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Diseases

Infectious mononucleosis

OVERVIEW

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DIAGNOSIS

  • Diagnostic Approach
  • Risk Factors
  • History & Exam
  • Tests
  • Differential Diagnosis
  • Criteria
  • Screening

TREATMENT

  • Tx Approach
  • Tx Options
  • Emerging Tx
  • Prevention

FOLLOW-UP

  • Overview
  • Complications

REFERENCES

  • Citations
  • Guidelines
  • Credits

PATIENT RESOURCES

  • Patient Instructions

Highlights & Basics

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Key Highlights
  • Infectious mononucleosis is characterized by the classic triad of fever, pharyngitis, and lymphadenopathy, along with atypical lymphocytosis. It is often subclinical in young children.

  • Caused by infection with Epstein-Barr virus (EBV) in 80% to 90% of cases. Positive serologic test for antibodies against EBV is usually diagnostic.

  • Rare but potentially life-threatening complications include severe upper airway obstruction, splenic rupture, fulminant hepatitis, encephalitis, severe thrombocytopenia, and hemolytic anemia.

  • Treatment is usually symptomatic.

Quick Reference

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          Definition

          Epidemiology

          Etiology

          Pathophysiology

          content by BMJ Group
          Last updated

          Citations

            Key Articles

            • Vetsika EK, Callan M. Infectious mononucleosis and Epstein-Barr virus. Expert Rev Mol Med. 2004 Nov 5;6(23):1-16.[Abstract]

            • Katz BZ. Update on chronic fatigue syndrome and Epstein-Barr virus. Pediatr Ann. 2002 Nov;31(11):741-4.[Abstract]

            • Ganzel TM, Goldman JL, Padhya TA. Otolaryngologic clinical patterns in pediatric infectious mononucleosis. Am J Otolaryngol. 1996 Nov-Dec;17(6):397-400.[Abstract]

            • De Paor M, O'Brien K, Fahey T, et al. Antiviral agents for infectious mononucleosis (glandular fever). Cochrane Database Syst Rev. 2016 Dec 8;(12):CD011487.[Abstract][Full Text]

            Other Online Resources

            • Centers for Disease Control and Prevention: Epstein-Barr virus and infectious mononucleosis

            Referenced Articles

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            • 2. Gershburg E, Pagano JS. Epstein-Barr virus infections: prospects for treatment. J Antimicrob Chemother. 2005 Aug;56(2):277-81. [Abstract][Full Text]

            • 3. Cohen JI. Epstein-Barr virus infection. N Engl J Med. 2000 Aug 17;343(7):481-92.[Abstract]

            • 4. Bottieau E, Clerinx J, Van den Enden E, at al. Infectious mononucleosis-like syndromes in febrile travelers returning from the tropics. J Travel Med. 2006 Jul-Aug;13(4):191-7.[Abstract][Full Text]

            • 5. Chapman AL, Watkin R, Ellis CJ. Abdominal pain in acute infectious mononucleosis. BMJ. 2002 Mar 16;324(7338):660-1.[Abstract][Full Text]

            • 6. Auwaerter PG. Infectious mononucleosis in middle age. JAMA. 1999 Feb 3;281(5):454-9.[Abstract]

            • 7. Drebber U, Kasper HU, Krupacz J, et al. The role of Epstein-Barr virus in acute and chronic hepatitis. J Hepatol. 2006 May;44(5):879-85. [Abstract]

            • 8. Doja A, Bitnun A, Ford Jones EL, et al. Pediatric Epstein-Barr virus-associated encephalitis: 10-year review. J Child Neurol. 2006 May;21(5):384-91.[Abstract]

            • 9. Connelly KP, DeWitt LD. Neurologic complications of infectious mononucleosis. Pediatr Neurol. 1994 May;10(3):181-4.[Abstract]

            • 10. Bolis V, Karadedos C, Chiotis I, et al. Atypical manifestations of Epstein-Barr virus in children: a diagnostic challenge. J Pediatr (Rio J). 2016 Mar-Apr;92(2):113-21.[Abstract][Full Text]

