related to antibiotics given for tonsillitis. The primary rash, most often non-specific, pinkish and maculopapular (similar to that of rubella), occurs in about 5% of cases only.
The secondary rash is most often precipitated by one of the penicillins, especially ampicillin or amoxycillin. About 90-100% of patients prescribed ampicillin or amoxycillin will be affected; up to 50% of those given penicillin will develop the rash. It can be extensive and sometimes has a purplish tinge. The complications of EB mononucleosis are presented in Table 25.3 and the differential diagnoses in Table 25.4.
The following confirm the diagnosis of EB mononucleosis.
• White cell count shows absolute lymphocytosis.
• Blood film shows atypical lymphocytes.
• Paul Bunnell test for heterophil antibody is positive (although positivity can be delayed or absent in 10% of cases).
• Diagnosis confirmed (if necessary) by EBV- specific antibodies, viral capsule antigen (VCA) antibodies—IgM, IgG.
Table 25.3 Complications of EB mononucleosis 1
• antibiotic-induced skin rash
• prolonged debility
• haemolytic anaemia
• upper airway obstruction (lymphoid hypertrophy)
• ruptured spleen
• cranial nerve palsies, especially facial palsy
• Guillain-Barre syndrome
• transverse myelitis
Source: World Health Organisation 1995 figures Table 25.4 Differential diagnoses of EB mononucleosis 1
Other agents that cause typical EBM syndrome
• HIV infection (acute initial illness)
Exudative tonsillitis resembling EBM
• acute streptococcal pharyngitis
• adenovirus infection
• diphtheria (unlikely in Australia)
Lymphadenopathy, fever and splenomegaly
Complications of EBM without other manifestations
• drug reaction
Source: World Health Organisation 1995 figures
However culture for Epstein-Barr virus and tests for specific virus antibodies are not done routinely. False positives for Paul Bunnell test:
• Hodgkin's disease
• acute leukaemia
EBM usually runs an uncomplicated course over 6-8 weeks. Major symptoms subside within 2-3 weeks. Patients should be advised to take about 4 weeks off work.
• supportive measures (no specific treatment)
• rest (the best treatment) during the acute stage, preferably at home and indoors
• aspirin or paracetamol to relieve discomfort
• gargle soluble aspirin or 30% glucose to soothe the throat
• advise against alcohol, fatty foods, continued activity especially contact sports (risk of splenic rupture)
• ensure adequate hydration
• corticosteroids for:
o neurological involvement o thrombocytopenia o threatened airway obstruction
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