Diagnosing and Treating Mononucleosis

US Pharm. 2017;42(5):HS-7-HS-10.

Infectious mononucleosis (IM or Mono) is usually caused by the Epstein–Barr virus (EBV), which is a member of the herpes virus family. This virus was discovered by the renowned Russian pediatrician Nil Filatov in 1885. IM is characterized by a triad of symptoms: fever, tonsillar pharyngitis, and lymphadenopathy. It is primarily spread through saliva, and those who are infected can spread the disease weeks before symptoms develop. Spreading may occur through objects such as drinking glasses or toothbrushes and can be prevented by not sharing personal items or kissing infected individuals. Drinking enough fluids, getting sufficient rest, and taking pain medications such as acetaminophen and ibuprofen are the best recommendations. There is no vaccine for EBV, and mono generally gets better on its own.

Mono is primarily diagnosed based on the symptoms and can be confirmed with blood tests for specific antibodies. Another typical finding is increased blood lymphocytes, of which more than 10% are atypical. Mono most commonly affects those between the ages of 15 to 24 years in the developed world. In the developing world, people are more often infected in early childhood when the symptoms are less severe. In those between ages 16 and 20 years, it is the cause of about 8% of sore throats. Mononucleosis was first described in the 1920s and is generally known as the kissing disease. The relationship between EBV and IM was established when a laboratory worker was infected with EBV and developed IM. A few other viruses may also cause the disease.

The background, pathogenesis, clinical manifestation, diagnosis, and treatment of IM in adults and adolescents will be briefly reviewed in this article.

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Pros and Cons of Calcium Supplements

Calcium is one of the most important nutritional elements for optimal bone and dental health. Several studies suggest that calcium, along with vitamin D, may have benefits beyond bone health, and it is generally accepted that the heart, muscles, and nerves also need calcium to function properly. Millions of women in the United States take calcium supplements in an attempt to boost bone strength, especially after menopause when the risk of fractures increases. Patients with rheumatoid arthritis and other inflammatory forms of the disease also routinely take calcium supplements.

Most people get enough calcium through their diets. However, those who do not may need to take calcium supplements. It is important for individuals to know how much calcium they need and what types of supplements are the most appropriate.1

Calcium supplements are not for everyone. For instance, people who have a health condition that causes excess calcium in their bloodstream (hypercalcemia) should avoid calcium supplements. Too much or too little calcium, whether through diet or supplements, could be problematic for these individuals.1

In this article, we briefly discuss daily human calcium requirements, types of calcium supplements, nutritional considerations of calcium, and problems with too little or too much calcium intake.

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Fish Oil: Is it Cadioprotective?

Diets rich in fish and fish-oil supplements have long been claimed to prevent heart disease. The evidence to support this is the vast body of research studies and references that support the cardiovascular benefits of fish consumption and omega-3 supplementation. However, a recent large study (Alpha Omega Trial) examining the role of omega-3–enriched margarine as a functional food for secondary prevention of heart attacks revealed negative results.  Using a meta-analysis, other investigators also showed insufficient evidence of a secondary preventive effect of omega-3 fatty acid supplements against overall cardiovascular events among patients with a history of cardiovascular disease.  Publication of these studies has caused skepticism about the cardioprotective effects of omega-3 fats and has generated controversy over fish-oil and omega-3 supplements.

In 2002 in its scientific statement on fish consumption, fish oil, omega-3 fatty acids, and cardiovascular disease, The American Heart Association announced that “randomized controlled trials have demonstrated that omega-3 fatty acid supplements can reduce cardiac death, nonfatal MI, nonfatal stroke, and atherosclerosis in coronary patients. But, additional research is needed to confirm the health benefits of omega-3 fatty acid supplements for both primary and secondary prevention.”

The FDA has also approved Lovaza (omega-3-acid ethyl esters) as the only fish-oil supplement. While Lovaza is indicated for lowering elevated triglycerides, its labeling specifically states that “the effect of Lovaza on cardiovascular mortality and morbidity in patients with elevated triglyceride levels has not been determined.”

In late 2004, the FDA also announced, “Supportive but not conclusive research shows that consumption of eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA] omega-3 fatty acids may reduce the risk of coronary heart disease.”

A recent investigation showed that 60% of U.S. clinicians surveyed agreed that one of their roles as health care professionals is to provide information to patients about appropriate dietary supplements. The most popular supplements among cardiologists were multivitamins, omega-3/fish oil, and vitamin C.  A majority of the U.S. population consumes fish-oil supplements daily, and this is due to the fact that a high percentage of health care providers recommend the daily use of these products to the public.

With the results of the above studies, the questions remain: Is fish oil cardioprotective or not? And what happens to the potential advocacy by health care professionals? In this article, we will review recent literature and recommendations on this major food supplement. Ultimately, consumers must educate themselves about the benefits of fish oil as well as consult with their doctors when deciding whether to take the supplements or not.

Polymyalgia Rheumatica

Polymyalgia rheumatica (PMR) is an inflammatory condition of the muscles and joints and is characterized by stiffness and pain in the neck, shoulders, hips, and buttocks. Morning stiffness that lasts several hours is common. The onset of pain can be sudden or gradual and affects both sides of the body. Approximately 15% of patients with PMR develop giant cell arteritis (GCA), and nearly 50% of patients with GCA will develop PMR over time.

PMR is a complicated disease with many complex symptoms. An accurate diagnosis must exclude many other potential diseases. Corticosteroids (e.g., prednisone) are considered the treatment of choice. Patients have an excellent prognosis, although exacerbations may occur if steroids are tapered too rapidly, and relapse is common.

