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      Cytomegalovirus Primary Infection in an Immunocompetent Female with Mononucleosis Features: A Review of Mononucleosis-Like Syndromes

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      Canadian Journal of General Internal Medicine
      Dougmar Publishing Group, Inc.

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          Abstract

          Background The clinical triad of fever, pharyngitis, and lymphadenopathy was first described in 1889 as “glandular fever” and later defined as infectious mononucleosis. We present a case report and review of mononucleosis-like syndromes in an immunocompetent patient. The review of common etiologies includes Epstein-Barr virus (EBV), acute human immunodeficiency virus (HIV), human herpesvirus 6 (HHV-6), cytomegalovirus (CMV), and Toxoplasmosis gondii. Case Vignette A 37-year- old, immunocompetent female presented with a three-week history of fever, pharyngitis, fatigue, night sweats, and abdominal pain. Physical examination revealed hepatosplenomegaly, but no lymphadenopathy, rashes, or tender joints. Investigations showed lymphocytosis and a normal peripheral smear. A Hematology consultation excluded hematologic malignancy. Her CD4/CD8 ratio was 0.2 in keeping with a viral infection, but EBV monospot test was negative. Serology for hepatitis B and C were negative. Human immunodeficiency virus (HIV) testing was not done in the absence of risk factors. Quantitative PCR for CMV was positive with a value of 965.25 units/mL. The patient was diagnosed with CMV viremia and treated with a two-week course of valganciclovir with resolution of symptoms. A two-month follow-up revealed a normal complete blood count and resolving hepatosplenomegaly. Conclusions In immunocompetent patients presenting with symptoms of mononucleosis, the differential diagnosis should include EBV, CMV, HHV-6, acute HIV and Toxoplasmosis gondii. CMV commonly affects young patients and is less associated with tonsillitis, pharyngitis, and lymphadenopathy. HHV-6 can present with headaches, encephalitis, and abdominal pain. Consideration of acute HIV mononucleosis should prompt early serologic testing. Toxoplasmosis is often associated with undercooked food or cat excrement, requiring anti-IgM antibody testing to distinguish from EBV. Although EBV infectious mononucleosis may be suspected, the general practitioner should consider a complete review of other infectious etiologies.

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          Severe cytomegalovirus infection in apparently immunocompetent patients: a systematic review

          Background The morbidity and mortality associated with cytomegalovirus (CMV) infection in immunocompromised patients (especially in HIV-infected patients and transplant recipients), as well as with congenital CMV infection are well known. In contrast, relatively little attention has been paid to the morbidity and mortality that CMV infection may cause in immunocompetent patients. Methods We reviewed the evidence associated with severe manifestations of CMV infection in apparently immunocompetent patients and the potential role of antiviral treatment for these infections. We searched in PubMed, Scopus, and the Cochrane Library for the period of 1950–2007 to identify relevant articles. Results We retrieved 89 articles reporting on severe CMV infection in 290 immunocompetent adults. Among these reports, the gastrointestinal tract (colitis) and the central nervous system (meningitis, encephalitis, transverse myelitis) were the most frequent sites of severe CMV infection. Manifestations from other organ-systems included haematological disorders (haemolytic anaemia, thrombocytopenia), thrombosis of the venous or arterial vascular system, ocular involvement (uveitis), and lung disease (pneumonitis). The clinical practice reported in the literature has been to prescribe antiviral treatment for the most severe manifestations of monophasic meningoencephalitis (seizures and coma), ocular involvement, and lung involvement due to CMV. Conclusion Severe life-threatening complications of CMV infection in immunocompetent patients may not be as rare as previously thought.
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            Infectious mononucleosis.

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              Cytomegalovirus infection in immunocompetent critically ill adults: literature review

              Cytomegalovirus (CMV) infection is increasingly recognized in critically ill immunocompetent patients. Some studies have demonstrated an association between CMV disease and increased mortality rates, prolonged intensive care unit and hospital length of stay, prolonged mechanical ventilation, and nosocomial infections. However, there is a considerable controversy whether such association represents a causal relationship between CMV disease and unfavorable outcomes or just a marker of the severity of the critical illness. Detection of CMV using polymerase chain reaction and CMV antigenemia is the standard diagnostic approach. CMV may have variety of clinical manifestations reflecting the involvement of different organ systems. Treatment of CMV in critical care is challenging due to diagnostic challenge and drug toxicity, and building predictive model for CMV disease in critical care setting would be promising to identify patients at risk and starting prophylactic therapy. Our objective was to broadly review the current literature on the prevalence and incidence, clinical manifestations, potential limitations of different diagnostic modalities, prognosis, and therapeutic options of CMV disease in critically ill patients.
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                Author and article information

                Journal
                Canadian Journal of General Internal Medicine
                Can Journ Gen Int Med
                Dougmar Publishing Group, Inc.
                2369-1778
                1911-1606
                August 27 2018
                August 27 2018
                : 13
                : 3
                : 39-43
                Article
                10.22374/cjgim.v13i3.258
                dc734e7f-91c8-4476-9b1c-e3cbb33439dc
                © 2018

                Copyright of articles published in all DPG titles is retained by the author. The author grants DPG the rights to publish the article and identify itself as the original publisher. The author grants DPG exclusive commercial rights to the article. The author grants any non-commercial third party the rights to use the article freely provided original author(s) and citation details are cited. To view a copy of this license, visit https://creativecommons.org/licenses/by-nc/4.0/


                General medicine,Geriatric medicine,Neurology,Internal medicine
                General medicine, Geriatric medicine, Neurology, Internal medicine

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