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Complicaciones=
de
la Mononucleosis infecciosa en la edad adulta. A propósito de un caso clínico. <=
/b>
Complications of infectious mononucleosis in
adulthood. On the subject of a clinical case.
Tirapé Castro
Hugo Arturo. ,
Cajamarca Sacta Lía Cristina. , Villa Cuzco Leonardo Vicente. & Uguńa Uguńa Daniel Esteban
D=
OI: https://doi.org/10.33262/anatomiadigital.=
v3i4.1472
Abstract.
Infectious mononucleosis is a disease caused mai=
nly
by the Epstein-Barr virus, it is widespread and it generally occurs in
childhood and adolescence, cases in adulthood are rarely reported. Due to=
its
very general characteristics such as thermal rise, pharyngitis and
lymphadenopathy, being in most cases self-limited and together with a low
incidence of complications in its evolution, it is usually no to diagnose=
d and
it is confused with similar conditions such as the cold. However, there i=
s a
small percentage of these patients who can have much greater complications
and can even lead to death if they are not properly diagnosed and managed,
especially when they reach adulthood. Next, a clinical case of atypical
mononucleosis is presented, since characteristics such as age, initial
manifestations, as well as complications were not the usual ones, which is
why it is proposed not to forget the existence of this pathology in
differential diagnoses and the importance of an adequate assessment and
management.
Keywords: Infectious Mononucleosis, Adult, Complications,
Epstein Barr, Hepatic.
Resumen.
La mononucleosis infecciosa es una enfermedad oc=
asionada principalmente por el virus Epstein-Barr, está ampliamente extendi=
da y generalmente se produce en la infancia y la adolescencia, siendo poco =
común reportar casos en la edad adulta. Debido a sus características muy ge=
nerales como alza térmica, faringitis y adenopatías, siendo en la mayoría d=
e casos auto limitada y junto a una baja incidencia de complicaciones en su=
evolución, hacen que sea habitual no diagnosticarla y confundirla con cuad=
ros similares como por ejemplo el resfriado común. Sin embargo, existe un p=
equeńo porcentaje de estos pacientes que pueden tener complicaciones mucho =
mayores e incluso llegar a la muerte si no son adecuadamente diagnosticados=
y manejados, sobre todo al llegar=
a la edad adulta. A continuación,=
se presenta un caso clínico de mononucleosis atípica, ya que característic=
as como edad, manifestaciones iniciales, así como las complicaciones no fue=
ron las habituales, motivo por el que se propone no olvidar la existencia d=
e esta patología en los diagnósticos diferenciales y la importancia de una =
adecuada valoración y manejo. Palabras claves: Mononucleosis Infecciosa, Adulto, Complicaciones=
, Epstein Barr, Hepática
Introducción.
La mononucleosis es una enfermedad infecciosa de
origen viral también conocida como la enfermedad del beso debido a que esta=
es
la vía más ampliamente usada por el virus para diseminarse ( Méndez-Sánchez,
N., Uribe, M., 2004, p. 75) ,
se produce en un 95% por el virus Epstein-Barr, pudiendo en un porcentaje
cercano al 2% ser producido por Citomegalovirus ( Tinoco
Racero, I., Caro Gómez, N., Rodríguez Leal, C., López Tinoco, E., 2014, p.
2954) y en un porcentaje aún m=
enor
por Toxoplasma gondii ( García-=
Torres,
M.L., Primo, J., 2008).
