فهرست مطالب

Archives of Pediatric Infectious Diseases - Volume:5 Issue:3, 2017
  • Volume:5 Issue:3, 2017
  • تاریخ انتشار: 1396/05/15
  • تعداد عناوین: 16
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  • Shree V. Dhotre, Milind S. Davane, Basavraj S. Nagoba * Page 1
    Context: Earlier evidences show that periodontitis with inflamed and ulcerated crevicular or pocket epithelium surrounding the teeth may be a portal of entry for bacteria into the bloodstream. A newly proposed causal model predicts that an early bacteremia may affect the endothelial surface of the heart over many years and promote valve thickening rendering the heart valve susceptible to vegetation by a later bacteremia that would culminate over a few weeks into fulminant infection.
    Evidence Acquisition: In this review, various published sources of information pertaining to periodontitis, bacteremia and infective endocarditis were reviewed. This review is focused on the role of the viridans group streptococci (VGS) in periodontitis, bacteremia and infective endocarditis.
    Results
    The viridans group streptococci present in the oral cavity were the most important causes of bacteremia following dental procedures and infective endocarditis. In most of the studies, significantly higher rates of bacteremia occurring in patients with periodontitis than patients without periodontitis indicated that periodontitis opens up the route for oral streptococci to gain entry into the bloodstream. In addition, the significantly higher rates of isolation of the VGS from the patients of infective endocarditis with periodontitis showed that there was a positive association between periodontitis, infective endocarditis and the VGS.
    Conclusions
    The literature survey presented in this review suggests that there is a definite relation between periodontitis, bacteremia and infective endocarditis and would provide valuable data for the future dentists as well as the physicians, because a large proportion of the world’s population lives a lifetime with periodontitis. Moreover, infective endocarditis still remains a cause of concern as this disease is a cause of considerable morbidity and mortality regardless of modern antimicrobial and surgical treatment.
    Keywords: Periodontitis, Viridans Group Streptococci, Bacteremia, Infective Endocarditis
  • Farideh Shiva, Anahita Sanaei Dashti *, Hossein Hosseini Khorami Page 2
    Background
    Hospitalization exposes young infants to a high-risk environment. The aim of this study was to identify the reasons and risk factors associated with infant hospitalization.
    Methods
    Healthy infants of 6 to 24 months of age were recruited from outpatient clinics of university hospitals. Data collected from parents by trained personnel. Risk factors were compared between children hospitalized between 1 - 6 months of life (Group A), with those without hospitalization history (group B).
    Results
    A total of 1046 infants were participated in this study. Mean age was 13.3 months and 49.9% were females; 192 infants had been hospitalized as neonates, and 121 from 1 to 6 months. The Most common reasons for admission during the infancy period were proven or presumed sepsis, and respiratory (36.3%) or gastrointestinal problems (33%). There was a significant difference in hospitalization rate among infants in whom breastfeeding was discontinued before three months in comparison with those breastfed for at least three months, (30.1% vs. 8.1%, respectively, P = 0.000). This condition were similar for breast discontinuation from three to six months and after six months (24.1% vs. 8%, P = 0.000). Also, low birth weight, university education and maternal education less than nine years were statistically significant between group A and B.
    Conclusions
    Based on our data, low birth weight, discontinuation of breastfeeding and low levels of maternal education are identified as risk factors for infant hospitalization.
    Keywords: Infant, Hospitalization, Educational Status, Maternal, Low Birth Weight, Breastfeeding
  • Ferial Lotfian *, Golnaz Lotfian, Mohammad Reza Bolursaz, Payam Tabarsi, Aliakbar Velayati Page 3
    Background
    Tuberculosis (TB) is a main health problem worldwide. Despite the high incidence of TB in adolescents, studies mainly focus on the risk factors of TB in adults.
    Objectives
    The current study aimed at comparing the demographic, clinical, and microbiological characteristics of extrapulmonary TB (EPTB) and pulmonary TB (PTB) in adolescents.
    Methods
    The current retrospective study compared 30 EPTB and 113 PTB cases, aged 10 to 18 years, admitted to Masih Daneshvari Medical center, Tehran, Iran, from March 2006 to March 2011.