            • 11. Luzuriaga K, Sullivan JL. Infectious mononucleosis. N Engl J Med. 2010 May 27;362(21):1993-2000.[Abstract]

            • 12. Pariente M, Bartolome J, Lorente S, et al. Age distribution of serological profiles of Epstein-Barr virus infection: review of results from a diagnostic laboratory [in Spanish]. Enferm Infecc Microbiol Clin. 2007 Feb;25(2):108-10.[Abstract]

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            • 15. Kuri A, Jacobs BM, Vickaryous N, et al. Epidemiology of Epstein-Barr virus infection and infectious mononucleosis in the United Kingdom. BMC Public Health. 2020 Jun 12;20(1):912.[Abstract][Full Text]

            • 16. Winter JR, Taylor GS, Thomas OG, et al. Predictors of Epstein-Barr virus serostatus in young people in England. BMC Infect Dis. 2019 Nov 28;19(1):1007.[Abstract][Full Text]

            • 17. Dowd JB, Palermo T, Brite J, et al. Seroprevalence of Epstein-Barr virus infection in U.S. children ages 6-19, 2003-2010. PLoS One. 2013 May 22;8(5):e64921.[Abstract][Full Text]

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            • 19. Crawford DH, Macsween KF, Higgins CD, et al. A cohort study among university students: identification of risk factors for Epstein-Barr virus seroconversion and infectious mononucleosis. Clin Infect Dis. 2006 Aug 1;43(3):276-82. [Abstract][Full Text]

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            • 21. Naito T, Kudo N, Inui A, et al. Causes of infectious mononucleosis-like syndrome in adult patients. Intern Med. 2006;45(13):833-4. [Abstract][Full Text]

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            • 23. Fafi-Kremer S, Morand P, Brion JP, et al. Long-term shedding of infectious Epstein-Barr virus after infectious mononucleosis. J Infect Dis. 2005 Mar 15;191(6):985-9.[Abstract][Full Text]

            • 24. Yao QY, Rickinson AB, Epstein MA. A re-examination of the Epstein-Barr virus carrier state in healthy seropositive individuals. Int J Cancer. 1985 Jan 15;35(1):35-42.[Abstract]

            • 25. Higgins CD, Swerdlow AJ, Macsween KF, et al. A study of risk factors for acquisition of Epstein-Barr virus and its subtypes. J Infect Dis. 2007 Feb 15;195(4):474-82. [Abstract][Full Text]

            • 26. Thomas R, Macsween KF, McAulay K, et al. Evidence of shared Epstein-Barr viral isolates between sexual partners, and low level EBV in genital secretions. J Med Virol. 2006 Sep;78(9):1204-9.[Abstract]

            • 27. Woodman CB, Collins SI, Vavrusova N, et al. Role of sexual behavior in the acquisition of asymptomatic Epstein-Barr virus infection: a longitudinal study. Pediatr Infect Dis J. 2005 Jun;24(6):498-502.[Abstract]

            • 28. Vetsika EK, Callan M. Infectious mononucleosis and Epstein-Barr virus. Expert Rev Mol Med. 2004 Nov 5;6(23):1-16.[Abstract]

            • 29. Abbott RJ, Pachnio A, Pedroza-Pacheco I, et al. Asymptomatic primary infection with Epstein-Barr virus: observations on young adult cases. J Virol. 2017 Oct 13;91(21).[Abstract][Full Text]

            • 30. Cohen JI. Vaccine development for Epstein-Barr virus. Adv Exp Med Biol. 2018;1045:477-93.[Abstract][Full Text]

            • 31. Winter JR, Jackson C, Lewis JE, et al. Predictors of Epstein-Barr virus serostatus and implications for vaccine policy: A systematic review of the literature. J Glob Health. 2020 Jun;10(1):010404.[Abstract][Full Text]

            • 32. Rühl J, Leung CS, Münz C. Vaccination against the Epstein-Barr virus. Cell Mol Life Sci. 2020 Nov;77(21):4315-24.[Abstract][Full Text]