Epidemiológicamente la mononucleosis es una
enfermedad ampliamente distribuida a nivel mundial, siendo así que se tiende
datos que llevan a pensar que el 95% de los individuos sanos tienen marcado=
res
serológicos positivos para Epstein-Barr, habiendo cursado la enfermedad sin
haberse percatado de la misma (Markin, R.S., 1994, =
p. 1 ) ( Fica,
A., 2003 p. 235 )
( Angulo,
A., Arizcurren, M., Tiberio López, Oteiza Olaso., 2003, p. 311 ). Esto se da debido a q=
ue
las características clínicas de la mononucleosis son muy inespecíficas (alza
térmica, astenia, odinofagia y presencia de linfadenopatía) lo cual hace fá=
cil
la confusión con un proceso gripal común, esto sumado a que la mayor parte =
de
los pacientes tienen una evolución favorable debido a que la enfermedad es
autolimitada, dificulta aún más su identificación. ( Balfour,
H., Dunmire, S., Hogquist., 2015)
Pese a que es una enfermedad bastante común en
nuestro entorno y tal vez por la poca incidencia en complicaciones en Ecuad=
or
no se tiene un dato estadístico exacto sobre el porcentaje de pacientes con
marcadores para Epstein-Barr, sin embargo en un estudio realizado por G. To=
bar
en la ciudad de Quito en el cual de una muestra aleatoria de 85 adolescente=
s de
entre 14 y 15 ańos determinó que el 96.48% de los participantes tenían
anticuerpos IgG para VEB y apenas un 3.52% no lo tenían dejando en evidencia
que al menos 9 de cada 10 jóvenes se han contagiado antes de cumplir la may=
oría
de edad. ( Balfour et al., 2015)
Se debe considerar que, pese a que las
complicaciones no suelen ser frecuentes, estas existen y se encuentran liga=
das
a diversos factores, siendo uno de los más importantes la edad, ya que mien=
tras
más joven sea el paciente menos complicaciones tendrá, esto en relación a
aquellos pacientes que se contagian ya en la edad adulta ( Littman,
A., Rossing, M., Madeline, M., Chen, M., Yasui, Y., 2003, p.728).
Repor=
te
de caso.
Paciente masculino de 27 ańos de edad, etnia mesti=
za,
sin hábitos dańinos para la salud de importancia, sin antecedentes patológi=
cos
personales relevantes para el caso, madre con hepatopatía no especificada y
hermana con artritis reumatoide. Presenta cuadro de 7 días de evolución
caracterizado inicialmente por dolor abdominal tipo cólico de moderada
intensidad, se acompańa de astenia, hiporexia, alza térmica no cuantificada,
odinodisfagia y deposiciones diarreicas en número aproximado de 4 por día en
poca cantidad, acude a medico quien diagnostica de gastroenteritis y envía<=
span
style=3D'mso-spacerun:yes'> tratamiento a base de Levofloxacina 750=
mg
cada día, mismo que toma por 3 días sin presentar mejoría, 24 horas previo =
a su
ingreso el cuadro de dolor abdominal se exacerba, razón por la cual es valo=
rado
en el servicio de emergencias, destaca al examen físico piel con tinte icté=
rico
generalizado, mucosas orales secas, lengua saburral, neurológicamente con tendencia a la
somnolencia, en cuello se evidencia presencia de adenopatías cervicales
bilaterales de 0.5cm de diámetro, no dolorosas no móviles, hemodinámicamente con una frecuencia ca=
rdiaca
de 130 latidos por minuto, tensión arterial 140/100mm/hg, saturando sobre 9=
0%
sin soporte de oxígeno complementario, con patrón respiratorio adecuado, el
abdomen blando, leve dolor a la palpación profunda en hipocondrio derecho e
izquierdo, con ruidos hidroaéreos conservados,
diuresis adecuadas, al momento sin alza térmica, se realizan exámenes
complementarios evidenciando en ecografía abdominal vesícula distendida de
paredes engrosadas, alitiásica, con colédoco permeable, mientras que en la
química sanguínea se evidencia aumento de: leucocitos 16200 células/ľl,
neutrófilos 19.8 X 103 ľl, linfocitos 74.1 X 103 ľl, TGO=
217.5
U/L, TGP 334.5 U/L, GGT 1425 U/L, bilirrubina directa 6.3 mg/dl, fosfatasa
alcalina 206 U/L, se plantean diagnósticos iniciales de colangitis vs síndr=
ome
colestásico, equipo quirúrgico decide realizar colangiopancreatografía
retrógrada endoscópica, durante el procedimiento encuentran vía biliar de
aproximadamente 0.5 cm permeable, sin imágenes endoluminales, pese a ello se
coloca stent, proceden a iniciar terapia antibiótica a base de Piperacilina=
+
Tazobactam 4,5 gramos IV cada 6 horas, sin embargo se evidencia que los val=
ores
de transaminasas continúan en aumento con bilirrubina directa (8 mg/dL), se
realiza exámenes serológicos para hepatitis con resultados negativos, por lo
cual el servicio de cirugía interconsulta a reumatología bajo sospecha de
hepatitis autoinmune quien solicita los marcadores correspondientes (ANAS,
AMA-M2), panel hepático autoinmune, panel gastrointestinal autoinmune y
complementos C3 y C4, siendo todos estos resultados negativos.