    Results
    The mean age of the patients with PTB and EPTB were 15.4 ± 2.3 and 16.1 ± 1.7 years, respectively. Sixteen (53%) and 74 (65.5%) of the patients with EPTB and PTB, respectively, were female. Multivariate logistic regression analysis showed that contact with adult patients with TB (odds ratios (OR): 0.07; 95% confidence intervals (CI): 0.009 - 0.58) and smear positivity (OR: 0.062; 95% CI: 0.005 - 0.80) were associated with PTB, while having a fever (OR: 21.49; 95% CI: 1.35 - 339.96) was associated with EPTB.
    Conclusions
    The current study findings in adolescent patients confirmed the quiet onset of EPTB with a lower rate of bacteriologic diagnosis and source detection rate. New strategies are required to improve the early diagnosis and prevention of EPTB in adolescents.
    Keywords: Tuberculosis, Adolescents, Extrapulmonary
  • Mahdi Behdani, Hoshang Rafatpanah, Alireza Mohammadzadeh*, Kiarash Ghazvini, Mostafa Amiri, Jalal Mardaneh Page 4
    Background
    Resistance to rifampin in multidrug-resistant M. tuberculosis (MDR-TB) is one of the major threats to the global public health system.
    Objectives
    The aim of the present study was to explore the molecular characterization of resistance against rifampin amongst multidrug-resistant (MDR) and extensively drug-resistant (XDR) isolates obtained from patients.
    Methods
    In this study, we used XDR (n = 6), MDR (n = 9) and rifampin sensitive (n = 39) isolates whose drug susceptibility patterns were identified by proportion method. A simple single-step multiplex-allele specific-polymerase chain reaction (MAS-PCR) assay was optimized to detect the three most frequent mutations in rifampin resistance-determining region (RRDR) fragment of rpoB gene. Additionally, single-strand conformational polymorphism (SSCP)-PCR and Sequencing were utilized.
    Results
    Out of nine MDR isolates, five were detected by MAS-PCR as rifampin resistant (sensitivity; 55.5%). In comparison with the proportion method, the sensitivity of SSCP for XDR, MDR and rifampin sensitive isolates were 83.3%, 77.7% and 97.4%, respectively. The DNA sequencing revealed that three of the 6 XDR isolates had several silent mutations, one isolate had one silent mutation, one strain had no mutations and only one isolate had mutations at codon 531.
    Conclusions
    In sum, although the molecular methods are rapid, they are not able to identify resistance against rifampin efficiently.
    Keywords: Mycobacterium tuberculosis, Multidrug, Resistant, Extensively Drug, Resistant, Rifampin
  • Alireza Mohammadzadeh, Jalal Mardaneh, Reza Ahmadi *, Javad Adabi Page 5
    Background
    Pseudomonas aeruginosa is a ubiquitous microorganism, which is present in diverse environmental niches and is seldom a member of normal human microbiota community. P. aeruginosa is an increasingly problematic drug-resistant bacterium in today’s world. In fact, we are now faced with growing clones of pandrug-resistant P. aeruginosa in hospital settings.
    Objectives
    The aim of the present study was to examine the antibiotic resistance patterns and presence of nan1 and int1 virulence genes (encoding neuraminidase and class 1 integrons, respectively) in clinical P. aeruginosa isolates and to analyze the measured values with regard to hospital wards, specimens, and antibiotic resistance of the strains.
    Methods
    In this cross sectional study, strains recovered consecutively from different samples of hospitalized patients between 2014 and 2016 in Gonabad, Iran, were tested. Culture of specimens was performed on common bacteriological culture media. The isolates were recognized as P. aeroginosa, based on morphological and biochemical tests. The isolates, identified as presumptive P. aeruginosa, were further confirmed by species-specific polymerase chain reaction (PCR) to detect exoA gene. All the isolates were tested for their antimicrobial susceptibility patterns, using the standard guidelines issued by the clinical and laboratory standards institute (CLSI). Genes encoding the virulence factors (nan1 and int1) were investigated by PCR using specific primers.
    Results
    Overall, 95 P. aeruginosa isolates were studied during the study period. The isolates were recovered from 30 (31.6%) males and 65 (68.4%) females. In total, 34 (35.5%) infected patients were in the age group of 30 - 44 years. There were 24 (25.3%) patients hospitalized in the intensive care unit (ICU). A total of 31 (32.6%) strains were isolated from the blood. Colistin was the most effective antibiotic against the isolates, and ticarcillin was the least effective antimicrobial agent. Based on the findings, 21.1% of the P. aeroginosa strains were resistant to the quinolone class of antimicrobial agents. Also, ceftazidime resistance was detected in the isolates (10.5%). Based on the results, 5.26% of the tested isolates were co-resistant to ceftazidime, amikacin, and piperacillin/tazobactam. Among 95 P. aeroginosa isolates on which PCR assay was performed, 44.2% had the nan1 gene.
