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Infectious Mononucleosis
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Synonym: glandular fever, kissing disease
Infectious mononucleosis is usually a self-limiting infection caused by Epstein-Barr virus (EBV) (which is a human herpes virus) that is particularly common in adolescents and children.1
- Clinical infection is particularly common in young adults. The infection is therefore most common in populations with many young adults, such as active-duty military personnel and college students.2
- The incidence of infectious mononucleosis shows no consistent seasonal peak.2
- The incubation period is between 33-49 days.3
Most patients have few if any symptoms (most adults show serological evidence of previous EBV infection).
- Low grade fever, fatigue and prolonged malaise
- Sore throat; tonsillar enlargement is common and may be massive; palatal petechiae and uvular oedema
- Fine macular non-pruritic rash, which rapidly disappears
- Transient bilateral upper lid oedema
- Lymphadenopathy, especially neck glands
- Nausea and anorexia
- Arthralgias and myalgias occur but are less common than in other viral infectious diseases and rarely severe
- Other symptoms include cough, chest pain, and photophobia
- Older adults and elderly patients often have few throat symptoms or signs and have little or no lymphadenopathy
- Later signs include:
- Mild hepatomegaly and splenomegaly (splenic enlargement returns to normal or near normal usually within three weeks after the clinical presentation) with tenderness over the spleen
- Jaundice (in less than 10% in young adults, but in as many as 30% of infected elderly patients)
- Exudative pharyngitis is commonly confused with group A streptococcal pharyngitis. 30% of patients with infectious mononucleosis have group A streptococcus in the oropharynx.
- Bilateral periorbital oedema without generalised oedema may also be due to Kawasaki disease, allergic reactions, or bilateral periorbital cellulitis.
- Prominent lymphadenopathy: leukaemia.
- Atypical lymphocytes must be differentiated from abnormal lymphocytes, which are associated with lympho-reticular malignancies.
- Other causes of abnormal liver function tests.
- Patients with a negative Paul-Bunnell or Monospot® reactions for 6 weeks and those with a negative EBV-specific test result, should be tested for the causes of heterophile-negative infectious mononucleosis. These include HIV, human herpes virus 6, toxoplasmosis, cytomegalovirus, rubella, viral hepatitis.
See separate article Infectious Mononucleosis Tests.
- Full blood count: leucocytosis; lymphocytosis; relative atypical lymphocyte count is greater than 20%; elevated ESR.
- Mild elevation of the serum transaminases. Alkaline phosphatase and gamma-GT levels are not usually elevated.
- Heterophile antibody tests:
- EBV infection induces a variety of unrelated non-EBV heterophile antibodies.
- Sheep red blood cells agglutinate in the presence of heterophile antibodies and are the basis for the Paul-Bunnell test.
- Agglutination of horse red cells on exposure to heterophile antibodies is the basis of the Monospot® test.
- Heterophile test antibodies are highly sensitive and specific, are present in peak levels 2-6 weeks after primary infection and they remain positive in low levels for up to a year. The heterophile antibody test results may be negative early in the course of infection.
- Specific tests for IgM antibodies to EBV
- Abdominal ultrasound: for splenomegaly
EBV is also associated with:
- Burkitt's lymphoma
- B-cell lymphomas in patients with immunosuppression
- Undifferentiated carcinomas, e.g. of nasopharynx and salivary glands
- Duncan's syndrome: rare, X-linked recessive; defective T cells fail to destroy EBV infected cells; associated development of autoimmune disease and lymphoma
- Advise patients to avoid contact sports for 6 weeks - because of risk of splenic rupture.4
- Avoid alcohol for duration of illness.4
- Advise paracetamol for analgesia and control of fever.
- No specific antiviral therapy is available.
- There is insufficient evidence to recommend steroid treatment for symptom control in glandular fever.5
- Short courses of corticosteroids are beneficial for haemolytic anaemia, central nervous system involvement or extreme tonsillar enlargement.
- Ampicillin and amoxicillin cause a maculopapular rash and should not be given in any patient who might have infectious mononucleosis.
- Patients may require hospital admission for intravenous fluids.
- Surgery is necessary for spontaneous splenic rupture, which is rare but may be the initial presentation of the condition.
- Extreme tonsillar enlargement may result in upper airway obstruction.
- Myocarditis and cardiac conduction abnormalities are rare complications.
- Splenic rupture is rare, but potentially lethal.6 Splenectomy increases susceptibility to various infections.
- Haemolytic anaemia, thrombocytopenia.
- Acute interstitial nephritis.
- Neurological, including optic neuritis, transverse myelitis, aseptic meningitis, encephalitis, meningoencephalitis, cranial nerve palsies (especially facial palsy) or Guillain-Barre syndrome.
- Prolonged fatigue; depression.
- Usually asymptomatic or short duration and self-limiting.
- Fatigue and myalgia may persist for several or even many months after the acute infection has resolved.2
- If splenic rupture is recognised and surgery performed quickly, the prognosis is good.
Document references
- Cohen JI; Epstein-Barr virus infection. N Engl J Med. 2000 Aug 17;343(7):481-92.
- Ebell MH; Epstein-Barr virus infectious mononucleosis. Am Fam Physician. 2004 Oct 1;70(7):1279-87. [abstract]
- Guidelines on control of communicable diseases in schools and nurseries, Health Protection agency (2006)
- Haines JD Jr; When to resume sports after infectious mononucleosis. How soon is safe? Postgrad Med. 1987 Jan;81(1):331-3. [abstract]
- Candy B, Hotopf M; Steroids for symptom control in infectious mononucleosis. Cochrane Database Syst Rev. 2006 Jul 19;3:CD004402. [abstract]
- Asgari MM, Begos DG; Spontaneous splenic rupture in infectious mononucleosis: a review. Yale J Biol Med. 1997 Mar-Apr;70(2):175-82. [abstract]
Internet and further reading
- Cunha BA; Infectious Mononucleosis.; eMedicine; October 2008.
- M. A. Epstein MA, Crawford DH; The Epstein-Barr virus. Oxford Textbook of Medicine 4th edition; Section 7.12.
Document ID: 2321
Document Version: 22
Document Reference: bgp370
Last Updated: 20 Feb 2009
Planned Review: 20 Feb 2011
The authors and editors of this article are employed to create accurate and up to date content reflecting reliable research evidence, guidance and best clinical practice. They are free from any commercial conflicts of interest. Find out more about updating.
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