El deterioro hepático se exacerba, mediado por
elevación de bilirrubina directa a 9.6 mg/dL y se suma al cuadro descenso
sostenido de los valores de sodio sérico los cuales no se mantienen normales
tras realizar correcciones rápidas, siendo necesario nuevas correcciones
diarias, por lo cual es valorado con el servicio de endocrinología que cataloga al paciente=
como afectado
por un SIHAD (secreción inadecuada de la hormona antidiurética) y se indica
dejarlo con restricción hídrica, se interconsulta al servicio de cuidados
críticos, quienes disponen sea recibido en el servicio de terapia intermedi=
a, se
realizan exámenes complementarios como determinación de cortisol, electroli=
tos
en orina, T3 T4 TSH, además de
tomografía abdominal contrastada en busca de masas tumorales, así como
marcadores tumorales en sangre, siendo todos estos negativos.
El paciente va deteriorando su estado y se suma ah=
ora
presencia de calambres generalizados continuos, además se evidencia que los
valores de TGO y TGP continúan incrementándose en los días posteriores, (TGO
516 U/L TGP 514 U/L) se consulta al servicio de Gastroenterología quien a=
nte
la duda del procedimiento inicial CPRE solicita la realización de una
Resonancia Magnética de vías biliares, reportándose normal, el paciente
persiste con cuadros febriles sin mejoría desde su ingreso, por lo cual se
interconsulta al servicio de infectología quienes tras valoración solicitan prueba de Epstein Barr, siend=
o este
positivo se maneja a paciente con hidratación parenteral, adicionalmente us=
o de
vitamina A por vía oral, con lo cual presenta una evolución favorable en un
lapso de 4 días, con posterior disminución de los valores de enzimas hepáti=
cas,
después de 12 días de hospitalización, y 2 en el área de cuidados intermedi=
os
paciente es dado de alta en mejores condiciones y bajo vigilancia
epidemiológica.
Revis=
ión
de Literatura.
Dentro de las posibles
complicaciones patológicas de la mononucleosis infecciosa está el compromiso
hepático, específicamente la hepatitis, que suele cursarse de forma leve y =
auto
limitada, sobre todo en los pacientes inmunocompetentes, esto es debido a q=
ue
uno de los principales virus causantes de la mononucleosis infecciosa es el
virus de Epstein Barr, el mismo que durante su proliferación tiende también=
a
afectar las células hepáticas. En caso de
que la inflamación se vuelva persistente puede deberse al síndrome de
infección crónica activa por virus de Epstein Barr. ( Cisneros-Herreros, J.M.,
Herrero-Romero, M., 2006, p. 392).
La afectación hepátic=
a se
evidencia por un leve aumento de transaminasas, tanto ALT como AST, el cuad=
ro
no cursa de forma agresiva por lo que no amerita de una biopsia hepática, y
solo el 5% desarrollará una hepatitis aguda colestásica. En ocasiones pudie=
ra
presentar conjuntamente linfocitos atípicos en sangre periférica así como
anticuerpos inmunoglobulina M contra la cápside VCA, esto atribuido a toxicidad ocasionada p=
or la
ingesta de antiinflamatorios no esteroideos como por ejemplo el ibuprofeno.=
(Barreales,
M., Pérez Carreras, M., Meizoso, T., Garrido, M., Masedo, A., Colina, F.,
Solís, J.A., 2006, p.483).
