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Infectious Mononucleosis

Infectious mononucleosis is a common viral infection known to cause pharyngitis and fever. It is primarily an infection of teenagers and young adults caused by the Epstein Barr virus.


Presentation

The majority of patients with infectious mononucleosis have mild symptoms. However a few will complain of the following features:

  • Once EBV is acquired it does not immediately cause any symptoms. The virus has to multiply and reach a certain threshold before it results in symptoms. The incubation period for EBV is about 4-6 weeks.
  • Prodrome of general malaise, fatigue and headache may start 3-4 days prior to the actual sore throat and fever. The majority of symptomatic patients will complain of a prolonged history of fatigue and malaise.
  • The fever in infectious mononucleosis is low grade but continuous. The sore throat is often the second complaint and may vary from moderate to severe. Complaints of muscle and joint pain is also rare, which is different from other viral infections like influenza where the muscle pain is moderate.
  • Patients with infectious mononucleosis may also complain of a dry cough, lack of appetite and vague chest pain.
  • The rare patient with CNS involvement may complain of a headache, visual disturbances and dizziness. The CNS features of infectious mononucleosis usually occur late.
  • The physical exam in a patient with infectious mononucleosis depends on when the patient presents. Patients presenting early in the course of the infection may have a fever, skin rash, redden throat and localized cervical adenopathy.
  • Those patients presenting late may present with splenomegaly, palatal petechiae, jaundice and abdominal pain if there is splenic rupture/enlargement. If the spleen is enlarged, the patient may complain of tenderness to palpation.
  • Skin discoloration and icterus is sometime seen in patients with hepatosplenomegaly, and is slightly more common in elderly individuals.
  • Examination of the oral cavity usually will shows a redden pharynx with signs of an inflammatory process. The pharyngitis may be exudative and often confused with group A streptococcal infection. The tonsils are usually enlarged and the upper airway passageway may appear narrowed. Petechiae on the soft palate are also common.
  • Rarely some patients with infectious mononucleosis may present with generalized macular papular rash that is non pruritic and seen on the face and trunk. This rash is faint and often disappears within several days.
  • Other rare observation may include bilateral periorbital edema, conjunctivitis or eyelid edema.
  • The oral cavity should not be repeatedly examined or manipulated as it may irritate the swollen tonsil and result in sudden airway distress. This patient is best monitored in an intensive care setting and an intubation set and a tracheostomy set should be available at the bedside.
Splenomegaly
  • Clinical estimates of splenomegaly are fallible. Laboratory determinations, commonly by 2D ultrasonography, must take account of methodology, the formulae used in calculations and the individual's body size.[ncbi.nlm.nih.gov]
  • In adolescent and adult patients presenting with sore throat, the presence of posterior cervical, inguinal or axillary adenopathy, palatine petechiae, splenomegaly, or atypical lymphocytosis is associated with an increased likelihood of mononucleosis.[ncbi.nlm.nih.gov]
  • We discuss the current literature surrounding the outpatient follow-up of splenomegaly associated with infectious mononucleosis, as well as current practice and treatment options when rupture occurs.[ncbi.nlm.nih.gov]
  • A 49-year-old man with diabetic mellitus suffered from IM with fever, pharyngitis, parotiditis with lymphadenopathies, thrombocytopenia and splenomegaly.[ncbi.nlm.nih.gov]
  • Characteristic clinical features of EBV IM include bilateral upper lid edema, exudative or nonexudative pharyngitis, bilateral posterior cervical adenopathy, and splenomegaly maculopapular rash.[ncbi.nlm.nih.gov]
Cervical Lymphadenopathy
  • To depict the grey-scale and Doppler features of cervical lymphadenopathy due to infectious mononucleosis (IM) and to compare the findings with other benign conditions and lymphoma.[ncbi.nlm.nih.gov]
  • Infectious mononucleosis (IM) is a common viral illness that predominantly causes sore throat, fever and cervical lymphadenopathy in adolescents and young adults.[ncbi.nlm.nih.gov]
  • lymphadenopathy is typical, but anterior cervical lymphadenopathy is possible. 8 Children can present with nonspecific or no symptoms, which can lead to missed diagnoses. 1 , 8 , 11 A 2013 study of college students demonstrated that sore throat (93%)[aafp.org]
  • Imaging is usually not necessary, but certain findings on imaging can be suggestive: CT splenomegaly possible splenic rupture splenic infarction has been reported 3 generalised lymphadenopathy , including cervical lymphadenopathy tonsillar enlargement[radiopaedia.org]
