Infectious mononucleosis/kissing disease/glandular fever

  • A self-limiting disease caused by infection of B lymphocytes by the Epstein-Barr virus,(herpes virus family)

  • it may also replicate in the epithelial cells of the pharynx and parotid duct

  • infection is common in

    • children under 3 years(developing countries)
    • between the ages of 15 and 25 years (in developed countries)

  • it is often called the kissing disease since kissing can spread the virus

  • it may also be spread by coughing, sneezing, or sharing a glass or food

  • it is not as contagious as common cold 

  • the incubation period : about 4-8weeks


    Signs and symptoms

    • 98 % had sore throat, lymph node enlargement, fever, and tonsillar enlargement
    • petechial haemorrhagic covering of the soft palate and whitish exudate covering the tonsils
    • older adults are less likely to have sore throat and adenopathy but more likely to have hepatomegaly and jaundice


    Other features

    • lymphadenopathy
      • posterior cervical adenopathy (1)
      • axillary adenopathy
      • inguinal adenopathy
    • headache
    • skin rash
    • loss of appetite
    • splenomegaly (soft)
    • night sweats

  • the patient may develop a fine macular rash, the incidence of which is higher if the patient has been given ampicillin early in the illness.

  • image 

    Differential diagnosis
    • acute  (HIV)
    • streptococcal tonsillitis
    • diphtheria
    • when lymphadenopathy is prominent:
      • leukaemia
      • toxoplasmosis  (splenomegaly,hepatomegaly,lymphocytosis,atypical lymphocytosis )
      • cytomegaloviral infection (splenomegaly,hepatomegaly,lymphocytosis,atypical lymphocytosis )
    • when jaundice is the prominent feature:
      • infectious hepatitis
      • measles
      • rubella


    Screening tests:
    • FBC - leucocytosis of between 10,000 and 20,000 cells/mm3
    • blood film : many atypical ((large, irregular nuclei)) activated T lymphocytes (mononucleosis cells).
    • positive Paul Bunnell reaction - IgM heterophile antibodies that agglutinate sheep erythrocytes )
    imagePeripheral blood smear showing lymphocytosis consistent with mononucleosis.
    Specific tests:
    • more sensitive tests include:
      • viral capsid antigen (VCA)-IgG
      • VCA-IgM
        the isolation of EBV is difficult and rarely performed.

    Hoagland's criteria for the diagnosis of infectious mononucleosis
    • this includes the following features in the presence of fever, pharyngitis, and confirmed by a positive serologic test
      • at least 50 percent lymphocytes
      • at least 10 percent atypical lymphocytes .
    • these criteria are most useful for research purposes


    • there is no specific treatment available for glandular fever.
    • the mainstay of treatment for infectious mononucleosis includes
      • good supportive care
      • adequate hydration
      • for fever and myalgias:
        • NSAIDs
        • paracetamol
      • to relieve throat discomfort
        • throat lozenges
        • sprays
        • gargling with a 2%lidocaine (Xylocaine) solution

    • Ampicillin and amoxycillin should not be used if there is any possibility of EBV infection as they cause a rash. Penicillin is apparently safer.


    1. splenic rupture
    2. airway blocked by pharyngeal oedema
    3. pneumonitis
    4. thrombocytopaenia
    5. haemolytic anaemia
    6. hepatitis
    7. cardiac involvement - 10% of patients develop minor T-wave changes
      • myocarditis and cardiac conduction abnormalities
    8. neurologic abnormalities
      • meningitis - benign
      • encephalitis - 33% mortality of an 11 case series
      • cranial nerve palsies
      • single nerve palsies
      • retrobulbar neuritis
      • Guillain-Barre syndrome


    • In many cases symptoms resolve in 2-4 weeks.
    • However in some cases fatigue, malaise, and anorexia may last for weeks or even months.
    • Poor physical functioning consistently predicts delayed recovery


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