Tratamiento
Aunque en la actualid=
ad
no exista un tratamiento curativo de la mononucleosis infecciosa, podemos
incluir cierta terapia que según la bibliografía consultada y estudios
realizados aportan un grado válido de mejoría clínica sea en cuanto a sínto=
mas
o duración de la enfermedad y carga vírica. La mononucleosis infecciosa no
complicada responde de forma adecuada al tratamiento sintomático en la mayo=
ría
de los casos, tales medidas son líquidos, dieta blanda y evitar realizar
ejercicio por un tiempo aproximado de un mes mientras se resuelve la
esplenomegalia (en el caso de que esta sea confirmada) para evitar complica=
ciones
como la ruptura de la misma. (Rezk=
, E.,
Nofal, Y.H., Hamzeh, A., Aboujaib, M.F., AlKheder, M.A., Al Hammad, M.F., 2=
015)
Asociado a estas medi=
das
generales se puede incluir como tratamientos farmacológicos que ayuden al
alivio de los síntomas más comúnmente presentados en la enfermedad a
medicamentos tales como analgésicos y antipiréticos por ejemplo paracetamol=
o
ibuprofeno enfocados para manejo de alzas térmicas, inflamación y dolor.
Hay que tener especial
cuidado con el uso de ácido acetil salicílico ya que al tratarse de una
enfermedad vírica es posible el riesgo de síndrome de Reye. (Rezk et al. 20=
15)
Corticosteroides
En el estudio Estero=
ides
para el control de síntomas de mononucleosis infecciosa publicado en el ańo
2015 el tratamiento con esteroides alivió el dolor de garganta a corto plaz=
o (a
las 12 horas). Los investigadores notaron un beneficio a los dos o cuatro d=
ías
cuando los esteroides se usaron en combinación con un fármaco antiviral, pe=
ro
estos hallazgos son limitados ya que se evaluaron en uno o dos ensayos
solamente.
Los hallazgos sobre el
efecto de los esteroides solos o cuando se usan con un fármaco antiviral pa=
ra
otros síntomas fueron menos claros. Como conclusión se obtuvo que no h=
ay
evidencia suficiente de la eficacia de los esteroides para controlar los
síntomas de la mononucleosis infecciosa. Hay una falta de investigación sob=
re
los efectos secundarios y las complicaciones a largo plazo. (Rezk et al. 2015)
Antivirales
En el estudio agentes virales p=
ara
la mononucleosis infecciosa se incluyeron siete ECA con un total de 333
participantes en la revisión, los antivirales de los estudios incluidos fue=
ron:
aciclovir, valomaciclovir y valaciclovir. El seguimiento osciló entre 20 dí=
as y
seis meses. El diagnóstico de mononucleosis infecciosa se basó en los sínto=
mas
clínicos y los parámetros de laboratorio. La calidad de las pruebas se cali=
ficó
como muy baja para todos los resultados por lo que estos deben interpretarse
con cuidado. Se evidencio que hubo una reducción media en la duración de la linfadenopatía =
de
nueve días (IC del 95%: &=
#8208; 11,75 a ‐ 6,14; dos estudios, 61 participantes) a favor del
grupo de tratamiento. En cuanto a la replicación viral, el efecto general de
seis estudios fue la supresión de la replicación al administrar tratamiento=
con
antivirales, aunque este efecto no se mantuvo al interrumpir el tratamiento=
. Para
todos los otros resultados, no hubo diferencias estadísticamente significat=
ivas
entre los grupos de tratamiento antiviral y de control. (De Paor, M., O'Bri=
en, K., Fahey, T., Smith, S.M., 2016).
Como conclusiones los autores manifiestan que la efectividad de los agentes antivirales (acicl=
ovir,
valomaciclovir y valaciclovir) en la mononucleosis infecciosa aguda es
incierta. La calidad de las pruebas es muy baja. La mayoría de los estudios
incluidos estuvo en riesgo de sesgo poco claro o alto por lo cual aún hay
interrogantes acerca de la efectividad de esta intervención. (De Pao=
r et
al. 2016).
Discu=
sión.