            • 33. Fugl A, Andersen CL. Epstein-Barr virus and its association with disease - a review of relevance to general practice. BMC Fam Pract. 2019 May 14;20(1):62.[Abstract][Full Text]

            • 34. Auwaerter PG. Recent advances in the understanding of infectious mononucleosis: are prospects improved for treatment or control? Expert Rev Anti Infect Ther. 2006 Dec;4(6):1039-49.[Abstract]

            • 35. Rea TD, Russo JE, Katon W, et al. Prospective study of the natural history of infectious mononucleosis caused by Epstein-Barr virus. J Am Board Fam Pract. 2001 Jul-Aug;14(4):234-42.[Abstract][Full Text]

            • 36. Ebell MH, Call M, Shinholser J, et al. Does this patient have infectious mononucleosis?: the rational clinical examination systematic review. JAMA. 2016 Apr 12;315(14):1502-9. [Abstract]

            • 37. Ebell MH. Epstein-Barr virus infectious mononucleosis. Am Fam Physician. 2004 Oct 1;70(7):1279-87.[Abstract][Full Text]

            • 38. Centers for Disease Control and Prevention. Laboratory testing for Epstein-Barr Virus (EBV). Apr 2024 [internet publication].[Full Text]

            • 39. Bruu AL, Hjetland R, Holter E, et al. Evaluation of 12 commercial tests for detection of Epstein-Barr virus-specific and heterophile antibodies. Clin Diagn Lab Immunol. 2000 May;7(3):451-6.[Abstract][Full Text]

            • 40. Bell AT, Fortune B, Sheeler R. Clinical inquiries. What test is the best for diagnosing infectious mononucleosis? J Fam Pract. 2006 Sep;55(9):799-802.[Abstract]

            • 41. Hess RD. Routine Epstein-Barr virus diagnostics from the laboratory perspective: still challenging after 35 years. J Clin Microbiol. 2004 Aug;42(8):3381-7.[Abstract][Full Text]

            • 42. Smellie WSA, Forth J, Smart SRS, et al. Best practice in primary care pathology: review 7. J Clin Pathol. 2007 May;60(5):458-65.[Abstract][Full Text]

            • 43. Vouloumanou EK, Rafailidis PI, Falagas ME. Current diagnosis and management of infectious mononucleosis. Curr Opin Hematol. 2012 Jan;19(1):14-20.[Abstract]

            • 44. Niller HH, Bauer G. Epstein-Barr virus: clinical diagnostics. Methods Mol Biol. 2017;1532:33-55.[Abstract][Full Text]

            • 45. American Medical Society for Sports Medicine. Ten things physicians and patients should question. Choosing Wisely, an initiative of the ABIM Foundation. 2022​ [internet publication].[Full Text]

            • 46. Putukian M, McGrew CA, Benjamin HJ, et al. ​American Medical Society of Sports Medicine position statement: mononucleosis and athletic participation. Clin J Sport Med. Jul 2023;33(4):359-67.[Abstract][Full Text]

            • 47. ​Becker JA, Smith JA. Return to play after infectious mononucleosis. Sports Health. 2014 May;6(3):232-8.[Abstract][Full Text]

            • 48. Centers for Disease Control and Prevention. About infectious mononucleosis (mono)​. May 2024 [internet publication].[Full Text]

            • 49. Simundic AM, Bölenius K, Cadamuro J, et al. Joint EFLM-COLABIOCLI recommendation for venous blood sampling. Clin Chem Lab Med. 2018;56(12):2015-38.[Abstract]

            • 50. Mergoum AM. Amoxicillin rash in infectious mononucleosis. N Engl J Med. 2021 Sep 9;385(11):1033.[Abstract][Full Text]

            • 51. Schechter S, Lamps L. Epstein-Barr virus hepatitis: a review of clinicopathologic features and differential diagnosis. Arch Pathol Lab Med. 2018 Oct;142(10):1191-5. [Abstract][Full Text]

            • 52. Kofteridis DP, Koulentaki M, Valachis A, et al. Epstein Barr virus hepatitis. Eur J Intern Med. 2011 Feb;22(1):73-6. [Abstract][Full Text]

