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Tuesday, August 12, 2025

Glandular fever


Definition

Glandular fever, also known as infectious mononucleosis, is an acute viral illness most commonly caused by Epstein–Barr virus (EBV), a member of the herpesvirus family. It is characterized by fever, sore throat, lymphadenopathy, and fatigue. The condition is self-limiting but may be associated with prolonged convalescence and, in rare cases, serious complications.

Etiology and Transmission

  • Primary cause: Epstein–Barr virus (EBV)

  • Less common causes: Cytomegalovirus (CMV), human herpesvirus 6 (HHV-6), HIV (acute infection), toxoplasmosis (mimics presentation)

  • Transmission:

    • Primarily via saliva (“kissing disease”)

    • Less commonly via sexual contact, blood transfusion, or organ transplantation

  • Incubation period: Typically 4–6 weeks after exposure

Pathophysiology

  • EBV infects oropharyngeal epithelial cells and subsequently B lymphocytes via CD21 receptors.

  • Infected B cells proliferate, triggering a robust cytotoxic T-cell response responsible for many symptoms.

  • This immune activation causes lymphoid tissue enlargement (lymph nodes, spleen, tonsils) and systemic symptoms.

Risk Factors

  • Adolescents and young adults (15–25 years old) are most commonly affected.

  • Close personal contact with infected individuals.

  • Immunocompromised states increase severity and duration.

Clinical Features

Classic Triad:

  1. Fever – often low-grade but may be high in acute illness

  2. Pharyngitis – severe sore throat with tonsillar enlargement, exudates, and petechiae on the palate

  3. Lymphadenopathy – typically bilateral, cervical (posterior > anterior)

Additional Symptoms:

  • Fatigue and malaise (can be prolonged)

  • Myalgia

  • Headache

  • Rash – especially after exposure to aminopenicillins (ampicillin or amoxicillin)

  • Hepatosplenomegaly – splenic enlargement in ~50% of patients; mild hepatic transaminase elevation common

  • Loss of appetite and nausea

In children – often mild or asymptomatic.

Complications

  • Hematologic: Hemolytic anemia, thrombocytopenia, neutropenia

  • Neurological: Meningitis, encephalitis, Guillain–Barré syndrome, cranial nerve palsies

  • Splenic rupture (rare, but potentially fatal) – usually within the first 3 weeks of illness

  • Upper airway obstruction due to tonsillar hypertrophy

  • Chronic active EBV infection – rare, severe, persistent illness

Diagnosis

Clinical suspicion: Fever + pharyngitis + lymphadenopathy in a young person, especially with prolonged fatigue.

Laboratory tests:

  • Full blood count: Lymphocytosis (>50% lymphocytes, with >10% atypical lymphocytes)

  • Liver function tests: Mild–moderate transaminase elevation in most patients

  • Heterophile antibody test (Monospot): Positive in ~85% of adolescents/adults after first week; less sensitive in children

  • EBV-specific serology:

    • Anti-VCA (viral capsid antigen) IgM – acute infection

    • Anti-VCA IgG – past or current infection

    • Anti-EBNA (nuclear antigen) – appears weeks after infection, indicates past infection

  • PCR: Detects EBV DNA in selected cases (immunocompromised patients, atypical presentations)

Differential Diagnosis

  • Streptococcal pharyngitis

  • Cytomegalovirus mononucleosis

  • Acute HIV infection

  • Toxoplasmosis

  • Viral hepatitis

  • Adenovirus infection

Management

There is no specific antiviral therapy for uncomplicated glandular fever – treatment is supportive.

Supportive Measures

  • Adequate hydration

  • Rest (relative, avoiding strenuous activity until recovery)

  • Analgesics/antipyretics:

    • Paracetamol (acetaminophen) 500–1000 mg orally every 4–6 hours as needed (max 4 g/day)

    • Ibuprofen 400 mg orally every 6–8 hours as needed (max 2.4 g/day)

  • Warm saline gargles, lozenges for sore throat

Corticosteroids

  • Not routinely indicated in uncomplicated cases

  • May be considered for:

    • Severe tonsillar hypertrophy with impending airway obstruction

    • Massive splenomegaly with risk of rupture

    • Severe hemolytic anemia or thrombocytopenia

  • Example: Prednisolone 40–60 mg orally daily for 3–5 days, tapered as clinically indicated

Antibiotic Use

  • Only if bacterial superinfection (e.g., streptococcal pharyngitis) is confirmed

  • Avoid aminopenicillins (ampicillin, amoxicillin) – can trigger widespread maculopapular rash in EBV infection

Activity Restrictions

  • Avoid contact sports and heavy lifting for at least 3–4 weeks from onset, or until splenomegaly resolves (to reduce risk of splenic rupture)

  • Gradual return to normal activity based on clinical recovery and follow-up assessment

Prognosis

  • Most symptoms resolve within 2–4 weeks; fatigue may persist for weeks to months

  • Life-threatening complications are rare with appropriate monitoring and supportive care

  • Immunity is typically lifelong after infection




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