La
mononucleosis infecciosa es una enfermedad ampliamente distribuida a nivel
mundial, con mayor incidencia en países en vías de desarrollo y en Ecuador =
su
presencia está dada mayormente en la infancia y la adolescencia presentando
anticuerpos IgG en 8 de cada 10 personas antes de cumplir los 16 ańos (Méndez-Sánchez,
N., Uribe, M., 2004, p. 75). Al ser una enfermedad q=
ue en
la mayoría de ocasiones se presenta como autolimitada y con una sintomatolo=
gía
muy poco específica es común que pase desapercibida. ( Barreales,
M., Pérez Carreras, M., Meizoso, T., Garrido, M., Masedo, A., Colina, F.,
Solís, J.A., 2006, p. 483) En el caso presentado =
se
evidencia por tanto una de esas excepciones a la regla, pues el paciente er=
a un
adulto, quien debuta con una sintomatología distinta a la habitual y presen=
ta
varias complicaciones que luego en retrospectiva parecieran ser bastante ob=
vias,
sin embargo a su debido momento causaron confusión al personal de salud, si=
endo
este caso un ejemplo de como en ocasiones una enfermedad con un manejo
inadecuado puede terminar complicando e incluso comprometiendo la integrida=
d de
un paciente.
El pa=
ciente
ingresa con un cuadro de 7 días de dolor abdominal, alza térmica y deposici=
ones
diarreicas, lo cual de entrada no nos sugiere por los síntomas como parte de
los diagnósticos diferenciales a la mononucleosis infecciosa y al momento d=
e su
ingreso el paciente suma al cuadro tinte ictérico lo cual sugiere al person=
al
de salud la patología colangitis (triada de Charcot) ( Camacho, J.F., 2012, p. 148) , se realizan los exámenes complementarios y
encuentran en ellos elevación de las transaminasas, bilirrubinas elevadas y
formula leucocitaria alta lo cual casi confirma la sospecha de los
especialistas de una colangitis esto sumado a una ecografía que muestra una
vesícula distendida de paredes gruesas, lo que lleva al personal médico a
decidir realizar una CPRE, para sorpresa del equipo médico la vesícula está
libre y es de paredes conservadas, esto debido en gran manera a que la
patología vesicular aguda es una entidad muy común dentro de los diagnóstic=
os
diferenciales de dolor abdominal, y si bien la ultrasonografía es uno de los
métodos más fácilmente accesibles no podemos olvidar que este es un método
operador-dependiente lo cual aumenta la probabilidad de confusión. ( Motta
Ramírez, G., Rodríguez Trevińo, C., 2010).
Los valores de transaminasas así como
bilirrubinas siguieron aumentando, otra sospecha diagnostica que se barajo =
fue
la posibilidad de una Hepatitis Toxica producida por los medicamentos
utilizados previo ingreso del paciente, ya que esta patología suele present=
arse
tras la administración de fármacos y exacerbar al poco tiempo sin dar cambi=
os
estructurales a nivel hepático ( Navarro, V., Senior, =
J.,
2006, p. 354), sin embargo al realizar revisar en los antecedentes del paciente est=
e ya
había tomado dicha medicación previamente sin haber presentado ningún tipo =
de alteración
( Andrade,
R.J., Tulkens, P.M., 2011, p.1431) , de igual manera se descartó algún tipo de hepati=
tis
alcohólica ya que el paciente era abstemio y jamás había consumido alcohol =
en
su vida, razón por lo cual el equi=
po médico
decide realizar exámenes complementarios bajo sospecha de una hepatitis
autoinmune y pese a que este es más frecuente en mujeres ( García-Torres, M.L.,
Primo, J., 2008, p.400), no se puede descartar la posibilidad de su presencia ante un caso en=
el
cual se han desechado ya otras patologías más comunes, sin embargo estas
también fueron negativas.
