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