  • An 11-year-old pupil presents with fever, Tonsillitis, and cervical lymphadenopathy. What is the diagnosis? Rubella Infectious mononucleosis Scarlet fever Parotitis Measles 3.[lecturio.com]
Generalized Lymphadenopathy
  • There is an increase in mononuclear white blood cells and other atypical lymphocytes, generalized lymphadenopathy, splenomegaly, and occasionally hepatomegaly with hepatitis.[fpnotebook.com]
  • lymphadenopathy in the inguinal, axillary, posterior auricular, and cervical nodes. 1 Additionally, patients commonly experience fatigue that may be severe.[uspharmacist.com]
Posterior Cervical Adenopathy
  • Characteristic clinical features of EBV IM include bilateral upper lid edema, exudative or nonexudative pharyngitis, bilateral posterior cervical adenopathy, and splenomegaly maculopapular rash.[ncbi.nlm.nih.gov]
  • The likelihood of mononucleosis is reduced with the absence of any lymphadenopathy (summary sensitivity, 0.91; positive LR range, 0.23-0.44), whereas the likelihood increases with the presence of posterior cervical adenopathy (summary specificity, 0.87[ncbi.nlm.nih.gov]
Axillary Lymphadenopathy
  • Physical examination findings of palatal petechiae, posterior cervical lymphadenopathy, axillary lymphadenopathy, and inguinal lymphadenopathy increase the likelihood of a positive heterophile antibody test result.[aafp.org]
Sore Throat
  • Symptoms are of limited value for the diagnosis of mononucleosis; sore throat and fatigue are sensitive (range, 0.81-0.83) but nonspecific.[ncbi.nlm.nih.gov]
  • Two women presented with sore throat and fever. Their symptoms were not alleviated by antibiotics.[ncbi.nlm.nih.gov]
  • Symptoms Mono may begin slowly with fatigue, a general ill feeling, headache, and sore throat. The sore throat slowly gets worse. Your tonsils become swollen and develop a whitish-yellow covering.[mountsinai.org]
  • Infectious mononucleosis is a disease characterized by fever, sore throat, and enlarged lymph nodes, which is caused by Epstein-Barr virus – one of the herpeviruses.[csbsju.edu]
  • We present the first reported case of an IM-like syndrome with sore throat, fatigue, atypical lymphocytes, and elevated levels of serum transaminases likely due to Coxsackie A in an immunocompetent adult.[ncbi.nlm.nih.gov]
Cough
  • A 16-month-old boy was admitted because of cough that had lasted for 10 days.[ncbi.nlm.nih.gov]
  • We report the case of a 39-year-old man with pulmonary LYG who presented to a hospital after experiencing three months of fever, weight loss, dry cough and exertional dyspnea.[ncbi.nlm.nih.gov]
  • However, sneezes and coughs also can transmit the virus. To continue reading this article, you must login . Subscribe to Harvard Health Online for immediate access to health news and information from Harvard Medical School.[health.harvard.edu]
  • Do: Cough or sneeze into tissue. Dispose of tissue properly into trash can. Use of handkerchiefs is not recommended.[oakgov.com]
  • Make sure people are covering their mouths if coughing. IF YOU ARE ILL AND NOT GETTING BETTER OR ARE HAVING MORE SEVERE SYMPTOMS WITHIN 48 HOURS, CONTACT YOUR PRIMARY HEALTH CARE PROVIDER.[csbsju.edu]
Pharyngitis
  • Both cases involved young adults presenting with fever, pharyngitis, lymphadenopathy, hepatosplenomegaly, and atypical lymphocytosis confirmed by serologic tests, liver biopsy and electron microscopic study.[ncbi.nlm.nih.gov]
  • Thus, when radiologists encounter these CT findings of pharyngitis that is not alleviated by antibiotic therapy, infectious mononucleosis should be considered in the differential diagnosis.[ncbi.nlm.nih.gov]
  • Infectious mononucleosis is a common viral infection known to cause pharyngitis and fever. It is primarily an infection of teenagers and young adults caused by the Epstein Barr virus.[symptoma.com]
  • Nevertheless, symptoms can last for weeks and occasionally months.Symptoms include fever, lymphadenopathy, pharyngitis, hepatosplenomegaly and fatigue. Symptom relief and rest are commonly recommended treatments.[ncbi.nlm.nih.gov]
  • A 49-year-old man with diabetic mellitus suffered from IM with fever, pharyngitis, parotiditis with lymphadenopathies, thrombocytopenia and splenomegaly.[ncbi.nlm.nih.gov]
Tonsillar Hypertrophy
  • Upper airway obstruction from tonsillar hypertrophy is rare. Fulminant disease course of immunocompromised patients is rare. Splenic rupture is rare. Myocarditis and pericarditis are rare.[en.wikipedia.org]
Infectious Mononucleosis
  • The CNS features of infectious mononucleosis usually occur late. The physical exam in a patient with infectious mononucleosis depends on when the patient presents.[symptoma.com]
  • Statistical modelling showed that increasing sibship size was associated with a reduced risk of infectious mononucleosis and that younger siblings conferred more protection from infectious mononucleosis than older siblings.[ncbi.nlm.nih.gov]
  • There was a total of 3435 cases over the 20 years: 3064 with bacterial tonsillitis and 371 with infectious mononucleosis. The mean length of stay was 3.22 days for bacterial tonsillitis and 4.37 days for infectious mononucleosis.[ncbi.nlm.nih.gov]
