Fifteen patients with infectious mononucleosis (IM) had neurological signs and symptoms as the major and/or heralding features of the illness. In six, the only detectable clinical manifestations were neurological. The incidence of objective neurological involvement among 144 patients hospitalized with IM was 5.5%. Infectious mononucleosis should be one of the etiological considerations in children and young adults presenting with short histories and showing neurological deficits reflecting involvement of almost any part of the nervous system. Pharyngitis, adenopathy, splenomegaly, etc, need not be present.

Nervous system involvement in infectious mononucleosis. The heralding and-or major manifestation.

Infectious mononucleosis, considered here to be the same as 'glandular fever', has been regarded as a very rare cause of death. However, the number of reports said to describe fatalities from this disease has increased considerably in recent years. In 1953, Leibowitz found 38 case reports in the literature. Later, Albuquerque (1966) was able to find 50. By the end of 1969 the disease had been reported as proving fatal in at least 87 instances. In England and Wales from two to 11 deaths had been notified annually to the Registrar General (Statistical Review, 1968) during the years 1957 to 1967, and Thomsen and Vimtrup (1939) stated that they had observed even during the years 1927 to 1939 a mortality rate of about 1 %. A major problem in assessing previous reports is the frequent uncertainty of the diagnosis. Many diagnoses have been based on inadequate haematological or serological data. Some have been made only after histological examination of tissues (especially spleen, liver, and lymph nodes). But although the histological changes in infectious mononucleosis may be impressive they are not specific for this disease (Carter and Penman, 1969). Because of these difficulties in interpretation, both the actual number of reported fatalities from this disease and the relative incidence of the various complications as causes of death are uncertain. In this review, previous reports are examined critically in order to gain some idea as to how often death really has been reported in proven infectious mononucleosis, and to decide which complications may, on occasion, be fatal. The reported causes of death may be grouped thus: (1) splenic rupture; (2) neurological complications (excluding cerebral haemorrhage); (3) respiratory obstruction; (4) secondary infection; (5) liver failure; (6) miscellaneous. Each group will be

https://jcp.bmj.com/content/jclinpath/23/9/765.full.pdf

Fatal infectious mononucleosis: a critical review.

Excerpt Although involvement of the nervous system in patients with infectious mononucleosis has been described frequently during the past few years, its incidence has not been defined precisely. I...

Involvement of the nervous system in infectious mononucleosis

This report describes five patients who, following a neurologically complicated primary Epstein-Barr virus infection, developed progressive or relapsing neurologic deficits. The sequelae in four patients followed 4 to 12 years led to the diagnosis of multiple sclerosis (MS). The fifth patient presented with acute disseminated sclerosis and exhibits diffuse neurologic deficits that have persisted for 2 years. We suggest that the diagnosis of an unexplained acute neurologic or psychiatric syndrome should raise the question of a primary EBV etiology. A precisely timed serologic and hematologic study of the blood is imperative to capture the essential evidence. The data presented represent a clinical association between a neurologically complicated primary EBV infection and both chronic and acute demyelinating disease. The evidence does not justify a conclusion that EBV virus causes MS.

Demyelinating disease after neurologically complicated primary Epstein-Barr virus infection.

We examined 11 adult patients with cerebellar encephalitis (CE) during the acute phase of the disease and at least 12 months later. Five patients were aged between 23 and 31 years, 3 patients between 43 and 44 years and 3 patients between 60 and 64 years. Serological tests gave evidence of Epstein-Barr virus infection in 4 of the 5 young patients. Two patients had serological evidence of varicella-zoster virus reactivation, whereas the serological findings were negative in all other cases. All patients in the younger and middle age groups recovered within 3-30 weeks after onset of CE. If at all, they had only minor cerebellar deficits at the follow-up examination. Magnetic resonance imaging (MRI) examination performed at the follow-up examination was normal in all of them. In contrast, 2 of 3 patients older than 60 years had persistent cerebellar ataxia following CE. In these patients, MRI revealed infratentorial atrophy. Our data show that the clinical spectrum of CE in adults is wider than assumed so far. In addition to typical cases of CE in young male patients with good recovery, CE may also occur in older patients and give rise to persistent cerebellar ataxia.

Cerebellar encephalitis in adults

INFECTIOUS mononucleosis, until recently, has been regarded as a mild disease with few complications and with a uniformly favorable outcome. Glanzmann,1in 1930, stated in his monograph that the prognosis in infectious mononucleosis, as in German measles, is absolutely favorable. In the opinion of Contratto2(1944) infectious mononucleosis is attended with no more complications than an ordinary infection of the respiratory tract. However, there are several forms of serious complications in this disease (hepatitis, thrombocytopenia, myocarditis, spontaneous rupture of the spleen and involvement of the central and peripheral nervous system), with instances of fatal outcome from the latter three. Multiple serious complications may occur in the same patient. Electrocardiographic changes have been reported by several authors,3with death in Jersild's3acase, Microscopic evidence of focal myocarditis and of involvement of the central nervous system was found in a recently discharged convalescent patient who had died in an airplane crash on

George S. Husson

Papers

Infectious mononucleosis with neurologic complications; report of a fatal case.