Infectious Mononucleosis

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Young children infected with EBV generally are asymptomatic or have such mild disease that symptoms are not recognized. Older children, teens, and young adults are more likely to develop the symptomatic clinical signs of IM. Once infected, some patients may experience a prodromal period of symptoms where they may experience headache, anorexia, and fatigue for 1 to 2 weeks before more classical symptoms become apparent. Classical symptoms of IM include pharyngitis, moderate-to-high fever, and generalized lymphadenopathy in the inguinal, axillary, posterior auricular, and cervical nodes.

Pharyngitis may produce pharyngeal inflammation and exudates. Pharyngitis can be caused by various bacteria e. Throat culture testing for group A streptococcus is likely the most common test to exclude before diagnosis of IM.

Infectious Mononucleosis

Patients with IM commonly complain of sore throat and fatigue. Splenic rupture is a rare but potentially life-threatening complication. It is more common in males, possibly due to the higher rates of participation in contact sports, although splenic rupture is spontaneous in roughly half of the cases. Pharyngitis, however, is a common complaint of various infections so other viral or bacterial causes need to be ruled out, such as the common cold or influenza.

If a patient with IM is treated with amoxicillin or ampicillin, a morbilliform rash will likely develop. A patient presenting with a morbilliform rash after taking a penicillin antibiotic for pharyngitis should be assessed for IM. Diagnostic laboratory tests include a positive heterophile antibody test Monospot and the presence of atypical lymphocytes on a peripheral-blood smear. Antibodies may remain positive for 9 months after the onset of IM, so a positive Monospot test may not indicate an acute infection of IM.

For the majority of patients, IM runs a self-limiting course and recovery occurs without sequelae, although complications can occur. These complications may include hemolytic anemia, thrombocytopenia, thrombotic thrombocytopenic purpura, and disseminated intravascular coagulation. Persistent fatigue lasting for 6 months or longer with functional impairment can also occur.

Recommended therapy for management of IM has not changed much over the years. Pharmacologic options remain limited and mostly include symptomatic treatment or supportive care. Fever, myalgias, and throat discomfort can be treated with nonsteroidal anti-inflammatory drugs NSAIDs or acetaminophen.

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Valacyclovir has also been studied in patients with IM. A total of 20 college students were treated with valacyclovir or placebo for 14 days. Results showed small decreases in severity of illness scores at day 15 and a reduction of EBV excretion in saliva; however, this was a small trial with questionably clinically significant results.


Reports have demonstrated that antivirals may decrease EBV shedding in saliva of treated patients, but since most people are EBV-seropositive from previous exposure, special precautions against transmission from symptomatic patients are not necessary. Corticosteroids have also traditionally been used for IM to prevent airway obstruction and lessen pharyngeal inflammation. The role of corticosteroids in the symptomatic treatment of IM was assessed by treating with prednisone 60 mg daily tapered over 10 days.

Results showed that fever and lymphadenopathy resolved slightly faster with corticosteroids compared to placebo, but clinical significance was questioned. The combination of acyclovir mg orally 5 times per day and prednisolone 0. The effectiveness of combination therapy was compared to acyclovir monotherapy in a double-blind, placebo-controlled trial of 94 patients. A meta-analysis was conducted to assess the efficacy of corticosteroids in IM and included four trials utilizing only corticosteroids and three trials using corticosteroids plus acyclovir.

Two of the seven trials found a reduction in sore throat pain within 12 hours with corticosteroids, but this benefit was not maintained.

What is infectious mononucleosis in teens and young adults?

The overall conclusion was that there was insufficient evidence to recommend corticosteroids for symptom control in IM. Furthermore, corticosteroids have not been proven to reduce disease complications, rates of hospital admission, or length of hospital stay. Nonpharmacologic treatment is an essential part of managing IM.

The mainstay of therapy includes restriction of activity. Adequate rest is important, but bed rest is not required. Maintaining adequate hydration is even more important in individuals taking NSAIDs for symptomatic relief to avoid renal insufficiency. IM is not a highly contagious disease, and most people have already been infected with EBV. In addition, patients with IM are typically infected and contagious for 4 to 8 weeks before symptoms appear. It is important to note that patients may experience fatigue and may have to ease back into their normal schedules.

Avoiding Splenic Rupture: As previously mentioned, splenomegaly is a common symptom encountered, rarely leading to splenic rupture.

Abdominal pain and decreasing hemoglobin are hallmark signs of splenic rupture. The exact cause of splenic rupture is unknown but might be secondary to lymphocytic infiltration of the spleen that disrupts the normal tissue anatomy and support structures, leaving the spleen fragile. Roughly half of all cases of splenic rupture occur spontaneously, but concern for traumatic damage remains. Since IM largely affects teenagers and young adults, many of whom participate in sports and other physical activities, participation in these activities should likely be avoided.

Infectious mononucleosis skin rash without previous antibiotic use

The question may arise as to when a patient with IM may return to sports or other physical activities. A case review of splenic rupture in athletes with IM showed that almost all patients had splenomegaly presenting between days 4 and 21 of illness onset and splenic rupture occurring between 4 and 7 weeks after illness onset. There are no specific guidelines that state when a patient with IM may return to athletic participation, but the general recommendation is roughly 3 weeks after initial symptom onset for athletes to resume activity in noncontact sports and at least 4 weeks after symptom onset for strenuous contact sports or activities that can lead to increased abdominal pressure e.

In the case of high contact or collision sports, a radiologic evaluation of the spleen might be warranted before return to activities. It may take several months for athletes to regain a pre-illness level of fitness.

Infectious mononucleosis

Chronic Fatigue: Whereas resolution of acute symptoms of IM is typical in 1 to 2 weeks, fatigue may linger for months. A study by Katz et al examined the course and outcome of CFS in adolescents aged 12 to 18 years over a 2-year period following IM. This study showed that female gender was associated with a greater incidence of CFS. Pharmacists can play a key role in the management and education of IM. The appearance of a morbilliform rash after penicillin administration for pharyngitis may signal that IM is the cause of the pharyngitis.

Although prescription agents are not usually necessary for IM, counseling on selection of NSAIDs or acetaminophen for supportive care may be needed. Providing answers to commonly asked questions about avoidance of sports and fatigue may also be needed. Infectious mononucleosis. Accessed February 1, Luzuriaga K, Sullivan J. N Engl J Med. Infectious mononucleosis in the athlete. Am J Sports Med. Infectious mononucleosis in adults and adolescents. Haines JD. When to resume sports after infectious mononucleosis: how soon is safe?

Postgrad Med. A prospective clinical study of Epstein-Barr virus and host interactions during acute infectious mononucleosis. J Infect Dis. Vetsika EK, Callan M. Infectious mononucleosis and Epstein-Barr virus. Typical symptoms of infectious mononucleosis usually appear four to six weeks after you get infected with EBV.

Symptoms may develop slowly and may not all occur at the same time. 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. 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. EBV is the most common cause of infectious mononucleosis, but other viruses can cause this disease. Typically, these viruses spread most commonly through bodily fluids, especially saliva. However, these viruses can also spread through blood and semen during sexual contact, blood transfusions, and organ transplantations. 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. If you have infectious mononucleosis, you should not take penicillin antibiotics like ampicillin or amoxicillin. Based on the severity of the symptoms, a healthcare provider may recommend treatment of specific organ systems affected by infectious mononucleosis. 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.

Laboratory tests are not usually needed to diagnose infectious mononucleosis.