  • Multiparameter flow cytometric analysis of CD4 and CD8 T cell subsets was performed in 19 children with acute infectious mononucleosis. The CD4 /CD8 ratio was found to be decreased (0.53) in children with infectious mononucleosis.[ncbi.nlm.nih.gov]
  • Infectious mononucleosis is a common viral illness of adolescence. Spontaneous splenic rupture is a rare but potentially fatal complication.[ncbi.nlm.nih.gov]
Fever
  • CMV-induced IMLS might be a cause of persistent fever in RA patients, particularly when biologics are used for treatment.[ncbi.nlm.nih.gov]
  • Fever of unknown origin (FUO) refers to fevers of  101 F that persist for  3 weeks and remain undiagnosed after a focused inpatient or outpatient workup.[ncbi.nlm.nih.gov]
  • We describe the case of an 18-year-old woman who presented 26days following an acute infectious mononucleosis diagnosis with agranulocytosis and fever.[ncbi.nlm.nih.gov]
  • Both cases involved young adults presenting with fever, pharyngitis, lymphadenopathy, hepatosplenomegaly, and atypical lymphocytosis confirmed by serologic tests, liver biopsy and electron microscopic study.[ncbi.nlm.nih.gov]
  • Infectious mononucleosis, also known as glandular fever or the kissing disease, is a benign lymphoproliferative disorder.[ncbi.nlm.nih.gov]
Fatigue
  • To determine appropriate management of the active individual with infectious mononucleosis (IM), including issues of diagnosis, the determination of splenomegaly, and other measures of disease status, the relationship of the disease to chronic fatigue[ncbi.nlm.nih.gov]
  • She suddenly developed intermittent high fever and general fatigue with liver dysfunction, remarkable lymphocytosis and laboratory data suggestive of CMV reactivation.[ncbi.nlm.nih.gov]
  • A few patients may develop prolonged fatigue for a few months or even years.[symptoma.com]
  • We present the first reported case of an IM-like syndrome with sore throat, fatigue, atypical lymphocytes, and elevated levels of serum transaminases likely due to Coxsackie A in an immunocompetent adult.[ncbi.nlm.nih.gov]
  • Infectious mononucleosis is caused by Epstein-Barr virus (EBV, human herpesvirus type 4) and is characterized by fatigue, fever, pharyngitis, and lymphadenopathy. Fatigue may persist weeks or months.[msdmanuals.com]
Lymphadenopathy
  • Both cases involved young adults presenting with fever, pharyngitis, lymphadenopathy, hepatosplenomegaly, and atypical lymphocytosis confirmed by serologic tests, liver biopsy and electron microscopic study.[ncbi.nlm.nih.gov]
  • A 20-year-old man was hospitalized for the evaluation of lymphadenopathy and systemic symptoms. His symptoms developed at the eighth week of the infliximab treatment and he required hospitalization.[ncbi.nlm.nih.gov]
  • A 49-year-old man with diabetic mellitus suffered from IM with fever, pharyngitis, parotiditis with lymphadenopathies, thrombocytopenia and splenomegaly.[ncbi.nlm.nih.gov]
  • She presented with fever, skin rash, lymphadenopathy, and hepatosplenomegaly. Laboratory tests revealed a marked increase of atypical lymphocytes in the peripheral blood and biphasic hepatic dysfunction.[ncbi.nlm.nih.gov]
  • Physical examination findings of palatal petechiae, posterior cervical lymphadenopathy, axillary lymphadenopathy, and inguinal lymphadenopathy increase the likelihood of a positive heterophile antibody test result.[aafp.org]
Malaise
  • The disease typically involves fever, enlarged lymph glands and malaise, with elevated blood lymphocyte counts that reflect an exaggerated cellular immune response to the infection.[els.net]
  • A 16-year-old, previously healthy girl presents with a several-day history of fever, sore throat, and malaise. She appears very tired and has a temperature of 39 C.[nejm.org]
  • Prodrome of general malaise, fatigue and headache may start 3-4 days prior to the actual sore throat and fever. The majority of symptomatic patients will complain of a prolonged history of fatigue and malaise.[symptoma.com]
  • Mononucleosis , formally infectious mononucleosis or glandular fever , infection in humans, caused by the Epstein-Barr virus (EBV), whose most common symptoms are fever, general malaise , and sore throat .[britannica.com]
  • This virus may be transmitted in urine and genital secretions. 5 Signs and symptoms Usually beginning 4 to 8 weeks after infection, common signs and symptoms of infectious mononucleosis include malaise, anorexia, fever, pharyngitis, periorbital edema,[journals.lww.com]
Loss of Appetite
  • The most common symptoms include excessive fatigue, headache, loss of appetite, sore throat, swelling of the tonsils, enlarged lymph nodes (swollen glands) in the neck, underarms, and groin.[infoplease.com]
  • The onset of illness can be abrupt, but often will appear gradually over several days, with chills, sweats and loss of appetite. How is it spread? The virus is spread from person to person through saliva.[hnhu.org]
  • Signs & Symptoms Symptoms usually show up about 4 to 7 weeks after infection with the virus and can include: being very tired fever sore throat with swollen tonsils that may have white patches loss of appetite swollen lymph nodes (commonly called glands[kidshealth.org]
