Epiglottitis and necrotizing fasciitis: A life-threatening complication of infectious mononucleosis

Objective

Life-threatening cervical complications associated with infectious mononucleosis are rare. The combination of acute epiglottitis and subsequent necrotizing fasciitis of the head and neck in a patient with infectious mononucleosis has not been reported to date.

Material and methods

A 47-year-old female with infectious mononucleosis and epiglottitis was admitted to hospital for i.v. therapy. Owing to her poor clinical condition and the spread of the infection to the throat and superior mediastinum, as evidenced by CT, a cervical debridement was performed.

Results

After cervical debridement, histological findings were consistent with necrotizing fasciitis. The bacteria identified were Streptococcus viridans, Veilonella spp. and Capnocytophaga spp. The patient was hospitalized for 33 days.

Conclusions

Mononucleosis, usually a benign condition, may be associated with life-threatening septic complications in the neck and chest. Serial CT or MRI scans are necessary to assess the development of the infection in the deep layers of the neck. Rapid medical treatment, extensive surgical debridement and intensive care are vital.     

Differentiation of Recurrent Nasopharyngeal Carcinoma and Skull Base Osteoradionecrosis by Epstein‐Barr Virus‐Derived Latent Membrane Protein‐1 Gene

Objectives In patients with nasopharyngeal carcinoma (NPC), the differentiation between recurrent primary cancer and osteoradionecrosis (ORN) is clinically difficult. Epstein‐Barr virus (EBV)‐derived latent membrane protein‐1 (LMP‐1) has been demonstrated to be highly associated with NPC. The objective of this study is to define the role of the LMP‐1 gene in the differential diagnosis of recurrent NPC and ORN. Study Design Prospective. Methods From July 1998 to June 2000, 15 postirradiated patients with NPC who were initially diagnosed to have skull base ORN underwent endoscopic sequestrectomy. The sequestra were examined for the presence of the LMP‐1 gene and cancer. Results Two of 15 patients had recurrent cancer and only these two patients demonstrated a positive LMP‐1 gene in their surgically removed sequestra. The presence of the LMP‐1 gene in the sequestrum coincided with biopsy‐proven local recurrence. Conclusions The LMP‐1 gene is a potential marker to differentiate between recurrent NPC and ORN. The presence of the LMP‐1 gene in patients with ORN may indicate local recurrence.     

Infectious mononucleosis treated by an antihistamine: a comparison of the efficacy of ranitidine (Zantac®) vs placebo in the treatment of infectious mononucleosis

This study investigated whether the course of infectious mononucleosis was influenced by medication with ranitidine (Zantac^®). A double-blind, placebo-controlled study enrolled 117 patients and either ranitidine 300 mg or placebo were given twice daily for 2 wk. Patients were examined on day 5, 10, 15 and 30. Efficacy variables included severity and duration of fever, scores of cervical lymph node size and tonsil size, eating problems, fatigue, influence on general condition, the use of analgesics and blood analyses. Results were analysed in 91/117 patients. Small differences were found between treatment groups in favour of the active drug. However, they were not statistically significant. After 2 wk of treatment abnormal ‘liver enzymes’ (ALAT/ASAT) were found in 13/48 (0.27) of the ranitidine group in contrast with 18/36 (0.50) of the placebo group (P = 0.03). The conclusion is that the course of infectious mononucleosis is little influenced by ranitidine treatment for 2 wks. The faster normalization of the ‘liver enzymes’ may reflect modulation of the immune system by ranitidine.     

误诊为腭扁桃体炎的传染性单核细胞增多症临床分析

目的：探讨误诊为腭扁桃体炎的传染性单核细胞增多症的临床特征。方法：应用外周血细胞变异淋巴细胞计数、嗜异性凝集试验及EBVCA-IgA检测诊断以腭扁桃体炎为表现的传染性单核细胞增多症患者6例，并给予药物治疗。结果：6例均确诊并治愈，无一例发生上呼吸道梗阻。结论：诊断腭扁桃体炎要注意变异淋巴细胞计数情况，恢复期和不伴有肝、肾功能损害的传染性单核细胞增多症容易误诊和漏诊，应引起注意。     

Obstructive sleep apnea (OSA): A complication of acute infectious mononucleosis infection in a child

Independently, obstructive sleep apnea (OSA) and infectious mononucleosis are not uncommon in the pediatric population, but acute onset of OSA, as a respiratory complication in the setting of acute EBV infection is extremely uncommon. Previous reports of this clinical entity are sparse and from nearly two decades ago. Urgent adenotonsillectomy was commonly advocated. This complication may be managed medically with systemic corticosteroids and non-invasive continuous positive airway pressure (CPAP), and a case is presented to highlight an updated management approach to this rarely encountered clinical problem in children.     

