GP - Glandular fever (infective mononucleosis)

Question 1

Which microorganism most commonly causes glandular fever?

Answer 1

Epstein-Barr virus (EBV), which is a human herpes virus

Question 2

How is glandular fever transmitted?

Answer 2

• Glandular fever is not particularly contagious but can spread via:
  
  • Contact with saliva e.g. kissing or sharing food
  • Sexual contact (through blood and semen)
  • Blood transfusion
  • Vertical transmission

Question 3

What is the incubation period of glandular fever?

Answer 3

Incubation period 4-7 weeks

Question 4

What age range does glandular fever usually affect?

Answer 4

Age 15-24 yrs

Question 5

What are the complications of glandular fever?

Answer 5

• Hepatic complications - hepatitis, abnormal LFTs ( AST, ALT 3 times upper limit), hepatomegaly, splenomegaly (increases risk of splenic rupture)
• Respiratory complications - peritonsillar abscess causing upper airway obstruction
• Cardiac complications - pericarditis, myocarditis, arrhythmias
• Renal complications - haemolytic uraemic syndrome
• Neurological complications - encephalitis, MS
• Haematological complications - mild thrombocytopenia and neutropenia
• Malignancy - Burkitt lymphoma (Non-Hodgkin’s lymphoma), Hodgkin’s lymphoma, esp in immunocompromised people

Question 6

How long does it take for glandular fever to resolve?

Answer 6

Self-limiting

Lasts 2-4 weeks

Once get infected by EBV, the virus remains in the body lifelong. Just like other herpes viruses, it can become reactivated if patients are immunocompromised, but it does not always cause symptoms

(The concept is like VZV causing shingles, the only difference is that VZV will cause symptoms e.g. rash)

Question 7

Is glandular fever a self-limiting disease?

Answer 7

Yes

Lasts 2-4 weeks

Question 8

What are the clinical features of glandular fever?

Answer 8

Presentations:

• Classic triad of:
  
  • Sore throat (severe) - with tonsillar enlargement and exudate, and palatal petechiae
  • Fever
  • Bilateral posterior cervical lymphadenopathy
• Prodromal symptoms such as headache, myalgia, fatigue, sweats
• Fine, macular, non-pruritic rash
• Splenomegaly –> increases risk of splenic rupture
• Hepatomegaly, jaundice (usually in elderly)

Question 9

What investigations would you carry out for glandular fever in primary care?

Answer 9

• For children < 12 yrs and in people who are immunocompromised
  
  • Blood tests for EBV viral serology and LFTs
• For children > 12 yrs and in immunocompetent adults:
  
  • Blood tests
    
    • FBC shows lymphocytosis; LFTs show markedly raised ALT and AST (2-3 times the upper limit of normal)
  • Monospot test (test for the presence of heterophile antibodies)
    
    • If negative, but patients have clinical features of glandular fever, arrange blood tests for EBV viral serology

Question 10

What blood tests are most important in diagnosing glandular fever?

Answer 10

FBC showing lymphocytosis

LFTs showing markedly raised ALTs and ASTs (2-3 times above the upper limit of normal)

Question 11

Give 3 differential diagnoses of glandular fever

Answer 11

• Strep throat
• Lymphoma
• CMV infection

Question 12

What is the difference between lymphoma and leukaemia

Answer 12

• Leukaemia occurs when the bone marrow produces TOO MANY abnormal WBCs
  
  • If a person has leukemia, their abnormal white blood cells do not die off in a normal cycle. Instead, the white blood cells multiply rapidly, eventually leaving less room for red blood cells required to carry oxygen through the body.
  • 4 types:
    
    • Acute Lymphocytic leukaemia
    • Chronic Lymphocytic leukaemia
    • Acute myeloid leukaemia
    • Chronic myeloid leukaemia
• Lymphoma starts in the immune system and affects the lymph nodes and lymphocytes
  
  • The 2 main types are:
    
    • Hodgkin lymphoma (involves abnormal B cell called Reed-Sterberg cell) - less common
    • Non-hodgkin lymphoma - start in either B or T cells and more common

Question 13

How would you manage patients with glandular fever in primary care?

Answer 13

Management is supportive

• Advise on the use of paracetmol or ibuprofen as antipyretic and analgesics
• Explain that symptoms usually last 2-4 weeks
• Advise the person:
  
  • That exclusion from work/ school is not necessary
  • To limit spread by avoiding kissing and sharing food and drinks
  • To avoid heavy lifting and contact sports for the first month of the illness - to reduce splenic rupture
  • To seek medical advice if they develop stridor, difficulty swallowing fluids, become systemically unwell, or develop abdominal pain (may indicate splenic rupture)
  • Stay hydrated
• Do NOT give amoxiciliin or cephalosporins as it can cause a pruritic maculopapular rash

Question 14

When should you admit the patient with glandular fever to hospital?

Answer 14

Stridor

Dehydration/ difficulty swallowing fluids

Serious complications e.g. splenic rupture

Question 15

What antibiotics must you avoid giving in glandular fever? Why?

Answer 15

Amoxicillin and cephalosporins as they can cause a pruritic maculopapular rash