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Mononucleosis
Aka: Mononucleosis, Acute Mononucleosis Syndrome, Epstein-Barr Virus, Epstein Barr Virus, EBV-Induced Mononucleosis, EBV- Etiology
- Epstein-Barr Virus
- Human Herpes Virus (Herpesviridae)
- Infects B Cells (B-Cell Lymphotrophic)
- Adults who have been infected and are carriers: 90%
- Epstein-Barr Virus
- Transmission
- Transmission through infected Saliva (kissing)
- Oral secretions transmit for up to 6 months
- Epidemiology
- Adolescents and young adults
- Commonly occurs in congested, confined spaces
- College Students
- Military recruits
- Incubation
- Range: 4-8 weeks (may be as short as 2 weeks)
- Symptoms
- Fever (in >97% of cases)
- Persists for 7-10 days
- Chills
- Malaise
- Fatigue (Test Sensitivity: 93%)
- Myalgia
- Severe Sore Throat
- Fever (in >97% of cases)
- Signs
- Exudative Pharyngitis (>97%)
- Prominent cervical Lymphadenopathy (>97%)
- Posterior cervical Lymphadenopathy most common
- Axillary and Inguinal Lymphadenopathy also common
- Pharyngeal erythema and edema (85%)
- Splenomegaly (75%)
- Palatal Petechiae (50%)
- Periorbital edema (33%)
- Hepatomegaly (20%)
- Labs
- Throat Culture
- Exclude coexisting Streptococcal Pharyngitis
- Concurrent Strep PharyngitisIncidence: 4-30%
- If positive, avoid Amoxicillin due to rash
- Lymphocyte predominance: >50%
- Lymphocyte atypia >10%
- Very specific to EBV
- No further tests needed if Lymphocyte atypia present

- Heterophil Antibody Test (Monospot Test)
- Efficacy: 95% sensitive and Specific
- Antibodies to EBV antigens:
- Acute phase antibodies: xEA, xIgM VCA
- Convalescent Antibody: xIgG VCA
- Recovered State: xIgG VCA, xEBNA
- Throat Culture
- Differential Diagnosis
- Diagnosis
- Management
- Symptomatic
- Rest
- Non-caffeinated fluids for adequate hydration
- Analgesics (NSAIDs or Acetaminophen)
- See Pharyngitis Symptomatic Treatment
- Avoid strenuous Exercise or contact sport
- Risk of splenic rupture
- Return to play
- Three weeks: Moderate training allowed
- No Splenomegaly
- No fever
- Liver Function Tests Normal
- Asymptomatic
- Four weeks: strenuous activity allowed
- Three weeks: Moderate training allowed
- Severe odynophagia or Airway compromise
- Oral Prednisone 30-50mg PO qd tapered 10-14 days or
- Oral Dexamethasone 0.3 mg/kg
- May require repeat doseing
- Antibiotics
- Only indicated for coexisting Strep Throat
- Rash develops in 90% of EBV patients on antibiotics
- Especially with Ampicillin
- Other ineffective agents
- No benefit with Acyclovir
- No benefit with Ranitidine
- Symptomatic
- Complications
- Meningoencephalitis
- Guillain-Barre Syndrome
- Bell's Palsy
- Pneumonitis
- Pericarditis
- Myocarditis
- Peritonsillar Abscess: 0.2%
- Rheumatic Fever: 0.2%
- Syndrome of inappropriate Antidiuretic Hormone (SIADH)
- Splenic rupture (days 4-21): 0.1-0.2% Incidence
- Airway Obstruction
- Hemolytic Anemia
- Thrombocytopenia
- Acute Interstitial Nephritis
- Retrobulbar neuritis
- Associated Conditions
- Chronic Fatigue Syndrome (possibly same viral agent)
- Course
- Athletes require 3-6 months to return to prior fitness
- Fatigue or Hypersomnia persists 6 months in 9-22%
- Fatigue present
- Initial: 77%
- Month 1: 28%
- Month 2: 21%
- Month 6: 13%
- Hypersomnia present
- Initial: 45%
- Month 1: 18%
- Month 2: 14%
- Month 6: 9%
- Arthralgias present
- Initial: 23%
- Month 1: 15%
- Month 2: 6%
- Month 6: 9%
- References
- Resources: Patient Education
- AAFP Family Doctor Patient Education Handout
- References
- Katz in Gershon (2004) Krugman's ID, p. 143-55
- Gantz in Noble (2001) Primary Care, p. 267-71
- Ebell (2004) Am Fam Physician 70(7):1279-87