While there have been no major studies on the relationship between inflammatory foods (e.g., wheat products) and PMR, many patients have reported that by following a paleo or gluten-free diet and exercising, they have been able to control their symptoms and taper off the steroids in a period of up to 1 year. In general, avoiding foods that cause inflammation and gastrointestinal problems can sometimes alleviate fibromyalgia. Fibromyalgia affects about 2% of the U.S. population, with women older than 50 years being more susceptible to the disorder than men.

Peripheral Artery Disease (PAD)

Peripheral artery disease is caused by buildup of fatty materials (atheroma) in arteries that carry blood from the heart to the head, internal organs and the limbs. Overtime this fatty deposits cause circulatory problem that in turn causes narrowing of the arteries and reduce blood flow to the organs to fail. Other causes include blood clots or embolism, congenital heart disease, and inflammation of the blood vessels (vasculitis).

Men and woman are equally affected by PAD; however, black race/ethnicity is associated with an increased risk of PAD. People of Hispanic origin may have similar to slightly higher rates of PAD compared to non-Hispanic whites. Approximately 8 million people in the United States have PAD, including 12-20% of individuals older than age 60. General population awareness of PAD is estimated at 25%, based on prior studies.

Peripheral artery disease is a warning sign for a more widespread accumulation of fatty deposits or plaques in major arteries that ends up with the hardening of the arteries (atherosclerosis). This condition will be reducing blood flow to heart and brain and increases the risk of heart attack or stroke.

The reduction of blood flow to the extremities — usually legs — causes leg pain during walking and causes a condition called claudication (pain, fatigue,aching,tightness, weakness, cramping or tingling in the legs). It can also increase skin ulcerations and in severe cases, tissue death in limbs that will end up to leg amputation. PAD leg pain occurs in the muscles, not the joints.

One in every 20 American over age of 50 has PAD. A research funded by the National Heart, Lung, and Blood Institute in June of 2011 revealed only one third of people with PAD, took their medications to control high blood pressure and high cholesterol.

As stated earlier, PAD often goes undiagnosed. Untreated PAD can be dangerous and can cause loss of a leg, increased risk of coronary artery disease and carotid atherosclerosis. The American Heart Association encourages people at risk to discuss PAD symptoms with their healthcare professional to ensure early diagnosis and treatment. By learning about PAD, people can lower their risk for PAD and its other major complications.

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The Emerging Role of Vitamin K2

Vitamin K refers to a group of fat-soluble vitamins with similar chemical structures that are needed for blood coagulation. Research over the last few decades has shown a new and emerging role for this vitamin in treating osteoporosis and cardiovascular diseases. Other new and exciting applications for this vitamin have been found in treating Alzheimer’s disease, skin aging, and a variety of cancers. This vitamin was discovered in the 1920s and was called “K” for koagulation due to its role in blood coagulation.  Unfortunately, many people are not aware of the health benefits of vitamin K. The K vitamins have been underrated and misunderstood until very recently by both the scientific community and the general public.

Although the effect of magnesium and vitamin D₃ on calcium metabolism was previously known, the importance of vitamin K in regulating the healthy function of calcium has only recently been recognized.  Vitamin K has now been found to have a role in putting calcium in the right places in the body, such as in the bones and blood, and preventing pathologic calcification of the vessels and soft tissues.

There are three different types of vitamin K: K₁, which is found in plants; K₂, which is made by bacteria or fermentation; and K₃, which is synthetic and, because of the generation of free radicals, is considered toxic. All members of the vitamin K group share a methylated naphthoquinone ring structure and vary in the aliphatic side chain attached at the 3-position. Although these vitamins share a major physiological role, each has other distinct physiological properties. Interestingly, the body is able to convert vitamin K₁ to the more active K₂.

Unlike other fat-soluble vitamins (A, D, and E), the body does not store vitamin K. It is recycled by the body but not in significant amounts, and therefore deficiencies are common.  This is probably due to inadequate dietary intake, lack of cofactors, prescription drugs, and environmental stressors that place high demands on the body’s vitamin K reserves.

Vitamin D3-The Sunshine Vitamin

The major role of vitamin D (calciferol) is to help the body absorb calcium and maintain bone density to prevent osteoporosis. But recent reports suggest new roles for this vitamin in protecting against certain chronic diseases such as diabetes, cardiovascular disease, cancer, and autoimmune disorders. This vitamin is available in two forms, vitamin D2 (ergocalciferol) and vitamin D3 (cholecalciferol). Ergocalciferol has a shorter shelf life compared to cholecalciferol and loses its potency faster.
Vitamin D2 is manufactured by plants or fungus, and it can be acquired through fortified foods such as juices, milk, and cereals. Vitamin D3 is formed when the body is exposed to sunlight. This occurs mainly through the exposure of the skin to the sun's ultraviolet A (UVA) and ultraviolet B (UVB) rays. Vitamin D3 can also be obtained by consuming animal products. The biologically active form of vitamin D or calcitriol (Rocaltrol) is used to treat and prevent low levels of calcium in the blood of patients whose kidneys or parathyroid glands are not working normally.

Recently, there has been extensive research and concern about the level of vitamin D in United States citizens. This stems from increasing reports of vitamin D deficiency and the fact that an estimated 10 million Americans over age 50 years are diagnosed with osteoporosis.³ This is because vitamin D is not abundant in our usual food sources, so we get most of the vitamin from sun exposure and taking multivitamins. The problem is that the sun is not a reliable source for everyone.

Many factors, such as the season, time of day, geography, latitude, level of air pollution, color of skin, and age, may decrease the skin's ability to produce enough vitamin D. Further, the form of vitamin D found in most multivitamins is vitamin D2, which does not deliver the same amount of the vitamin to the body as the more desirable D3 form.