Management of glandular fever

Treatment of the Epstein-Barr virus should be symptomatic, says Dr Julia MarkhamGlandular fever (infectious mononucleosis) is a viral infection caused by the Epstein-Barr (EB) virus, a member of the herpes virus family.

The EB virus infection is widespread and many people are immune to the virus by the time they reach adulthood.

However, it is not well understood by the general public, many of whom regard glandular fever as a very serious and debilitating condition.

In reality, most EB infections are without symptoms, especially if acquired during childhood, and many asymptomatic individuals carry the virus in their saliva.

However, if infection is acquired in adulthood there is a greater chance of symptomatic disease. Young adults, especially students, are most susceptible to episodes of symptomatic glandular fever.

The route of infection is through close or intimate contact, so much so that it is often called the ‘kissing disease’, but EB infection also spreads easily by coughs and sneezes. The incubation period is four to seven weeks, which makes disease control difficult.

Diagnosis
Most patients with glandular fever have abnormal liver function tests and some will have hepatomegaly and even frank jaundice.

It is always worth considering a diagnosis of glandular fever in a young person with severe tonsillitis that does not resolve after a course of antibiotics, and it is also valuable to be aware that erythematous rash appears in 90 per cent of patients with glandular fever if given ampicillin or amoxicillin.

Diagnosis can be confirmed during the second week of infection by the Paul-Bunnell test, which is both simple and sensitive.

Blood films often reveal a lymphocytosis, and usually at least 10 per cent of lymphocytes will be atypical, with enlarged mis-shapen nuclei and more cytoplasm than is usual.

The alternative name ‘infectious mononucleosis’ arises because the count of mononuclear leukocytes (white blood cells with a one-lobed nucleus) rises dramatically.

The two main types of mononuclear leukocytes, monocytes and lymphocytes, normally account for about 35 per cent of all white blood cells, but in infectious mononucleosis this can rise to 50–70 per cent. The total white blood count may increase to 10,000–20,000mm3.

Specific tests for Epstein-Barr virus immunoglobulin can also be a useful indicator of recent infection.

Treatment and prognosis
In most cases the infection lasts for two to four weeks. There is no specific treatment, and management is with simple analgesia with paracetamol and NSAIDs for fever and pain, rest in the acute phase of the illness and an adequate fluid intake.

Alcohol should be avoided if liver function is deranged.

If the spleen is enlarged it is normal to advise patients to avoid contact sports or heavy manual work for four to six weeks because of the potential risk of splenic rupture.

In a very unwell patient admission may be required to exclude serious complications and to provide supportive management.

Rare complications include pneumonia, myocarditis, mesenteric adenitis and meningo-encephalitis.

The GP should be supportive for problems arising because of inability to study, sit exams or work. Providing a medical certificate or letter may help the patient to manage problems with examinations.

The condition is unlikely to return, as in most cases infection should provide life-long immunity.

However, long-term sequelae following an episode of glandular fever may include debility, lethargy and  depression, and a possible link between glandular fever and chronic fatigue syndrome has been debated for many years. A proportion of patients may go on to experience some degree of chronic fatigue syndrome. 

Dr Markham is a GP in Solihull, West Midlands 

Signs and symptoms of glandular fever

  • Flu-like symptoms.
  • Sore throat with exudative tonsillitis.
  • Generalised lymphadenopathy (but especially posterior cervical node enlargement).
  • Malaise.
  • Anorexia.
  • Mild to severe fever is always present.
  • Fatigue.
  • Myalgia.  
  • Headache.
  • Splenomegaly is common.
  • An erythematous rash is possible.

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