    Conclusions
    Selection of the most effective anti-Pseudomonal drug (including in vitro test and report) is a decision best made by each clinical microbiology laboratory in consultation with the infectious diseases practitioners and pharmacologists, as well as therapeutic and hospital infection control committees. The guidelines for each bacterium include antibiotics of confirmed effectiveness, which show acceptable results in antibiotic susceptibility tests.
    Keywords: Hospital, Virulence Factors, Antibiotic Resistance, Pseudomonas aeroginosa
  • Parisa Badiee, Soheila Zareifar, Pedram Haddadi *, Hadis Jafarian Page 6
    Background
    Fungal infections are one of the most important causes of morbidity and mortality in patients with hematological disorders. The frequency of these infections has increased during the past decades.
    Objectives
    The rate of fungal infections was investigated in pediatric patients with hematological disorders, using traditional and real-time PCR methods, in order to establish proper management of these patients.
    Methods
    Over a 13-month period, 86 patients with hematological disorders were admitted and were kept under observation for the development of fungal infections. Fungal colonization was determined and clinical samples were examined by direct microscopic examination and culture. Blood specimens were cultured by bedside inoculation into a BACTEC medium. The results of the pathology smear were collected from the patients’ records. Real-time PCR was performed on all patients’ sera to diagnose invasive candidiasis and aspergillosis.
    Results
    Candida colonization was seen in 42 (48.8%) and oral candidiasis was diagnosed in 7 (8%) patients. The incidence of invasive fungal infections was 16.3% (14/86) with a mortality rate of 50% in pediatric patients. The etiologic agents were Candida albicans in 5 cases, Aspergillus flavus in 3, and Aspergillus fumigatus, Fusarium, Alterneria and Mucor, each in 1 case. In 2 cases with liver abscess, only Candida PCR was positive. Fungemia was observed in 4 patients.
    Conclusions
    The rate of invasive fungal infections in our study was high. Early and accurate detection of these infections could result in a better outcome. In critical ill cases where only blood samples are available, molecular methods such as PCR could be more effective than culture for the detection of etiologic agents.
    Keywords: Candidiasis, Aspergillosis, Hematologic Neoplasm
  • Marjan Iranzad, Mojdeh Hakemi-Vala * Page 7
    Background
    Urinary tract infections (UTIs) are the most common infectious diseases, imposing great costs on the community. Escherichia coli (E. coli) is the most frequent pathogen of UTIs. On the other hand, ciprofloxacin is a wide-spectrum antibiotic, used for the treatment of persistent and recurrent UTIs. Nevertheless, the increasing chromosomal or plasmid resistance of this bacterium has become a major health problem. In this study, we aimed to determine the role of parC, parE, and qnrB genes in ciprofloxacin-resistant E. coli isolates from urine samples of patients suffering from UTI.
    Methods
    Midstream urine samples of patients suffering from UTIs, who were referred to Imam Khomeini hospital, Tehran, Iran during May-October 2014, were collected and evaluated for E. coli isolates. All the isolates were subjected to antimicrobial susceptibility testing (AST) by the standard disk diffusion method, according to the clinical and laboratory standards institute (CLSI) 2014 guidelines. The role of chromosomal genes, parC and parE, in addition to plasmid gene qnrB, was determined by polymerase chain reaction (PCR) method and further sequencing.
    Results
    Among 124 patients, 64.5% of UTI cases were positive for E. coli. Based on the AST results, 77.5% of the isolates were resistant to ciprofloxacin. The size of PCR bands was 265 bp for parE, 389 bp for parC, and 268 bp for qnrB genes. Also, the frequency of intact genes among ciprofloxacin–resistant isolates was 90.9% for parC, 97.67% for parE, and 0% for qnrB genes. Some mutations were detected in the chromosomal genes after sequence analysis.
    Conclusions
    This study showed the important role of mutated chromosomal resistant genes in comparison with plasmid genes in the emergence of ciprofloxacin-resistant E. coli strains.
    Keywords: Urinary Tract Infections, Ciprofloxacin, Drug Resistance, Escherichia coli
  • Maryam Pourzare, Safoura Derakhshan *, Daem Roshani Page 8
    Background And Objectives
    Uropathogenic Escherichia coli (UPEC) strains are the most common cause of urinary tract infections (UTIs) in children. UPEC isolates express a range of virulence traits promoting effective colonization of urinary tract. The aim of this study was to determine antibiotic susceptibility and virulence determinants of UPEC isolated from children.