            • 53. Katz BZ. Update on chronic fatigue syndrome and Epstein-Barr virus. Pediatr Ann. 2002 Nov;31(11):741-4.[Abstract]

            • 54. Miller JM, Binnicker MJ, Campbell S, et al. A guide to utilization of the microbiology laboratory for diagnosis of infectious diseases: 2018 update by the Infectious Diseases Society of America and the American Society for Microbiology. Clin Infect Dis. 2018 Aug 31;67(6):e1-94.[Abstract][Full Text]

            • 55. Jiang SY, Yang JW, Shao JB, et al. Real-time polymerase chain reaction for diagnosing infectious mononucleosis in pediatric patients: a systematic review and meta-analysis. J Med Virol. 2016 May;88(5):871-6. [Abstract]

            • 56. Bauer CC, Aberle SW, Popow-Kraupp T, et al. Serum Epstein-Barr virus DNA load in primary Epstein-Barr virus infection. J Med Virol. 2005 Jan;75(1):54-8.[Abstract]

            • 57. Shi T, Huang L, Luo L, et al. Diagnostic value of serological and molecular biological tests for infectious mononucleosis by EBV in different age stages and course of the disease. J Med Virol. 2021 Jun;93(6):3824-34.[Abstract][Full Text]

            • 58. Merriam SC, Keeling RP. Beta-hemolytic streptococcal pharyngitis: uncommon in infectious mononucleosis. South Med J. 1983 May;76(5):575-6.[Abstract]

            • 59. Hoagland RJ. Infectious mononucleosis. Prim Care. 1975 Jun;2(2):295-307.[Abstract]

            • 60. Ganzel TM, Goldman JL, Padhya TA. Otolaryngologic clinical patterns in pediatric infectious mononucleosis. Am J Otolaryngol. 1996 Nov-Dec;17(6):397-400.[Abstract]

            • 61. Leach TC, Sumaya CV. Epstein-Barr virus. In: Feigin RD, Cherry J, Demmel G, et al., eds. Textbook of pediatric infectious diseases. 5th ed. Philadelphia, PA: WB Saunders; 2003:1932-48.

            • 62. Walter RB, Hong TC, Bachli EB. Life-threatening thrombocytopenia associated with acute Epstein-Barr virus infection in an older adult. Ann Hematol. 2002 Nov;81(11):672-5. [Abstract]

            • 63. Roy M, Bailey B, Amre DK, et al. Dexamethasone for the treatment of sore throat in children with suspected infectious mononucleosis: a randomized, double-blind, placebo-controlled, clinical trial. Arch Pediatr Adolesc Med. 2004 Mar;158(3):250-4.[Abstract][Full Text]

            • 64. Rezk E, Nofal YH, Hamzeh A, et al. Steroids for symptom control in infectious mononucleosis. Cochrane Database Syst Rev. 2015 Nov 8;(11):CD004402. [Abstract][Full Text]

            • 65. Webster J, Osborne S, Rickard CM, et al. Clinically-indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database Syst Rev. 2019 Jan 23;(1):CD007798.[Abstract][Full Text]

            • 66. Cyran EM, Rowe JM, Bloom RE. Intravenous gammaglobulin treatment for immune thrombocytopenia associated with infectious mononucleosis. Am J Hematol. 1991 Oct;38(2):124-9.[Abstract]

            • 67. Provan D, Stasi R, Newland AC, et al. International consensus report on the investigation and management of primary immune thrombocytopenia. Blood. 2010 Jan 14;115(2):168-86.[Abstract][Full Text]

            • 68. De Paor M, O'Brien K, Fahey T, et al. Antiviral agents for infectious mononucleosis (glandular fever). Cochrane Database Syst Rev. 2016 Dec 8;(12):CD011487.[Abstract][Full Text]

            • 69. Torre D, Tambini R. Acyclovir for treatment of infectious mononucleosis: a meta-analysis. Scand J Infect Dis. 1999;31(6):543-7.[Abstract]

