Glandular fever ( Infectious mononucleosis )

This chart discusses the pathophysiology, presentation, and complications of glandular fever ( infectious mononucleosis ). Laboratory results particularly changes in Lympocytes and LFTs and the heterophile tests to help diagnose glandular fever are mentioned. Rash with penicillin use was searched and the result is mentioned above references. Who should be referred can help with management and the complications are discussed in greater detail. This chart on A4Medicine can help the busy general practitioner to quickly review glandular fever during the consultation.

Infectious mononucleosis- also known as glandular fever is a benign lymphoproliferative disorder – viral infection caused by Epstein- Barr virus 
( EBV ) in 90 % cases
 EBV is a lymphocrytovirus – member of the Y-herpesvirus family – infects atleast 90 % of the population worldwide
 ( majority have no recognizable illness ) by adulthood
 Rest of the cases are caused by
○ cytomegalovirus
○ human herpesvirus 6
○ toxoplasmosis
○ adenovirus
 Seroconversion –> commonest in younger children and usually asymptomatic

Disease of primarily teenagers and young adults occurring in approximately 7 % with sore throat

As most population is positive for EBV special precautions against transmission are not necessary in most cases

Pathophysiology EBV first infects the oropharyngeal epithelial cells via C3d receptors After initial replication in the nasopharynx the virus infects B cells Integrates into the lifecycle of healthy B lymphocytes and can remain as lifelong latent infection Humoral response -Directed against EBV structural proteins structural response-T-lymphocyte cellular response – critical in control and determining the clinical expression of EBV infection

Epidemiology-Teenagers or young adults ( 15-24 yrs ) 50 % of children have detectable EBV antibodies by 5 yrs of age and 90 % of people will have antibodies by 25 yrs Any age can be infected

Transmission-Intimate contact with body secretions- primarily oropharyngeal Kissing between an uninfected and an EBV-seropositive person who is shedding the virus symptomatically Blood products ( rare ) Potentially can be shed from uterine cervix – implicating genital transmission ( rare ) Incubation period-About 4-7 weeks

Fever , Lymphadenopathy- Symmetric and can involve any group of nodes Typically posterior or cervical Also be
♦ anterior cervical
♦ submandibular
♦ sub-occipital
♦ post-auricular
♦ epitrochlear
♦ axillary
♦ inguinal Sore throat-In up to 90 %
○ tonsillar enlargement
○ white creamy exudate on tonsills
Exudate rarely discolored and it does not involve pharyngeal mucosa

○ palatal petechiae Sore throat which fails to improve or becomes worse over several days Prodromal symptoms- malaise , fatigue , myalgia , chills , sweats , anorexia and retro orbital headache Splenomegaly (8 % ) Hepatomegaly ( 7 % ) Jaundice with deranged LFTs Non-specific rash – may be macular , petechial ,urticarial or erythema multiforme like or maculopapular rash following amoxicillin use Children < 3 yrs symptoms indistinguishable from other viral illnesses of childhood

Differential-Streptococcal pharyngitis Cytomegalovirus Human herpesvirus 6 ( Roseola ) Herpes simplex virus Type 1 Acute viral hepatitis Acute toxoplasmosis Primary HIV infection Rubella Adenovirus Leukemia 

Blood film
Large atypical lymphocytes ( not specific for EBV )
 Heterophile antibodies-heterogenous group of antibodies composed mostly of IgM class generated in presence of EBV infection

○ Paul-Bunnell test +ve 2nd week of illness in around 90 % cases 
○ Monospot test

Heterophile test may be falsely negative in up-to 25 % of adults in the 1st week of symptoms 
 PCR emerging as a sensitive method for detecting EBV infection ELISA- can detect IgM anti-EBV capsid antibodies ( at presentation – suggest acute infection )
○ AST and ALT may be elevated ( 2-3 times ULN )
○ AlkPo4 may rise during convalescence ( usually resolves itself )

Treatment- Self- limiting illness usually resolves by 3 weeks Rest , hydration , analgesia and antipyretics Symptomatic treatment and address any complication if present Exclusion from work or school not required Avoid kissing , sharing eating or drinking utensils Do not engage in contact sports or heavy lifting -1st month of illness ( if return to contact sports essential before 1 month- arrange an US to r/o splenomegaly ) Steroids- insufficient evidence to the efficacy of steroids for symptom control ( lack of research on SEs and long-term complications ) Antivirals- use not advocated yet Metronidazole- more evidence required

Referral-Airway compromise Suspected splenic rupture Dehydration or difficulty swallowing fluids Immunocompromised or post-transplant patients Patients with infectious mononucleosis but negative for EBV antibodies ( illness caused by others-see background )

Complications-Upper airway obstruction Splenic rupture ( rare < 1 % ) and usually in 1st 3 weeks of illness Neurological complications ( 1-5 % ) as
○ Encephalitis or aseptic meningitis
○ Facial nerve palsy
○ Transverse myelitis
○ Guillain- Barrè syndrome
○ Cranial nerve lesions Fatigue- lasting > 6 months ( CFS association questionable ) Immunocompromised people
○ Malignancy
○ HIV -oral hairy leukoplakia and diffuse interstitial pneumonitis Haematological
○ Thrombocytopenia
○ Neutropenia
○ Hemolytic anaemia Increased risk of Multiple sclerosis Myocarditis , pericarditis , pancreatitis , interstitial peuomonia , rhabdomyolysis and psychological problems Burkitts lymphoma in children and nasopharyngeal carcinoma