    Methods
    This cross-sectional study was performed on 32 E. coli strains recovered from urine samples of children with UTI aged 0 to 12 years in spring 2015 (between April and June) in Sanandaj, Iran. The isolates were examined by PCR for the presence of virulence genes encoding haemolysin (hly), cytotoxic necrotizing factor type 1 (cnf1), P-fimbriae (Pap), and afimbrial adhesin (afa). Sensitivity to antibiotics was determined using the disk diffusion method.
    Results
    The prevalence of genes encoding adhesins was 25% for pap, and 15.6% for afa. The hly and cnf genes encoding toxins were amplified in 15.6% and 25% of isolates, respectively. The strains isolated from hospitalized patients displayed a greater number of virulence genes compared to the isolates from outpatients. Different patterns of virulence genes were identified. Nitrofurantoin and trimethoprim/sulfamethoxazole were the most and least effective antibiotics with susceptibility rates of 96.9% and 21.9%, respectively.
    Conclusions
    These data show the need for monitoring of drug resistance and its consideration in the treatment of E. coli infections. Investigation of bacterial pathogenicity associated with UTI may help have better medical intervention and management of UTI.
    Keywords: Virulence Factors, Urinary Tract Infections, Drug Resistance, Escherichia coli
  • Fattaneh Sabzehali, Mehdi Goudarzi, Hossein Goudarzi *, Hadi Azimi Page 9
    Background
    The incidence of coagulase-negative staphylococci (CNS) isolates, as causes of hospital-acquired infections, is increasing annually and it is a truly global challenge.
    Objectives
    The current study aimed at assessing aminoglycoside resistance genes among CNS isolated from hospitalized patients and investigating the prevalence of methicillin and aminoglycoside resistance genes using molecular methods.
    Methods
    A total of 103 species of coagulase negative staphylococci were isolated from clinical specimens from August 2013 to November 2014. All the specimens were identified using conventional microbiological methods including colony morphology, Gram staining, catalase, and slide and tube coagulase. The isolates were subjected to the API-20 Staph identification kit. Antibiotic susceptibility tests were performed using Kirby-Bauer disc diffusion method. The methicillin and aminoglycoside resistant genes among coagulase negative staphylococci were detected by polymerase chain reaction (PCR) and sequencing methods.
    Results
    The most frequent clinically isolated coagulase negative staphylococci species were Staphylococcus hominis and S. haemolyticus (51. 9%), S. epidermidis (21. 7%), S. lugdunensis (9. 8%), S. intermedius (4. 9%), S. saprophyticus and S. simulans (3. 9%), S. warneri (2. 9%), as well as S. chromogenes, S. sciuri, S. caprae, S. schleiferi, and S. xylosus (0. 98%). The overall rate of methicillin resistance among CNS species in the present study was 89 (86. 4%). The resistance of CNS isolates against tested antibiotics was as follows: 74 (71. 8%) to cefoxitin, 54 (52. 4%) to kanamycin, 51 (49. 5%) to gentamicin, 45 (43. 7%) to tobramycin, and 30 (29. 1%) to amikacin. The prevalence of aminoglycoside resistance genes such as ant (4'') -Ia, aac (6'') /aph (2«) and aph (3'') -IIIa were 89 (86. 4%), 87 (84. 5%), and 68 (66%), respectively.
    Conclusions
    The presence of antibiotic resistance among coagulase negative Staphylococcus species, which cause nosocomial infections, has increased. Therefore, identification of coagulase negative staphylococci within 24 hours after development of enzymatic tests would be very useful in any clinical microbiology laboratory for effective treatment. Resistance to antibiotics, including aminoglycosides, develops quickly in CNS species where these antimicrobial agents are widely used. Thus, a better understanding of antibiotic resistance of CNS species is essential to eliminate antibiotic resistance in hospitals and society.
    Keywords: Coagulase Negative Staphylococcus, API Test, Aminoglycoside Resistance Genes
  • Jirakrit Leelarungrayub *, Thirasak Borisuthibandit, Decha Pinkaew, Araya Yankai Page 10
    Background
    Pneumonia presents high oxidative stress, which directly affects the lung injury and oxygenation status. Evidence has shown the correlation of oxidative stress markers in tracheal aspirates (TA) in infant patients, however, not before or after chest physical therapy (CPT).