            • 70. Rafailidis PIM. Antiviral treatment for severe EBV infections in apparently immunocompetent patients. J Clin Virol. 2010 Nov;49(3):151-7. [Abstract]

            • 71. Ma C, Wong KC, Wong BCK, et al. Cytokine responses in a severe case of glandular fever treated successfully with foscarnet combined with prednisolone and intravenous immunoglobulin. J Med Virol. 2009 Jan;81(1):99-105. [Abstract]

            • 72. Balfour HH, Hokanson KM, Schacherer RM, et al. A virologic pilot study of valacyclovir in infectious mononucleosis. J Clin Virol. 2007 May;39(1):16-21. [Abstract]

            • 73. Adams LA, Deboer B, Jeffrey G, et al. Gancyclovir and the treatment of Epstein-Barr virus hepatitis. J Gastroenterol Hepatol. 2006 Nov;21(11):1758-60.[Abstract]

            • 74. Yager JE, Magaret AS,3, Kuntz SR, et al. Valganciclovir for the suppression of Epstein-Barr virus replication. J Infect Dis. 2017 Jul 15;216(2):198-202.[Abstract][Full Text]

            • 75. La Mantia I, Varricchio A, Andaloro C, et al. Pidotimod in children with infectious mononucleosis: a preliminary randomized controlled study. J Biol Regul Homeost Agents. 2020 Jul-Aug;34(4):1597-9.[Abstract][Full Text]

            • 76. Zhang L, Goudth J, Christmas D, et al. Microbial infections in eight genomic subtypes of chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME). J Clin Pathol. 2010 Feb;63(2):156-64.[Abstract][Full Text]

            • 77. Lerner AM, Beqaj SH, Deeter RG, et al. Valacyclovir treatment in Epstein-Barr virus subset chronic fatigue syndrome: thirty-six months follow-up. In Vivo. 2007 Sep-Oct;21(5):707-13.[Abstract][Full Text]

            • 78. Kogelnik AM, Loomis K, Hoegh-Peterson M, et al. Use of valganciclovir with elevated antibody titers against Human herpesvirus-6 (HHV-6) and Epstein-Barr virus (EBV) who were experiencing central nervous system dysfunction including long-standing fatigue. JJ Clin Virol. 2006 Dec;37(suppl 1):S33-8.[Abstract]

            • 79. Hickie I, Davenport T, Wakefield D, et al. Post-infective and chronic fatigue syndromes precipitated by viral and non-viral pathogens: prospective cohort study. BMJ. 2006 Sep 16;333(7568):575. [Abstract][Full Text]

            • 80. Nyland M, Naess H, Birkeland JS, et al. Longitudinal follow-up of employment status in patients with chronic fatigue syndrome after mononucleosis. BMJ Open. 2014 Nov 26;4(11):e005798. [Abstract][Full Text]

            • 81. Thompson DF, Ramos CL. Antibiotic-induced rash in patients with infectious mononucleosis. Ann Pharmacother. 2017 Feb;51(2):154-62. [Abstract]

            • 82. Farley DR, Zietlow SP, Bannon MP, et al. Spontaneous rupture of the spleen due to infectious mononucleosis. Mayo Clin Proc. 1992 Sep;67(9):846-53.[Abstract]

            • 83. Bartlett A, Williams R, Hilton M. Splenic rupture in infectious mononucleosis: a systematic review of published case reports. Injury. 2016 Mar;47(3):531-8. [Abstract]

            • 84. Stephenson JT, DuBois JJ. Nonoperative management of spontaneous splenic rupture in infectious mononucleosis: a case report and review of the literature. Pediatrics. 2007 Aug;120(2):e432-5.[Abstract]

            • 85. Heo DH, Baek DY, Oh SM, et al. Splenic infarction associated with acute infectious mononucleosis due to Epstein-Barr virus infection. J Med Virol. 2017 Feb;89(2):332-6.[Abstract]

            • 86. Ali K, Lawthom C. Epstein-Barr virus-associated cerebellar ataxia. BMJ Case Rep. 2013 Apr 22;2013. [Abstract][Full Text]

