Ear, Nose & Throat
Question 100 of 300
A 16 year old presents to the Emergency Department with a 10 day history of sore throat and fever. Your consultant suspects glandular fever. What infective cause is most likely?
Answer:
Glandular fever (infectious mononucleosis) is an infection most commonly caused by the Epstein-Barr virus (EBV). EBV causes approximately 80–90% of cases of glandular fever, with the remainder due largely to cytomegalovirus, human herpesvirus 6, toxoplasmosis, HIV, and adenovirus.Glandular Fever
Ear, Nose & Throat
Last Updated: 18th July 2021
Glandular fever (infectious mononucleosis) is an infection most commonly caused by the Epstein-Barr virus (EBV). EBV causes approximately 80–90% of cases of glandular fever, with the remainder due largely to cytomegalovirus, human herpesvirus 6, toxoplasmosis, HIV, and adenovirus.
Transmission
Glandular fever is most common in people aged 15–24 years and is spread mainly through contact with saliva, usually from asymptomatic carriers, such as through kissing or sharing food and drink utensils. It can also spread during sexual contact (through blood and semen), blood transfusions, organ transplantations, and by intrauterine transmission.
The incubation period of glandular fever is about 4–7 weeks. The disease is contagious during the incubation period and while symptoms are present; some people may be contagious for as long as 18 months after having the infection.
Clinical features
- Suspect glandular fever if a person has:
- Fever.
- Lymphadenopathy.
- Bilateral posterior cervical lymphadenopathy is typical. There may also be anterior cervical, submandibular, suboccipital, postauricular, epitrochlear, axillary, and inguinal lymphadenopathy.
- Lymph nodes are mildly tender and mobile.
- Sore throat (usually severe).
- There may be tonsillar enlargement, the tonsils may meet in the midline, and there is usually a 'whitewash' exudate on the tonsils.
- Pharyngeal inflammation and palatal petechiae are also common — petechiae are 1–2 mm in diameter and occur in crops lasting 3–4 days.
- Sore throat may fail to improve, or become worse, after several days.
- Other clinical features that may support a diagnosis of glandular fever include:
- Prodromal symptoms — this usually lasts for several days and includes general malaise, fatigue, myalgia, chills, sweats, anorexia, and retro-orbital headache.
- Non-specific rash — this may be macular, petechial, urticarial, or erythema multiforme-like, or a maculopapular rash that presents after being treated with amoxicillin.
- Splenomegaly — the spleen reaches maximum size at the beginning of the second week of illness and regresses over 7–10 days.
- Hepatomegaly — although more often there is mild tenderness in the right hypochondrium.
Investigations
- In children younger than 12 years of age and in people who are immunocompromised at any age:
- Arrange blood tests for Epstein-Barr virus (EBV) viral serology after the person has been ill for at least 7 days.
- In children older than 12 years of age and in immunocompetent adults:
- Arrange a full blood count (FBC) with differential white cell count and a monospot test (heterophile antibodies) in the second week of the illness.
- Glandular fever is likely if the monospot test is positive or the FBC has more than 20% atypical or 'reactive' lymphocytes, or more than 10% atypical lymphocytes and the lymphocyte count is more than 50% of the total white cell count.
- If the monospot test is negative/not supportive of infectious mononucleosis due to EBV, repeat the test in 5–7 days.
- If the person has clinical features of glandular fever and a negative monospot test, or if a rapid diagnosis is needed (for example if an urgent return to contact sports is desired), arrange blood tests for EBV viral serology.
- If a second monospot test is negative:
- Consider testing for cytomegalovirus and toxoplasmosis if the person is pregnant or immunocompromised.
- Consider testing for HIV in at-risk people.
- Arrange a full blood count (FBC) with differential white cell count and a monospot test (heterophile antibodies) in the second week of the illness.
- Consider checking liver function tests (LFTs).
- Usually aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are elevated to 2–3 times the upper limit of normal.
Management
- Advise on the use of paracetamol or ibuprofen to relieve pain and fever symptoms.
- Explain the expected course of the illness. Advise that:
- Symptoms usually last for 2–4 weeks.
- Tiredness is common and is often the last symptom to resolve.
- Advise the person:
- That exclusion from work or school is not necessary.
- To return to normal activities as soon as possible. If they are tired, they should tailor their activities to what they can manage comfortably. Bed rest is not normally needed.
- To limit spread of the disease by avoiding kissing and sharing eating or drinking utensils, and to thoroughly clean all items that may have been contaminated by saliva.
- To avoid heavy lifting and contact or collision sports for the first month of the illness (to reduce the risk of splenic rupture).
- Advise the person to seek urgent medical advice if they:
- Develop stridor or respiratory difficulty.
- Have difficulty swallowing fluids or have signs of dehydration, such as reduced urine output.
- Become systemically very unwell.
- Develop abdominal pain (may indicate splenic rupture).
Complications
- Hepatitis
- This is a common and self-limiting early complication of glandular fever.
- Fulminant hepatitis may rarely occur and can be life threatening.
- Upper airways obstruction
- This may be due to gross enlargement of the tonsils or a peritonsillar abscess.
- Cardiac complications
- Pericarditis, myocarditis, and cardiac conduction abnormalities have been reported in people with glandular fever.
- Renal complications
- Interstitial nephritis, myositis-associated acute kidney injury, haemolytic uraemic syndrome, and jaundice-associated nephropathy have rarely been reported in people with acute symptomatic glandular fever.
- Neurological complications
- Encephalitis occurs in about 1% of adolescents and adults with glandular fever, usually during the first 2 weeks of infection.
- Other possible neurological complications include aseptic meningitis, facial nerve palsy, transverse myelitis, Guillain-Barré syndrome, and optic neuritis.
- Haematological complications
- Mild thrombocytopenia has been reported in 25–50% of people with glandular fever, and autoimmune haemolytic anaemia in 3% of people.
- Mild neutropenia is common and self limiting. Rarely, severe neutropenia may cause neutropenic sepsis, pneumonia, or death.
- Splenic rupture
- This is rare (less than 1% of cases) and usually occurs in the first 3 weeks of the acute illness. About 50% of cases of splenic rupture are spontaneous, and 50% follow trauma (which may be minimal). People with glandular fever are advised to avoid heavy lifting and contact or collision sports for the first month of the illness to reduce the risk of splenic rupture, after which these activities can be resumed provided the person has no ongoing features of acute EBV infection.
- Chronic fatigue
- About 10% of people with glandular fever will experience prolonged fatigue, lasting for several months after the initial infection. Most people with persistent fatigue recover within 2 years.
- Cancer
- Association between glandular fever and lymphoproliferative cancers, especially Hodgkin's lymphoma and Burkitt lymphoma, are well established.
- Multiple sclerosis
- Glandular fever as a risk factor for multiple sclerosis has been documented and may be linked to genetic susceptibility.
- Chronic active Epstein-Barr virus (EBV) infection
- A very rare condition characterised by severe, chronic, or recurrent infectious mononucleosis-like symptoms after a well-documented primary infection with EBV in a previously healthy person.
- Chronic active EBV infection is occasionally associated with the development of lymphoma.
- Abnormal liver function tests (LFTs)
- LFTs are abnormal in about 90% of people with glandular fever, with aspartate aminotransferase (AST) and alanine aminotransferase (ALT) being elevated to 2–3 times the upper limit of normal. The increase in LFTs typically peaks in the second week of the illness and then normalises over the next 3–4 weeks.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