A este
caso se suma hiponatremia, los valores de sodio no se recuperan pese a las
correcciones que se realizan, esto confunde aún más al personal de salud ya=
que
siempre se orienta primero a pensar en una misma enfermedad que produce dos
síntomas antes de pensar en dos
enfermedades distintas en el mismo paciente, sin embargo bajo sospecha de S=
IHAD
como enfermedad de descarte (Tensiones arteriales normales, Densidad urinar=
ia
dentro de rangos y aumento del sodio urinario), endocrinología sugiere
restricción hídrica como tratamiento de base, lo cual desencadena un aument=
o en
las enzimas hepáticas y en una descompensación del paciente acompańada por
calambres continuos y dolor generalizado. ( Runkle & Villabona, 2014, p.425)
Se
reinstaura proceso febril y con un paciente ya en cuidados intermedios se
realizan pancultivos siendo todos estos negativos, una valoración integral =
del
paciente y una vista en retrospectiva nos permite revalorar al mismo y busc=
ar
nuevas opciones diagnósticas. Considerando la fiebre, los ganglios inflamad=
os,
la odinofagia y el posterior deterioro hepático del paciente, en conjunto c=
on
el servicio de infectología se decide realizar examen de Epstein Bar, dando
este un resultado positivo, se reinicia hidratación amplia a paciente y los
valores hepáticos mejoran considerablemente. (Méndez -Sánchez
& Uribe, 2004, p.75)
Conclusiones:
En el
caso presentado de un paciente adulto sin hábitos ni antecedentes de
importancia se suscita un cuadro hepático que lo lleva a permanecer en el
ámbito hospitalario durante 12 días, recibiendo múltiples exámenes e incluso
procedimientos invasivos, para posteriormente ser diagnosticado de
Mononucleosis Infecciosa, llevándonos a las siguientes conclusiones:
ˇ =
Nos recuerda que la medicina no siempre es s=
olo la
suma síntomas y signos, sino el proceso lógico y estratificado de encontrar=
la
causa del problema sin olvidar la atipicidad de cada patología.
ˇ&nb=
sp;
La importancia
fundamental de la historia clínica detallada, exhaustiva no solo en los síntomas sino también e=
n los
factores de riesgo dentro de los tiempos acordes a las patologías probables=
.
ˇ&nb=
sp;
El trabajo del equ=
ipo
médico multidisciplinario en los pacientes con cuadros atípicos es fundamen=
tal
para considerar los diferentes enfoques y caminos a seguir en pos de descub=
rir
y lograr la curación de las diferentes patologías de difícil resolución.
=
Referencias Bibliographical.
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of
antibiotics used in primary care. J
Antimicrob Chemother , 66(7), 1431-1446 https://=
doi.org/10.1093/jac/dkr159
Angulo,
A., Arizcurren , M., Tiberio López, Oteiza Olaso . (2003)
Clinical and analytic characteristics and complications in patients with
infectious mononucleosis referred from primary care to specialists. Atención
Primaria, 311.
Balfour, H., Dunmire, S., Hogquist. (2015) Infecti=
ous
mononucleosis: clin transl immunology. http://www.nature.com/cti/jour=
nal/v4/n2/pdf/cti20151a.pdf
Barreales,
M., Pérez Carreras, M., Meizoso , T., Garrido, =
M., Masedo , A., Colina, F., Solís, J.A. (2006) Infección =
por el
virus de Epstein-Barr y hepatitis aguda colestásica. Servicios de Medicina Aparato Digestivo y Anatomía Patológica. Hospital
Universitario. AN. MED. INTERNA (Madrid), Vol. 23, N. ş 10, 483-486.
Camacho,
J.F. (2012) Historia y filosofía de la medicina: Charcot y su legado a la m=
edicina.
Gaceta Médica de México, 6, =
148-321.
Cisneros-Herreros,
J.M., Herrero-Romero, M. (2006) Hepatitis por virus del grupo herpes. Enferm <=
/span> Infecc Microbiol Clin=
, 24,
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7De Paor , M., O'Brien,
K., Fahey, T., Smith, S.M. (2016) Antiviral agents for infectious
mononucleosis (glandular fever). Cochrane Database of Systematic Reviews, 1=
2, CD011487 https://doi.org/=
10.1002/14651858.CD011487
Fica,
A. (2003) Síndrome de mononucleosis infecciosa en pacientes adolescentes y
adultos. Revista Chilena de Infectología , 20, 235-242.
García-Torres,
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