Glandular Fever/EBV infection/Infective Mononucleosis

Background

  • Infectious, usually self-limiting disease caused by Epstein-Barr virus (EBV).
    • Incubation period ~33-49 days
    • Usually transmitted via contact with saliva (kissing/sharing drinks/food)
    • Any patient who has been infected can potentially be a carrier (asymptomatic)
  • Although usually self limiting, EBV infection can result in malignancy (lymphoproliferative disease/CNS lymphoma/Hodgkin’s lymphoma and nasopharyngeal cancer)
  • Around 1/500 per year; peak age 17-19 years and rare over 35 (slightly more common in men)

Presentation

  • There may be prodromal symptoms e.g. malaise, myalgia, chills, sweats, fever, anorexia, bloating, headache
  • Lymphadenopathy occurs in practically all patients (usually posterior cervical cf GBS- anterior)
  • Severe sore throat can last 3-5 days then improves over 7-10 days
    • Usually with tonsillar enlargement; occasionally with pharyngeal redness and exudate
  • Fever
  • Acute fatigue can be severe and may persist for several weeks-months
  • Splenomegaly occurs in around half of patients (can predispose to splenic rupture in rare cases)
    • Less common findings include periorbital oedema; hepatomegaly; rash; jaundice; palatal petechiae
  • Younger children can be asymptomatic; whereas older individuals can present atypically without sore throat or lymphadenopathy but with prolonged fever and jaundice

Investigations

  • FBC
    • >20% atypical/reactive lymphocytes or >10% and lymphocyte:total WBC ratio >0.5 (i.e. >50%)
  • LFTs
    • AST/ALT can be raised 2-3 times normal (anything >10 times normal suggests another cause)
  • Paul-Bunnell/Monospot test (heterophile antibodies)
    • Usually in week 2 of symptoms
    • If negative, repeat 7 days later.  If negative again, test also for cytomegalovirus/toxoplasmosis if the patient is immunodeficient or pregnant
    • If the patient is immunocompromised (or in young children <12)- EBV serology (after 7 days)
  • Test for HIV in at risk individuals

Management

  • Paracetamol and ibuprofen
  • Do NOT prescribe penicillins for these patients (in particular/usually amoxicillin) as this will not help recovery and can cause the development of a widespread erythematous rash
  • Prednisolone should only be used in severe cases with bad pharyngeal oedema
  • Advise avoidance of contact sports/heavy lifting as spleen is at increased risk of rupture (be weary of a patient who comes in with this)
    • Return to work/school ASAP

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