Author:Gao Xiaopeng[1]Huang Xingqin[2]
Units:[1] Xi'an Children's Hospital Central Laboratory [2] Department of Hematology, Southwest Hospital of Army Military Medical University
Spring has come, the earth has awakened, everything has revived, the spring girl has draped the earth with green clothes, the grass has grown tender buds, and the flowers have bloomed, which is beautiful. Families want to take their children outdoors, and infectious mononucleosis, which is more prevalent in children, is also increasing.
The new crown is raging, and Chang'an has finally unsealed it! Finally, work resumed, and the number of outpatients slowly increased. At 9 o'clock in the morning, my colleague held the child and took a blood list to see us, wondering if there was a problem with blood diseases. Holding the blood routine, I saw the following results:
Mild increase in white blood cells, lymphocyte ratio and absolute values, mild anemia, normal platelet count. Asked about the child's basic situation: 3 years old and June boy, just returned from his grandparents' hometown after the Spring Festival, had a fever for four days and a body temperature of up to 40 ° C. The child's face is pale, the spirit is slightly weak, the eyes are quite large, but the eyelids look a little swollen, although the child's reluctant opening can also see the enlarged tonsils, the surface has purulent discharge, and the left side of the neck is obviously enlarged with three small lymph nodes.
Seeing such clinical and blood routines, considering the most likely infectious mononucleosis, it is recommended to directly prick a finger to push the blood slide to see the lymphocyte morphology and lymphatic lymphoids. After 10 minutes of rapid dyeing, the reading and classification patterns are as follows:
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After microscopic classification, the handwritten report was written: white blood cells were mildly elevated, and 16% of the lymphocytes were accounted for; the morphology of red blood cells was generally normal; the small clusters of platelets were visible and the morphology was roughly normal. EBV antibody testing is recommended.
The next day, colleagues reported that the EBV IgM antibody was positive and he was hospitalized.
Let's take a look at infectious mononucleosis.
Infectious mononucleosis, commonly known as "kissing disease", is an acute self-limiting infectious disease caused by EBV (belonging to the herpes virus) infection. The EBV is abundant in oral secretions and can persist for weeks, months, or even years. It is super contagious, kissing, sharing tableware, droplets will cause transmission, especially through close oral contact transmission, mainly invading children and adolescents, can invade multiple system organs of the human body, is the most common infectious disease in pediatrics. In the past two years, due to the new crown epidemic, the whole people wear masks, and people's science popularization and awareness in this regard, the incidence rate has decreased slightly, but it is still often seen. It can be imagined that the rare epidemic liberation is the Spring Festival, visiting relatives and friends, such a cute baby can not avoid being kissed by a meal, it is easy to induce "kissing disease". In fact, flyers occur throughout the year, but spring and autumn are high seasons, and they are more common in children aged 3 to 6 years. Spring blossoms, everything recovers, and the virus also uses every opportunity to attack the human body.
Clinical manifestations
The main clinical manifestations of the leaflets are fever, angina pharyngitis, cervical lymphadenopathy, that is, "triple sign", more than 50% of patients have mild splenomegaly, eyelid edema, liver damage, rash, etc., severe diseases may appear EBV-related hemophagocytic syndrome, encephalitis, myocarditis and other complications.
How are flyers diagnosed?
The diagnosis of infectious mononucleosis generally requires 2 tests.
The first is intravenous blood test EBV antigen or antibody detection, EBV-related tests mainly include: EB-VCA-IgM, EB-VCA-IgA, EB-EA-IgG, EB-EA-IgA combination antibody detection, EB-VCA-IgM (EBV virus capsid antigen IgM antibody) positive can confirm that it is in the acute infection period. A higher than normal EBV-DNA is also an important indicator of EPV infection. Such results are reported for more than four hours or the next day.
The second is to look at the peripheral blood smear, whether there are elevated lymphocytes, whether there are dysysphotyped lymphocytes, and the abnormal changes in the lymphocytes of the blood tablets under the microscope can quickly diagnose the leaflets.
Dysypolytic lymphocytes
So what are dysphthymic lymphocytes? This is what we usually call "heterogeneous". They are lymphocytes due to viral or drug stimulation response, causing lymphocytes to undergo regression changes, that is, primitive cytosis and naïve cytosis, its morphology is diverse, mainly manifested as cell volume increase, cell edge irregularity, deep dyeing can appear "skirt" phenomenon; cytoplasmic volume is more abundant, coloring from light blue to dark blue; the nucleus can also be irregular, chromatin loose enough dense, as shown in the following figure. In the EBV infection 4-5 days, 7-10 days to reach the peak, blood xyrrhea > 10% consider the flyer may be large, of course, in the chicken pox - herpes zoster virus, cytomegalovirus, hantavirus and other patients with blood smear will find different proportions of heterotypic lymphocytes.
Recommendations for the distribution of leaflet reports
The ICSH guidelines recommend that morphologically taxonomic counts report reactive lymphocytes as: atypical lymphocytes suspected of being reactive; when reactive lymphocytes ≥ 10%, level 2 can be described as "please combine clinically to exclude infectious mononucleosis possible", and level 3 may recommend viral infection-related testing.
Therapeutic measures for leaflets
At present, EBV infection can only be treated symptomatically, properly cared for, and in most cases can be self-healing. If more severe symptoms occur, it is necessary to use drugs such as ganciclovir and interferon for treatment or hospitalization under the guidance of a professional doctor.
In order to protect the baby from infection at the beginning of spring, you should wear a mask frequently in daily life, avoid kissing the child's mouth, especially do not feed with mouth to mouth, and use chopsticks. Once similar symptoms are found, first do the blood routine and push the film to see if there is dysplasia, and the increase in the lymphocytes of the blood tablet is diagnostic and fast to "kissing disease".
【Reference】
[1] Xia Yi, Gao Yu, Zhang Qing, et al. Clinical study of infectious mononucleosis caused by epstein-barred virus infection with multiple pathogens[J]. Chinese Journal of Pediatric Hematology and Oncology,2018,23(3):143-147.
Wang Qian,Zheng Lei,Sun Dehua. Diagnostic Atlas of Blood Cell Morphology. 2nd edition, Beijing: Science Press, 2021.3
[3] Guidelines for the Standardization of Blood Cell Analysis Reports, Hematology and Humors Group of the Laboratory Medicine Branch of the Chinese Medical Association, Chinese Journal of Laboratory Medicine, Vol. 43, No. 6, June 2020
Editor: Ren Mileage Reviewer: Xiao Ran