  • Other symptoms can include swollen lymph nodes in the neck and armpits, enlarged spleen or liver, headache, loss of appetite, and a pink rash all over the body that resembles measles . (2,3,5) For young children, however, getting mono can be a different[everydayhealth.com]
  • […] of appetite and slight weight loss Nausea and vomiting (occasionally) A red rash, usually on the chest.[drugs.com]
Severe Abdominal Pain
  • abdominal pain Stiff neck or severe weakness Trouble swallowing or breathing Prevention People with mono may be contagious while they have symptoms and for up to a few months afterwards.[mountsinai.org]
Palatal Petechiae
  • It should be suspected in patients presenting with sore throat, fever, tonsillar enlargement, fatigue, lymphadenopathy, pharyngeal inflammation, and palatal petechiae.[aafp.org]
  • Those patients presenting late may present with splenomegaly, palatal petechiae, jaundice and abdominal pain if there is splenic rupture/enlargement. If the spleen is enlarged, the patient may complain of tenderness to palpation.[symptoma.com]
  • Fatigue and malaise may persist for several months after the acute infection has resolved. [ 6 ] Sore throat; tonsillar enlargement is common, classically exudative and may be massive; palatal petechiae and uvular oedema.[patient.info]
  • Palatal petechiae or bilateral upper eyelid edema can be helpful diagnostically [ 23 - 25 ]. Studies in the literature report on the clinical evaluation of the skin rash and rarely on skin biopsy .[omicsonline.org]
Exudative Pharyngitis
  • Differential diagnosis Exudative pharyngitis is commonly confused with group A streptococcal pharyngitis.[patient.info]
  • Various other symptoms are categorized in TABLE 1 . 1,2,4 Pharyngitis may produce pharyngeal inflammation and exudates.[uspharmacist.com]
Tonsillar Exudate
  • exudates, fever, and absence of cough are less likely than with streptococcal pharyngitis or infectious mononucleosis Table 1.[aafp.org]
Jaundice
  • We report a case of infectious mononucleosis in a 72-year old jaundiced gentleman with ferritin level of 2438 that normalised on clinical improvement.[ncbi.nlm.nih.gov]
  • Infectious mononucleosis due to Epstein-Barr virus (EBV) infection sometimes causes acute hepatitis, which is usually self-limiting with mildly elevated transaminases, but rarely with jaundice.[ncbi.nlm.nih.gov]
  • Inflammation of The Liver and Jaundice One uncommon complication of mono is mono hepatitis (an inflammation of the liver) possibly resulting in jaundice.[lexingtonclinic.com]
  • Jaundice. A yellowing of your skin and the whites of your eyes (jaundice) also occurs occasionally.[mayoclinic.org]
  • Symptoms may include fever, swollen lymph glands in the neck, armpits, and groin, constant fatigue, sore throat, enlarged spleen, and jaundice, a yellow discoloration of the skin. Treatment includes rest and plenty of liquids.[hopkinsmedicine.org]
Hepatomegaly
  • The patient showed severe hepatomegaly incidentally, and dual positivity of Immunoglobulin (Ig) M to Epstein-Barr virus (EBV) viral capsid antigen (VCA) and cytomegalovirus (CMV).[ncbi.nlm.nih.gov]
  • Although the complaints at admission did not differ between these two patient groups, the incidence of clinical signs (tonsillopharyngitis, lymphadenopathy, hepatomegaly, and edema of the eyelids) was much higher in preschool children.[ncbi.nlm.nih.gov]
  • […] usually not necessary, but certain findings on imaging can be suggestive: CT splenomegaly possible splenic rupture splenic infarction has been reported 3 generalised lymphadenopathy , including cervical lymphadenopathy tonsillar enlargement possible hepatomegaly[radiopaedia.org]
  • […] weeks after infection, common signs and symptoms of infectious mononucleosis include malaise, anorexia, fever, pharyngitis, periorbital edema, and lymphadenopathy (which often involves the posterior cervical chain). 2 It may also be associated with hepatomegaly[journals.lww.com]
  • The spleen is often palpable and there may be hepatomegaly and jaundice. Skin rashes are frequent. A macular erythematous rash may occur in patients with infectious mononucleosis who are treated with ampicillin or amoxicillin.[askhematologist.com]
Hepatosplenomegaly
  • Both cases involved young adults presenting with fever, pharyngitis, lymphadenopathy, hepatosplenomegaly, and atypical lymphocytosis confirmed by serologic tests, liver biopsy and electron microscopic study.[ncbi.nlm.nih.gov]
  • Third, the frequency of CD4CXCR5ICOSPD1 Tfh subset was significantly higher in lymphadenectasis or hepatosplenomegaly patients, and associated with the level of alanine aminotransferase (ALT).[ncbi.nlm.nih.gov]
  • She presented with fever, skin rash, lymphadenopathy, and hepatosplenomegaly. Laboratory tests revealed a marked increase of atypical lymphocytes in the peripheral blood and biphasic hepatic dysfunction.[ncbi.nlm.nih.gov]