    Objectives
    The objective of this study was to evaluate the correlation between lung injury score (LIS) or PvO2/FiO2 ratio and oxidative stress parameters in TA before and after CPT in infant patients during recovery from pneumonia.
    Methods
    TA samples from 40 intubated patients aged 5.4 ± 0.15 months were collected before and after CPT for evaluating oxidative stress parameters; as a glutathione (GSH), vitamin E, hyarulonic acid (HA), and malondialdehyde (MDA). Furthermore, the LIS and PvO2/FiO2 ratio were recorded. The correlation between oxidative stress markers and LIS or PvO2/FiO2 ratio was evaluated before and after CPT.
    Results
    The results before CPT showed no significant correlation between LIS and all parameters, whereas, the PvO2/FiO2 ratio correlated with the thiol group (r = -0.566, P = 0.000) and HA (r = -0.507, P = 0.000). After CPT, LIS correlated with GSH and HA (r = -0.396 and -0.409, P = 0.01) and the PvO2/FiO2 ratio correlated significantly with the GSH, HA, and MDA (r = 0.609, 0.768, -0.482, P = 0.000).
    Conclusions
    Some oxidative stress markers, such as the GSH, HA, and MDA in TA possibly reflected lung injury and oxygenation and may respond with more correlation after CPT intervention than before it.
    Keywords: Oxidative Stress, PvO2, FiO2 Ratio, Post, Pneumonia
  • Faezeh Kabiri, Ramazan Rajabnia, Abazar Pournajaf, Mehrdad Gholami, Meysam Hasannejad Bibalan, Aziz Kassani, Sajad Yaghoubi, Abdollah Ardebili * Page 11
    Background
    Allelic single nucleotide polymorphisms (SNPs) in cytokine-encoding genes can affect the degree of cytokine production, and may be related to the tendency to infectious illnesses as well as various clinical consequences.
    Objectives
    The aim of this work was to evaluate the possible role of SNPs in the regions of the IL-10 (-592), IL-15 (-367), IL-18 (-656), IL-12 (흟), IFN-γ (), TNF-α (-308), and TNF-β (�) genes in susceptibility or resistance to brucellosis and its crucial complications.
    Methods
    In a period of one year, 125 patients with acute brucellosis referring to 3 large public teaching hospitals were enrolled in this study. We studied the SNPs of IL-10, IL-15, IL-18, IL-12, IFN-γ, and TNF-α/β genes using the allele specific polymerase chain reaction (AS-PCR) with sequence-specific primers.
    Results
    Frequency of GG genotype in the TNF-α and TNF-β-encoding genes increased significantly by 52% and 31.2% in patient and control groups, respectively. For IFN-γ, TA genotype was found highly enhanced in patients (60%), while the frequency of AA and TT genotypes were higher in controls (23.2% and 26.4%, respectively). The AA and CC SNPs in IL-12 were dominant in both patient (78.4%) and control (14.4%) groups. In the patient group, the GG and TT genotypes had a higher frequency for genes encoding IL-15 (33.6%) and IL-18 (89.6%).
    Conclusions
    Based on the present study, some SNPs within the several cytokine genes, including TNF-α/β (-308/�), IFN-γ (), IL-15 (-367), IL-18 (-656), and IL-12 (흟) are related to the susceptibility or resistance to brucellosis. In order to approve the biological consequence of our results, additional investigations should be carried out in larger population groups.
    Keywords: Brucellosis, Cytokines, Single Nucleotide Polymorphisms
  • Houman Hashemian *, Abtin Heidarzadeh Page 12
    Background
    Pneumonia is a leading cause of children’s morbidity and mortality worldwide. Some studies have reported that vitamin D deficiency is associated with an increased incidence of lower respiratory illness requiring hospitalization.
    Objectives
    Due to the weather conditions of Guilan province, Iran, in this study, we aimed at determining the relationship between serum level of vitamin D and developing pneumonia in children who were hospitalized due to pneumonia.
    Methods
    In this case-control study, children aged 3 months to 5 years admitted in 17 Shahrivar hospital of Rasht, Iran, with pneumonia were compared with healthy children of the same age as the control group. Serum levels of vitamin D in both groups were measured by chemiluminescence method.