Coronavirus-associated antibodies in nasopharyngeal carcinoma and infectious mononucleosis

Summary Coronavirus-like particles are found within the cytoplasm of NPC tumor cells, within the cytoplasm of the tumor cells of the regional metastases, and within tumor cells grown on nude mice. For the immunologic identification of the coronaviruses, the cultures of human tracheal epithelium (MRC-C) were used and inoculated with a known coronavirus strain. Whereas blood sera from NPC patients (n=73) contain significantly elevated antibody titers against corona viruses, unselected sera from patients without NPC showed a low antibody titer (n=83). Only patients suffering from infectious mononucleosis (n=40) showed a titer pattern similar to that of NPC patients. For demonstration of antigen-antibody reaction within the NPC tumor cell cytoplasm, sera with a high antibody content against coronaviruses deriving from other than NPC patients or anticoronavirus sera from rabbits were used. By indirect immunofluorescence, the NPC tumor cells showed a bright cytoplasmic fluorescence. No fluorescence was seen when tumor cells were exposed to human sera with known low or absent corona antibody titer or to normal rabbit sera. The results indicate that next to a DNA virus infection (EBV), an RNA virus infection (coronavirus) may play a role in NPC as well as in infectious mononucleosis.Supported by the Deutsche Forschungsgemeinschaft, grant no. Ar 120     

EB病毒Rta蛋白抗体检测对鼻咽癌病理分级的临床价值

目的探讨EB病毒Rta蛋白抗体对鼻咽癌病理分级的临床价值。方法选择我院诊治的鼻咽癌患者共计68例,选取同一时期来我院体检健康人54例,测定血清Rta-IgG水平,血清Rta-IgG与鼻咽癌病理分级采用spearman相关分析。结果7观察组(I期、II期、III期、IV期)血清Rta-IgG水平均高于对照组,鼻咽癌患者中I期、II期、III期、IV期血清Rta-IgG水平依次升高,有差异(P<0.05)。血清Rta-IgG水平与鼻咽癌病理分级之间呈正相关(P<0.05)。结论EB病毒Rta蛋白抗体对鼻咽癌病理分级有预测价值。     

Specific IgA antibodies to recombinant early and nuclear antigens of Epstein–Barr virus in nasopharyngeal carcinoma1

hsu m .‐m ., hsu w .‐c ., sheen t .‐s . & kao c .‐l . (2001) Clin. Otolaryngol. 26, 334–338 Specific IgA antibodies to recombinant early and nuclear antigens of Epstein–Barr virus in nasopharyngeal carcinoma Nasopharyngeal carcinoma is a common cancer in Taiwan. The Epstein–Barr virus (EBV) is closely associated with nasopharyngeal carcinoma. The sera of patients with nasopharyngeal carcinoma have IgA antibodies to a variety of EBV latent and replicated antigens. Recently, an enzyme‐linked immunosorbent assay (ELISA) kit, combining both the EBV early antigen (EA) and nuclear antigen (EBNA‐1) became commercially available. The purpose of this study was to assess its clinical application. Serum IgA antibodies to the EBV EA and EBNA‐1 were measured by using the ELISA kit in various groups of subjects. Fluorescence antibody (FA) tests against EBV viral capsid antigen (VCA) and EA in the IgA and IgG classes were also studied for comparison. The DNA content analysis was also carried out to investigate the association with IgA antibody titres using ELISA. The sensitivity, specificity and accuracy of the ELISA test were 98.1%, 81.8% and 88.7% respectively. It was far better than any FA tests. The IgA antibody titres showed no association with DNA content analysis. Univariate analysis of various factors revealed that IgA antibody titres were statistically correlated to N stage (P = 0.0291) and M status (P = 0.001). However, there was no association with the age, sex, T stage and clinical stage. Multivariate analysis of various factors was found to be statistically significant in patients with T4 (P = 0.0133), N3 (P = 0.0244) or M1 (P = 0.001) respectively. Serial testing of antibody titres in 22 previously untreated patients found a trend of decreasing IgA antibody titres after initial treatment when the tumours disappeared (P = 0.0358). The ELISA kit to identify specific IgA antibodies with the combination of EBV EA and EBNA‐1 recombinant antigens has high sensitivity and acceptable specificity and accuracy in the diagnosis of nasopharyngeal carcinoma. This assay should be useful for early diagnosis and mass screening of patients.     

Fulminant epstein‐barr virus‐associated hemophagocytic lymphohistiocytosis

Hemophagocytic lymphohistiocytosis (HLH) is a rare, severe, and often fatal disorder. Its hereditary and sporadic form can present as a significant diagnostic challenge to the otolaryngologist. This report describes two fatal cases of adult patients with HLH initially presented as infectious mononucleosis to an otorhinolaryngologist. The clinical presentation, serological and histological features, and management are discussed.     

Epstein-Barr virus DNA is not increased in tonsillar carcinoma

Epstein-Barr virus (EBV) is a known oncogenic virus associated with a wide variety of cancers, including nasopharyngeal carcinoma. Waldeyer's ring, a collection of lymphoid tissues, includes the nasopharynx, pharyngeal, and lingual tonsils. To determine if EBV plays a causative role in carcinomas arising from other tissues in Waldeyer's ring, we examined pharyngeal tonsillar carcinomas for evidence of EBV infection. As previously reported, DNA was extracted from 53 consecutive tonsil cancers, as well as from age- and gender-matched non-cancerous tonsillectomy specimens. Three different sets of primers for discrete exons of EBV were then used to determine if active or latent EBV infection was expressed in the extracted DNA using the polymerase chain reaction (PCR). All positive bands were then sequenced to confirm the presence of amplified EBV fragments. None of the samples showed evidence for active EBV infection. In primers demonstrating latent infection, 1 of 53 (1.9%) of tumors were positive, versus 6 of 53 (11.3%) of the controls. These results indicate that EBV expression is not increased in DNA from tonsil cancers and that EBV infection does not have a causal relationship with tonsil cancer.