  • Nevertheless, symptoms can last for weeks and occasionally months.Symptoms include fever, lymphadenopathy, pharyngitis, hepatosplenomegaly and fatigue. Symptom relief and rest are commonly recommended treatments.[ncbi.nlm.nih.gov]
  • Some patients show hepatosplenomegaly. Characteristic are the crimson, swollen tonsils with the typical dirty gray membranes.[lecturio.com]
Photophobia
  • 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.[patient.info]
Petechiae
  • In adolescent and adult patients presenting with sore throat, the presence of posterior cervical, inguinal or axillary adenopathy, palatine petechiae, splenomegaly, or atypical lymphocytosis is associated with an increased likelihood of mononucleosis.[ncbi.nlm.nih.gov]
  • It should be suspected in patients presenting with sore throat, fever, tonsillar enlargement, fatigue, lymphadenopathy, pharyngeal inflammation, and palatal petechiae.[aafp.org]
  • Petechiae on the soft palate are also common. Rarely some patients with infectious mononucleosis may present with generalized macular papular rash that is non pruritic and seen on the face and trunk.[symptoma.com]
  • Fatigue and malaise may persist for several months after the acute infection has resolved. [ 6 ] Sore throat; tonsillar enlargement is common, classically exudative and may be massive; palatal petechiae and uvular oedema.[patient.info]
  • Typical petechiae at the transition from hard to soft palate. Putrefactive Foetor ex-ore. Hepatosplenomegaly with jaundice. Generalized lymph node swelling (weakly painful, strong, mobile).[lecturio.com]
Urticaria
  • We describe a patient who developed generalized anhidrosis and cholinergic urticaria accompanied by heat intolerance after infectious mononucleosis infection.[ncbi.nlm.nih.gov]
  • Skin signs of EBV infection There are a variety of uncommon skin conditions associated with EBV infection , including: Infantile papular acrodermatitis (Gianotti-Crosti syndrome ) Erythema multiforme Erythema nodosum Urticaria including cold urticaria[dermnetnz.org]
  • Less common clinical symptoms were also described such as erythema multiforme-like and herpetiform lesions, urticaria, petechiae, transient cold urticaria, immune-related thrombocytopenic purpura, erythema nodosum or pedunculated papule on the tongue.[omicsonline.org]
Exanthema
  • Timár L, Baló-Banga JM, Budai J (1987) [Infectious mononucleosis and drug exanthema].Orv Hetil 128: 1871-1874.[omicsonline.org]
  • The administration of penicillin and aminopenicillins can trigger exanthema formation. CAVE : No antiviral medication, such as acyclovir and valaciclovir, should be used in patients with adequate immune function.[lecturio.com]
  • Amoxicillin-induced exanthema in patients with infectious mononucleosis: allergy or transient immunostimulation?. Allergy . 2007 Dec. 62(12):1474-5. [Medline] . Jenson HB. Acute complications of Epstein-Barr virus infectious mononucleosis.[emedicine.medscape.com]
Headache
  • Common symptoms include: fever swollen lymph glands in the neck, armpits and groin extreme fatigue sore throat, which can make swallowing difficult swollen spleen or liver headache or body aches The symptoms usually last for about two to four weeks, but[childrenshospital.org]
  • Symptoms Mono may begin slowly with fatigue, a general ill feeling, headache, and sore throat. The sore throat slowly gets worse. Your tonsils become swollen and develop a whitish-yellow covering.[mountsinai.org]
  • Essential Oils Essential oils can help you to relieve mono symptoms such as sore throat, headache, body aches, fatigue and inflammation. One of the best essential oils for a sore throat is thyme oil.[draxe.com]
  • The rare patient with CNS involvement may complain of a headache, visual disturbances and dizziness. The CNS features of infectious mononucleosis usually occur late.[symptoma.com]
  • The most common symptoms include excessive fatigue, headache, loss of appetite, sore throat, swelling of the tonsils, enlarged lymph nodes (swollen glands) in the neck, underarms, and groin.[infoplease.com]
Guillain-Barré Syndrome
  • Patients may be infectious before experiencing signs and symptoms and remain infectious for 6 to 18 months. 2 Rare complications include Guillain-Barré syndrome, meningitis, encephalitis, and splenic rupture. 2 Airway obstruction may occur with extreme[journals.lww.com]
  • Organ involved Symptoms and signs Spleen Splenomegaly (an enlarged spleen) Joints Arthritis in one or more joints Kidneys Glomerulonephritis Nervous system Meningoencephalitis Bell's palsy (facial palsy) Transverse myelitis GuillainBarré syndrome Gastrointestinal[dermnetnz.org]
  • Complications of mononucleosis may include: Anemia, which occurs when red blood cells in the blood die sooner than normal Hepatitis with jaundice (more common in people older than 35) Swollen or inflamed testicles Nervous system problems (rare), such as Guillain-Barré[mountsinai.org]
  • Other complications are Guillain-Barré Syndrome and Portillo’s Syndrome . Purtilo’s Syndrome Purtilo’s Syndrome is an X-linked recessive inheritance disorder of the immune response against EBV.[lecturio.com]

