What is mononucleosis

Mononucleosis or infectious mononucleosis is often called ‘glandular fever’, the ‘kissing disease’ or “mono.” Mononucleosis (infectious mononucleosis) is caused by human herpes virus type 4, more often known as Epstein–Barr virus (EBV). This virus is passed from person to person by saliva such as kissing, but you can also be exposed through a cough or sneeze, or by sharing a glass or food utensils with someone who has mononucleosis. Epstein–Barr virus (EBV) can also spread through blood and semen during sexual contact, blood transfusions, and organ transplantations. However, mononucleosis isn’t as contagious as some infections, such as the common cold. The incubation period from contact until symptoms is 1 to 2 months (30 to 50 days from the time of infection for glandular fever to develop). That means you’re infectious for up to 7 weeks before you get symptoms. A person with mononucleosis is contagious for months after the infection, so it’s important to follow good hygiene so others don’t get infected.

Mononucleosis typically affects teenagers and young adults aged 15 to 25 years. Symptoms can come on gradually, and at first there may be just tiredness and lack of energy. A sore throat, swollen glands (particularly in the neck) and a rash may occur. Upper abdominal pain can occur from a swollen liver or spleen. Glandular fever symptoms can last weeks to months, especially fatigue and lack of energy.

You’re most likely to get mononucleosis with all the signs and symptoms if you’re an adolescent or young adult. Young children usually have few symptoms, and the infection often goes unrecognized.

If you have mononucleosis, it’s important to be careful of certain complications such as an enlarged spleen. Rest and adequate fluids are key to recovery.

There’s no cure for mononucleosis (glandular fever), it gets better by itself.

DO

• rest and sleep
• drink plenty of fluids (to avoid dehydration)
• take painkillers like paracetamol or ibuprofen (don’t give aspirin to children under 16)

DON’T drink alcohol – your liver might be weak while you have mononucleosis.

You should feel better within 2 to 3 weeks. Some people might feel extremely tired for months.

Try to gradually increase your activity when your energy starts to come back.

Mononucleosis can cause your spleen to swell. For the first month, avoid sports or activities that might increase your risk of falling, as this may damage your spleen.

There is no specific treatment for infectious mononucleosis. Your doctor can advise on treatment for symptoms such as fever and sore throat. Rest and a balanced diet may be helpful.

How long do the symptoms last?

Most people with mononucleosis (glandular fever) are unwell for 2 to 3 weeks, but tiredness and swollen lymph nodes can persist for several more weeks. In fact, it may take a few months before you feel completely well. It is important to take your time in getting back to normal.

Ongoing fatigue that lasts for 2-3 months is quite common. Epstein-Barr virus (EBV) infection, like a number of other viruses, may be a trigger for the development of chronic fatigue syndrome (CFS). However, chronic fatigue syndrome is NOT regarded as a chronic (ongoing) EBV infection and EBV is not considered a specific cause of CFS.

When can I return to my normal activities?

You should rest as much as needed during the initial phase of the illness. Once your sore throat and fever are better and you start to feel less tired, increase your activities gradually, being careful not to push yourself too hard.

Contact sports, vigorous activities and heavy lifting should be avoided for at least a month because of the risk of rupturing the spleen, even in people who do not have a noticeably enlarged spleen.

Does my child have to stay away from school or child care?

Children should stay home from school or child care while they are feeling unwell, but there is no specific recommended time frame for staying away from school or day care.

When to see your doctor

If your symptoms are not improving after a couple of weeks, or your symptoms return after a period of improvement, you should see your doctor.

Mononucleosis complications

Complications of mononucleosis may be more serious than the disease itself.

Enlargement of the spleen

Mononucleosis may cause enlargement of the spleen. In extreme cases, your spleen may rupture, causing sharp, sudden pain in the left side of your upper abdomen. If such pain occurs, seek medical attention immediately — you may need surgery.

Liver issues

Problems with your liver also may occur:

• Hepatitis. You may experience mild liver inflammation (hepatitis).
• Jaundice. A yellowing of your skin and the whites of your eyes (jaundice) also occurs occasionally.

Less common complications

Mononucleosis can also result in the following less common complications:

• Anemia — a decrease in red blood cells and in hemoglobin, an iron-rich protein in red blood cells
• Thrombocytopenia — low count of platelets, which are blood cells involved in clotting
• Heart problems — an inflammation of the heart muscle (myocarditis)
• Complications involving the nervous system — meningitis, encephalitis and Guillain-Barre syndrome
• Swollen tonsils — which can block breathing

The Epstein-Barr virus can cause much more serious illness in people who have impaired immune systems, such as people with HIV/AIDS or people taking drugs to suppress immunity after an organ transplant.

Mononucleosis causes

How do you get mononucleosis

Mononucleosis (infectious mononucleosis) is caused by an infection with Epstein-Barr virus (EBV). The virus is transmitted through saliva, and can be passed from person to person through kissing. It can also be spread via sneezing, coughing or sharing eating utensils, drinking containers or by sucking on toys.