    Results
    In this study, 40 children aged 3 months to 5 years with pneumonia (19 males and 21 females) and 40 healthy children of the same age (22 males and 18 females) were studied. The mean serum levels of vitamin D in the group with pneumonia and the control group was 26.16 ± 15.2 ng/mL and 30.45 ± 15.69 ng/mL, respectively. The difference between the 2 groups was not significant (t test, P value = 0.218). However, this difference was significant in the age group of 24 to 60 months (t test, P value = 0.015).
    Conclusions
    In this study, a significant relationship was observed between children’s vitamin D serum levels and development of pneumonia, only at the age of 24 to 60 months, although high prevalence of vitamin D deficiency in healthy children (control group) must be considered. The difference in the serum vitamin D levels of children with pneumonia and healthy children in the age group of 24 to 60 months suggest the need for preventive measures of vitamin D deficiency after infancy period.
    Keywords: Child, Pneumonia, Vitamin D Deficiency
  • Saeed Khoshnood, Gita Eslami *, Ali Hashemi, Aghil Bahramian, Mohsen Heidary, Neda Yousefi, Fariba Mohammdi, Mehrdad Gholami Page 13
    Background
    Acinetobacter baumannii is an important cause of nosocomial infections, particularly in burn patients. Hospital Infections caused by these bacteria are difficult to treat.
    Objectives
    The present study aimed at determining the frequency of genes encoding aminoglycoside-modifying enzymes in A. baumannii strains isolated from burn patients in Shahid Motahari hospital.
    Methods
    This study was performed on 100 A. baumannii strains collected from Shahid Motahari hospital in Tehran during 2013 and 2014. The bacteria were cultured and identified. Antibiotic susceptibility testing was performed by disk diffusion method according to the CLSI guidelines. PCR assay was done to find the genes encoding aminoglycoside-modifying enzymes.
    Results
    In this study, highest resistance to antibiotic was reported for ceftriaxone, ciprofloxacin, and ceftizoxime (100%), whereas the highest susceptibility was observed for colistin (100%), followed by gentamicin, amikacin, and tobramycin with (93%), (90%), and (87%), respectively. In the total of 100 strains studied, aphA6, aadB, aacC1 and aadA1 genes were found in 657 221 and 37 of A. baumannii isolates, respectively; 8 isolates had aadB and aphA6 genes and 3 had aadB, aadA1, aacC1, and aphA6 genes.
    Conclusions
    This study showed the high frequency aminoglycoside-resistance genes among A. baumanni strains. Thus, the implementation of appropriate programs to prevent the spread of the bacteria seems necessary in the Shahid Motahari hospital.
    Keywords: Aminoglycoside Resistance Genes, Multidrug Resistance, Burn, Acinetobacter baumannii
  • Kawasaki Disease and Hypertension in an Infant
    Shirin Sayyahfar *, Rozita Hoseini Page 15
    Introduction
    Kawasaki disease (KD) is the second most common vasculitis of medium-sized vessels in children. Hypertension is rarely reported in this disease.
    Case Presentation
    Herein, we report a 5-month-old male infant with atypical KD and new onset of hypertension without cardiac involvement or renal vessel stenosis. Hypertension was self-limited and resolved within six months after the onset of disease.
    Conclusions
    Clinicians should consider KD as a potential source of secondary hypertension in children, and high blood pressure ought to be considered as a significant complication in Kawasaki patients.
    Keywords: BCG Scar, Hypertension, Kawasaki Disease, Renal Disease, Vasculitis
  • Mojtaba Kamali Aghdam, Kambiz Eftekhari * Page 16
    Introduction
    Infectious mononucleosis is a relatively common childhood disease caused by the epstein-barr virus (EBV). Typical cases are seen in young children and are mostly clinically mild or asymptomatic. In this disease, leukocytosis with predominance of lymphocytes is found. Classical clinical symptoms associated with atypical lymphocytosis in the peripheral blood smear helps in diagnosis.
    Case Presentation
    The patients were proven cases of infectious mononucleosis disease and unlike the typical cases of this infection; they showed high ESR (erythrocyte sedimentation rate), CRP (C-reactive protein), and neutrophilic leukocytosis, instead of lymphocytosis. All of them were discharged in good general condition after receiving corticosteroids.
    Conclusions
    According to our findings, EBV infection cannot be ruled out in exudative pharyngitis, despite having neutrophilic leukocytosis, high levels of ESR and CRP. Therefore, EBV diagnostic tests should be conducted in these patients.
    Keywords: Infectious Mononucleosis, Neutrophilic Leukocytosis, Exudative Pharyngitis