Workup

The diagnosis of infectious mononucleosis may be suspected on clinical presentation, but confirmation requires some type of laboratory study. Over the years several tests have been developed to identify antibodies to EBV in serum [6] [7].

The test most commonly performed is the latex agglutination assay which identifies heterophile antibodies (Monospot test). These antibodies often peak 14 to 40 days after an infection and may be detectable in blood for 12 months, albeit at low levels. It is important to be aware that the Monospot test may be negative when performed right after the infection but the test does start to become positive over the next several weeks. There are some patients who will have a negative Monospot test and yet manifest symptoms of mononucleosis, these individuals should be considered as having heterophile-negative infectious mononucleosis after further examination. It is also important to note that falsely positive Monospot tests may occur in people with rubella, toxoplasmosis and certain malignancies like lymphoma and leukemia.

Other blood work

Patients with suspected infectious mononucleosis may require other blood tests that are not specific for mononucleosis but can help eliminate other causes. Blood work often done includes:

  • Complete blood count (CBC) and white cell count. Leukocytosis is a common feature of infectious mononucleosis and absence of this should suggest an alternative diagnosis. Lymphocytosis and thrombocytopenia alone are not confirmative for infectious mononucleosis because such a finding can be seen with many other noninfectious causes (malignancies) and viral infections. Anemia is not a common presentation of infectious mononucleosis and hence, if present, should suggest an alternate diagnosis.
  • Erythrocyte sedimentation rate (ESR) is often elevated in patients with infectious mononucleosis but is usually within normal limits in patients with group A streptococcal pharyngitis. However, ESR alone is a very nonspecific finding as it may be elevated in many other disorders, besides infections.
  • Blood smear may reveal lymphocytosis.
  • Liver function tests may reveal increase in serum transaminases, but such elevations can also be seen in patient with viral hepatitis.
  • Throat culture is rarely done in patients with infectious mononucleosis as the yield for group A streptococci is very low. Even presence of group A streptococci from the throat is not diagnostic because of colonization.