Most adults have been exposed to EBV at some time in their lives and are immune to glandular fever. Because many people are infected with EBV during childhood and experience few or no symptoms, they are not aware that they have been exposed.

Mononucleosis prevention

There is no vaccine to protect against infectious mononucleosis. You can help protect yourself by not kissing or sharing drinks, food, or personal items, like toothbrushes, with people who have infectious mononucleosis.

To prevent glandular fever spreading:

DO

• careful hand washing with soap and running water, especially after sneezing and coughing and before touching other people
• cleaning with soap and water of soiled objects, such as toys of sick children
• wash bedding and clothes that may have spit on them

DON’T

• avoiding saliva contact (e.g. kissing) with people who are sick with infectious mononucleosis
• share cups, cutlery or towels

Mononucleosis symptoms

Symptoms of infectious mononucleosis (glandular fever), which typically appear 4 to 6 weeks after being infected with Epstein-Barr virus (EBV), include:

• Fever
• Sore throat
• Swollen tonsils
• Swollen lymph glands
• Headache
• Muscle ache
• Tiredness, and feeling generally unwell
• Rash
• Your doctor may find swelling of the spleen (splenomegaly) or liver (hepatitis)

These symptoms are common among teenagers and young adults with glandular fever. Younger children infected with Epstein-Barr virus (EBV) often experience few or no symptoms.

Sometimes a fine skin rash may appear if certain antibiotics (amoxycillin or ampicillin) have been prescribed in the mistaken belief that the symptoms have been caused by a bacterial throat infection.

However the virus can also affect other organs, as shown in the table 1 below. In about 50 per cent of people with mononucleosis the spleen (a large organ in the upper left side of your abdomen) becomes enlarged. An enlarged spleen (splenomegaly) generally causes no symptoms, but in rare cases the spleen can rupture, causing sudden and intense abdominal pain.

Enlarged spleen and a swollen liver are less common symptoms. For some people, their liver or spleen or both may remain enlarged even after their fatigue ends. Severe cases of mononucleosis can also be associated with liver inflammation (hepatitis) and jaundice (yellowing of the whites of the eyes and skin).

Most people get better in two to four weeks; however, some people may feel fatigued for several more weeks. Occasionally, the symptoms of infectious mononucleosis can last for six months or longer.

Most people make a complete recovery

Once infected, the virus remains in the body for life.

Table 1. Infectious mononucleosis other symptoms

Note: People with weakened immune systems may develop more severe symptoms and complications from Epstein-Barr virus (EBV) infection. They may also have more severe illness caused by Epstein-Barr virus (EBV) infection.

Involvement of the skin by infectious mononucleosis

Involvement of the skin is seen in about 10% of non-hospitalised patients with infectious mononucleosis. Most commonly, there is a faint, widespread, non-itchy rash, which lasts for about a week. It is described as maculopapular exanthem, i.e. there are flat patches that may contain small bumpy red spots. It thought to be directly due to the virus. This rash often appears on the trunk and upper arms first, and a few days later extends to involve the face and forearms. Other appearances of this rash include:

• Morbilliform (small, flat, measles-like patches)
• Papular (small bumps)
• Scarlatiniform (tiny spots like scarlet fever)
• Vesicular (little blisters)
• Purpuric (bruise-like)

This is in contrast to a more intense itchy maculopapular or morbilliform rash which appears on extensor surfaces and pressure points 7 to 10 days after treatment with beta-lactam antibiotics such as ampicillin, amoxicillin and cephalosporins. This rash indicates a ‘hypersensitivity reaction’ to the antibiotic. It is not a true allergy and does not occur if the antibiotic is given later on in the absence of Epstein-Barr virus (EBV) infection.

Figure 1. Mononucleosis rash

Mononucleosis diagnosis

Your doctor will ask about your symptoms and perform a physical examination.

Mononucleosis test

The Monospot test is not recommended for general use. The antibodies detected by Monospot can be caused by conditions other than infectious mononucleosis. Moreover, studies have shown that the Monospot produces both false positive and false negative results. For example, the heterophile antibodies detected by Monospot are often not present in children with infectious mononucleosis. At best, the Monospot test may indicate that a person has a typical case of infectious mononucleosis, but does not confirm the presence of Epstein-Barr virus (EBV) infection.

There are other antibody tests that can be used to test for mononucleosis early in the illness.

EBV Antibody Tests

Epstein-Barr virus (EBV) antibody tests are not usually needed to diagnose infectious mononucleosis. However, specific antibody tests may be needed to identify the cause of illness in people who do not have a typical case of infectious mononucleosis or have other illnesses that can be caused by Epstein-Barr virus (EBV) infection. Symptoms of infectious mononucleosis generally resolve within 4 weeks. If a person is ill for more than 6 months and does not have a laboratory-confirmed diagnosis of Epstein-Barr virus (EBV) infection, other causes of chronic illness or chronic fatigue syndrome should be considered.

Viral capsid antigen (VCA)

• Anti-VCA IgM appears early in EBV infection and usually disappears within 4 to 6 weeks.
• Anti-VCA IgG appears in the acute phase of EBV infection, peaks at 2 to 4 weeks after onset, declines slightly then persists for the rest of a person’s life.