            • 87. Fernandez-Pol S, Silva O, Natkunam Y. Defining the elusive boundaries of chronic active Epstein-Barr virus infection. Haematologica. 2018 Jun;103(6):924-7.[Abstract][Full Text]

            • 88. Kimura H, Hoshino Y, Kanegane H, et al. Clinical and virologic characteristics of chronic active Epstein-Barr virus infection. Blood. 2001 Jul 15;98(2):280-6.[Abstract][Full Text]

            • 89. Thacker EL, Mirzaei F, Ascherio A. Infectious mononucleosis and risk for multiple sclerosis: a meta-analysis. Ann Neurol. 2006 Mar;59(3):499-503.[Abstract]

            • 90. Sheik-Ali S. Infectious mononucleosis and multiple sclerosis - updated review on associated risk. Mult Scler Relat Disord. 2017 May;14:56-9.[Abstract]

            • 91. Belbasis L, Bellou V, Evangelou E, et al. Environmental factors and risk of multiple sclerosis: findings from meta-analyses and Mendelian randomization studies. Mult Scler. 2020 Apr;26(4):397-404.[Abstract][Full Text]

            • 92. Jacobs BM, Giovannoni G, Cuzick J, et al. Systematic review and meta-analysis of the association between Epstein-Barr virus, multiple sclerosis and other risk factors. Mult Scler. 2020 Oct;26(11):1281-97.[Abstract][Full Text]

            • 93. Houen G, Trier NH. Epstein-Barr virus and systemic autoimmune diseases. Front Immunol. 2020;11:587380.[Abstract][Full Text]

            • 94. Li ZX, Zeng S, Wu HX, et al. The risk of systemic lupus erythematosus associated with Epstein-Barr virus infection: a systematic review and meta-analysis. Clin Exp Med. 2019 Feb;19(1):23-36.[Abstract][Full Text]

            • 95. Bakkalci D, Jia Y, Winter JR, et al. Risk factors for Epstein Barr virus-associated cancers: a systematic review, critical appraisal, and mapping of the epidemiological evidence. J Glob Health. 2020 Jun;10(1):010405.[Abstract][Full Text]

            • 96. Kanda T, Yajima M, Ikuta K. Epstein-Barr virus strain variation and cancer. Cancer Sci. 2019 Apr;110(4):1132-9.[Abstract][Full Text]

            • 97. Candy B, Chalder T, Cleare AJ, et al. Recovery from infectious mononucleosis: a case for more than symptomatic therapy? A systematic review. Br J Gen Pract. 2002 Oct;52(483):844-51.[Abstract][Full Text]

            • 98. White PD, Thomas JM, Amess J, et al. Incidence, risk and prognosis of acute and chronic fatigue syndromes and psychiatric disorders after glandular fever. Br J Psychiatry. 1998 Dec;173:475-81.[Abstract]

            • 99. Vindegaard N, Petersen LV, Lyng-Rasmussen BI, et al. Infectious mononucleosis as a risk factor for depression: a nationwide cohort study. Brain Behav Immun. 2021 May;94:259-65.[Abstract][Full Text]

            • 100. Kim A, Yang HR, Moon JS, et al. Epstein-Barr virus infection with acute acalculous cholecystitis. Pediatr Gastroenterol Hepatol Nutr. 2014 Mar;17(1):57-60. [Abstract][Full Text]

            • 101. Leganés Villanueva C, Goruppi I, Brun Lozano N, et al. Acute acalculous cholecystitis due to a primary Epstein Barr virus infection in a pediatric patient. Pediatr Rep. 2021 Feb 6;13(1):86-90.[Abstract][Full Text]

            • 102. Moretti M, Lava SAG, Zgraggen L, et al. Acute kidney injury in symptomatic primary Epstein-Barr virus infectious mononucleosis: systematic review. J Clin Virol. 2017 Jun;91:12-7.[Abstract]

            • 103. Marsh RA. Epstein-Barr virus and hemophagocytic lymphohistiocytosis. Front Immunol. 2017;8:1902.[Abstract][Full Text]

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