Other studies

  • Patients with neurological symptoms may have CNS involvement and some type of imaging study is recommended. A CT scan or an MRI should be performed to rule out other causes.
  • Patients who present with neurological signs and symptoms with infectious mononucleosis should also undergo a lumbar puncture. The fluid obtained should be sent for culture, biochemistry and serological studies.
  • If the patient has seizures or any seizure like activity, an EEG may help rule out other causes of encephalitis.
  • In the rare patient in whom the diagnosis is not clear, a lymph node biopsy may be required. Because aspiration of a lymph node has very low yield a small open biopsy is required. Enough tissue must be obtained to rule out a lymphoma. If infectious mononucleosis is the cause, the history will reveal predominantly lymphocytic infiltration in the peripheral regions of the lymph node.
Globulins Increased
  • The abnormalities observed in infectious hepatitis were similar to those of infectious mononucleosis, except that in hepatitis alpha 2 globulin was decreased more consistently, gamma globulin increased less frequently, and beta globulin, which was normal[link.springer.com]
Lymphocytes Increased
  • The levels of liver enzymes and atypical lymphocytes increase with age.[ncbi.nlm.nih.gov]

Treatment

The majority of patients with infectious mononucleosis are managed as outpatients. The few patients who are ill looking and have enlarged tonsils, should be admitted for observation. There is a potential for airway compromise and hence, these patients should be admitted for close monitoring of the respiratory status for a period of 24 to 48 hours. If tonsillar enlargement is moderate to severe, an ENT consult should be made. In addition, anesthesia must also be notified about such an admission, in case there is a need for emergent intubation. At the bedside, an emergency tracheostomy must be available. All healthcare workers should be told to avoid oral cavity examination to prevent irritation of the tonsils that can potentially aggravate the respiratory distress. Admitted patients should have an intravenous line and oxygen if the saturation is below 94% at room air. If wheezing is present, bronchodilator therapy may be required. The decision to administer steroids rests on the severity. Some physicians do administer a short course of IV steroids to decrease the inflammation.

Surgery is required when patients present with rupture of the spleen. The diagnosis is often made with a CT scan. Attempts to salvage the spleen are often undertaken but if preservation is not possible, a splenectomy is performed.

Patients who are stable and have no airway compromise can resume a regular diet. In general, patients with infectious mononucleosis are told to refrain from physical activity for at least 3 to 4 weeks to ensure that splenic rupture does not occur. Those patients admitted for observation are only discharged when the tonsillar swelling has subsided and the patient is able to tolerate a diet. Following discharge patients need to be monitored to ensure that there is resolution of the symptoms. Patients should be warned that prolonged fatigue may occur [8] [9].

Prognosis

For the majority of patients with infectious mononucleosis, the prognosis is excellent.

  • Both central nervous system (CNS) involvement and airway obstruction are rare events and only anecdotal case reports exist. When managed appropriately these individuals have an excellent prognosis.
  • Those patients who have an enlarged spleen have a risk of rupture and should avoid all physical activity until the gland size returns to normal. Splenic rupture has been reported in the literature but is not a common complication. Even if spleen rupture occurs, the prognosis is good if the patient is able to get to an emergency room and undergo surgery. All patients who have the spleen removed are at risk for the postsplenectomy sepsis. These patients need to be monitored closely.
  • Patients with neurological signs also fully recover. However, a few patients with infectious mononucleosis may develop prolonged fatigue that may last a few months or even years.
  • Death following infectious mononucleosis is very rare and even when it occurs is due to comorbidity like a malignancy.
  • In patients who are immunocompromised, liver infection with EBV can lead to necrosis and death.
  • There are also reports suggesting that patients who undergo solid organ transplants may be at risk for developing a lymphoproliferative disorder induced by EBV. Other EBV associated malignancies reported in the literature include nasopharyngeal cancer, Burkitt lymphoma and leiomyosarcoma which may occur in immunocompromised individuals.

Etiology

The cause of infectious mononucleosis is acquisition of EBV from an infected individual. Individuals with infectious mononucleosis develop oral and nasal secretions that persist for many months after the symptoms have subsided. These secretions tend to have a high concentration of the virus. Individuals at highest risk for acquiring infectious mononucleosis are those who have immunosuppression from malignancies, chemotherapeutic agents, human immunodeficiency virus (HIV) infection or congenitally acquired immune deficiency syndromes. Children who develop Burkitt lymphoma which is also caused by EBV, are also at risk for development of infectious mononucleosis.

Epidemiology

Infectious mononucleosis is a global viral infection that is known to occur in people of all ages but is most common in teenagers and adolescents. Studies show that seroconversion is quite common before the age of five, but not all individuals develop clinical disease. However, teenagers and young adults who seroconvert often develop infectious mononucleosis.