Early antigen (EA)

Anti-EA IgG appears in the acute phase of illness and generally falls to undetectable levels after 3 to 6 months. In many people, detection of antibody to EA is a sign of active infection. However, 20% of healthy people may have antibodies against EA for years.

EBV nuclear antigen (EBNA)

Antibody to EBNA, determined by the standard immunofluorescent test, is not seen in the acute phase of EBV infection but slowly appears 2 to 4 months after onset of symptoms and persists for the rest of a person’s life. Other EBNA enzyme immunoassays may report false positive results.

Interpretation of EBV antibody tests and diagnosis of EBV infection is summarized as follows:

• Susceptibility to infection: People are considered susceptible to EBV infection if they do not have antibodies to the VCA.

• Primary (new or recent) infection: People are considered to have a primary EBV infection if they have anti-VCA IgM but do not have antibody to EBNA. Other results that strongly suggest a primary infection are a high or rising level of anti-VCA IgG and no antibody to EBNA after at least 4 weeks of illness. Resolution of the illness may occur before the diagnostic antibody levels appear. In rare cases, people with active EBV infections may not have detectable EBV-specific antibodies.

• Past infection:  The presence of antibodies to both VCA and EBNA suggests past infection (from several months to years earlier). Since over 90% of adults have been infected with EBV, most adults will show antibodies to EBV from infection years earlier. High or elevated antibody levels may be present for years and are not diagnostic of recent infection.

Testing paired acute- and convalescent-phase serum samples is not useful to distinguish between recent and past EBV infections. In most cases, the antibody response occurs rapidly during primary EBV infection. The clinical findings of infectious mononucleosis occur in conjunction with the appearance of IgG and IgM anti-VCA antibodies. However, the antibody pattern is not stable before symptoms appear.

Blood test

Your doctor may also order another blood test called a complete blood count (CBC) to check your white cell count. An increase in white blood cells (lymphocytes), particularly atypical lymphocytes (abnormal-looking lymphocytes), can be associated with mononucleosis. These blood tests won’t confirm mononucleosis, but they may suggest it as a possibility.

Mononucleosis treatment

There is no specific treatment for mononucleosis (glandular fever), but getting plenty of rest and keeping up your fluid intake are important for recovery.

Mononucleosis (glandular fever) is a viral illness, so antibiotics are not helpful (antibiotics are useful only in treating bacterial infections).

Gargling with salt water several times a day may help relieve a sore throat.

Pain relievers such as paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) can be used to treat pain and fever. Aspirin should not be given to children under the age of 16 years, because it can trigger a rare but serious condition called Reye’s syndrome.

People with glandular fever are sometimes treated with corticosteroids to help reduce severe swelling of the throat and tonsils.

Because your spleen may become enlarged as a result of infectious mononucleosis, you should avoid contact sports until you fully recover. Participating in contact sports can be strenuous and may cause the spleen to rupture.

Home remedies

Besides getting plenty of bed rest, these steps can help relieve symptoms of mononucleosis:

• Drink plenty of water and fruit juices. Fluids help relieve a fever and sore throat and prevent dehydration.
• Take an over-the-counter pain reliever. Use pain relievers such as acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin IB, others) as needed. These medicines have no antiviral properties. Take them only to relieve pain or a fever. Use caution when giving aspirin to children or teenagers. Children and teenagers recovering from chickenpox or flu-like symptoms should never take aspirin. This is because aspirin has been linked to Reye’s syndrome, a rare but potentially life-threatening condition, in such children.
• Gargle with salt water. Do this several times a day to relieve a sore throat. Mix 1/2 teaspoon salt in 8 ounces (237 milliliters) of warm water.

Wait to return to sports and some other activities

Most signs and symptoms of mononucleosis ease within a few weeks, but it may be two to three months before you feel completely normal. The more rest you get, the sooner you should recover. Returning to your usual schedule too soon can increase the risk of a relapse.

To avoid the risk of rupturing your spleen, wait at least one month before returning to vigorous activities, heavy lifting, roughhousing or contact sports. Rupture of the spleen results in severe bleeding and is a medical emergency.

Ask your doctor when it’s safe for you to resume your normal level of activity. Your doctor may recommend a gradual exercise program to help you rebuild your strength as you recover.

Coping and support

Mononucleosis can last weeks, keeping you at home as you recover. Be patient with your body as it fights the infection.

For young people, having mononucleosis will mean some missed activities — classes, team practices and parties. Without a doubt, you’ll need to take it easy for a while. Students need to let their schools know they are recovering from mononucleosis and may need special considerations to keep up with their work.

If you have mononucleosis, you don’t necessarily need to be quarantined. Many people are already immune to the Epstein-Barr virus because of exposure as children. But plan on staying home from school and other activities until you’re feeling better.

Seek the help of friends and family as you recover from mononucleosis. College students should also contact the campus student health center staff for assistance or treatment, if necessary.