The viral infection occurs in all races and in both genders. Because the infection is mild in many cases, most people do not come to medical attention. Hence exact numbers of people with infectious mononucleosis remains unknown, but the numbers are high.

Sex distribution
Age distribution

Pathophysiology

EBV is acquired after a person comes into contact with body secretions from an infected individual. Patients with infectious mononucleosis often develop profuse oral and nasal secretions with a high concentration of the virus. The virus is also known to be shed from the epithelial lining of the cervix, which suggests that it may be contracted during unprotected sex. There are also reports of EBV present in donated blood from patients with infectious mononucleosis, thus suggesting that it can be acquired via a blood transfusion [4].

Once EBV enters the systemic circulation, it has an affinity for the reticular endothelial system such as the lymph nodes, liver and spleen. Here the virus induces an immune response with proliferation of B and T lymphocytes [5]. It is this cellular response that governs the clinical expression of symptoms after EBV infection. If the cellular response is intense, the virus will be killed and only a mild infection is seen. In immunocompromised people the virus is freely able to divide and hence produces a marked systemic response. The fever seen in infectious mononucleosis is due to the release of various cytokines that occurs as a result of lymphocytes attacking the EBV. The pharyngitis occurs because of infiltration and proliferation of the infected B lymphocytes in the lymphatic tissue in the pharynx.

Prevention

The only way to prevent infectious mononucleosis is to avoid close contact with people who are already infected. This means avoiding contact with all body fluids, especially oral and nasal secretions since they harbor high concentrations of the virus. Washing hands frequently is also recommended. One needs to avoid using all personal care items from an infected person. Patients with infectious mononucleosis should avoid physical activity for 3 to 4 weeks to prevent splenic rupture.

Summary

Infectious mononucleosis is a common viral infection known to cause fever, pharyngitis and localized adenopathy. The disorder is caused by the Epstein Barr virus (EBV), which is acquired after contact with an infected individual. Blood work usually reveals presence of lymphocytosis and the diagnosis is confirmed with the Monospot test. The infection is common globally and often presents in teenagers and young adolescents. In the majority of cases, infectious mononucleosis presents with mild symptoms that are often mistaken for the common cold or streptococcal pharyngitis. The symptoms in children are mild whereas the symptoms in adults tend to be quite pronounced [1] [2] [3].

Patient Information

Infectious mononucleosis is a viral infection of the throat that presents with fever and swelling of the lymph nodes. While the infection is mild in most people, it can sometimes cause breathing difficulties, which requires admission to the hospital. Some patients may require a tube down the throat for a few days so that they can breathe. The virus can also cause enlargement of the spleen, which in some cases ruptures [10]. This often requires emergent surgery. Overall, the outcome of most patients with infectious mononucleosis is excellent. A few patients may develop prolonged fatigue for a few months or even years.

References

Article

  1. Georgalas CC, Tolley NS, Narula PA. Tonsillitis. BMJ Clin Evid. 2014 Jul 22;2014.
  2. Luzuriaga K, Sullivan JL. Infectious mononucleosis. N Engl J Med. 2010 May 27;362(21):1993-2000
  3. Stock I. Infectious mononucleosis--a "childhood disease" of great medical concern]. Med Monatsschr Pharm. 2013 Oct;36(10):364-8.
  4. Singer-Leshinsky S. Pathogenesis, diagnostic testing, and management of mononucleosis. JAAPA. 2012 May;25(5):58-62.
  5. Münz C. Role of human natural killer cells during Epstein-Barr virus infection. Crit Rev Immunol. 2014;34(6):501-7.
  6. Vouloumanou EK, Rafailidis PI, Falagas ME. Current diagnosis and management of infectious mononucleosis. Curr Opin Hematol. 2012 Jan;19(1):14-20.
  7. Taylor GS, Long HM, Brooks JM, Rickinson AB, Hislop AD. The Immunology of Epstein-Barr Virus-Induced Disease. Annu Rev Immunol. 2015 Feb 11
  8. Katz BZ, Jason LA. Chronic fatigue syndrome following infections in adolescents. Curr Opin Pediatr. 2013 Feb;25(1):95-102
  9. Cirilli AR. Emergency evaluation and management of the sore throat. Emerg Med Clin North Am. 2013 May;31(2):501-15.
  10. Becker JA, Smith JA. Return to play after infectious mononucleosis. Sports Health. 2014 May;6(3):232-8

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Last updated: 2018-06-21 22:31