Infectious mononucleosis

• Filatov 1887.
• Pfeiffer 1889.

Pfeiffer's glandular fever, Pfeiffer's disease, Pfeiffer's glandular fever, mononucleosis infectiosa, monocyte angina, kissing disease.

Infectious disease caused by Epstein-Barr virus (human herpes virus 4), which is characterized by fever, necrotizing angina and swelling of the lymph nodes.

• Often epidemic in spring.
• Adolescents and young adults are particularly affected.
• Overall, asymptomatic occurrence in 50% of cases.
• Up to 90% of infants are asymptomatic.
• Up to the age of 30 almost all of them have undergone the infection (often unconsciously).

• Transmission: droplet infection, transfusions.
• Incubation period: 4-50 days.

• Proliferation of the virus occurs in the oral mucosa and salivary glands, where it remains latent and is partially detectable even after the disease. For this reason it is called "kissing disease" because clinically healthy people can transmit the virus e.g. via saliva. EBV stimulates the B-cells, which proliferate and form heterophilic antibodies. 

• Angina with pseudomembranous coatings and locoregional lymphadenopathy.
• Febrile temperatures (often > 39°C), fatigue and exhaustion.
• In up to 15 % maculopapular exanthema occurs, which can appear morbilliform and rubeoliform.
• If a treatment with Ampicillin is performed, the occurrence of an exanthema is almost obligatory.
• Immunosuppression is associated with the risk of virus reactivation.
• In addition, there may be spleen swelling (there is a risk of lethal splenic rupture), meningitis, meningoencephalitis, myalgia, interstitial pneumonia, thrombocytopenia, polyneuritis, pericarditis, myocarditis, glomerulonephritis, Guillan-Barré syndrome and hepatitis-induced icterus. In individual cases, the disease can persist for months.
• Erythema nodosum (rare).

• Clinic.
• Laboratory (initial leukopenia, then leukocytosis with mononuclear cells, occasionally elevated liver enzymes).
• Rapid tests: Paul Bunnell Rapid Test (in up to 15% of adults and 20% of children false negative) and latex agglutination test.
• EBV-(VCA)-IgG, EBV-(VCA)-IgM.
• EBV immunoblot (virus-capsid antigen, EBV-specific nuclear antigen, early antigen).
• Upper abdominal sonography.
• CAVE: No spleen palpation because of the danger of rupture.

1. Cassingham RJ. Infectious mononucleosis. Oral Surgery, Oral Medicine, Oral Pathology 1971;31:610-23. 
2. Chen J, Konstantinopoulos PA, Satyal S, Telonis J, Blair DC. Just another simple case of infectious mononucleosis? The Lancet 2003;361:1182. 
3. Henle G, Henle W, Diehl V. Relation of Burkitt's tumor-associated herpes-ytpe virus to infectious mononucleosis. Proceedings of the National Academy of Sciences 1968;59:94-101. 
4. Horwitz CA, Henle W, Henle G, et al. Clinical and Laboratory Evaluation of Cytomegalovirus-Induced Mononucleosis in Previously Healthy Individuals. Medicine 1986;65:124.
5. Johannsen EC, Kaye KM. Epstein-Barr Virus (Infectious Mononucleosis, Epstein-Barr Virus–Associated Malignant Diseases, and Other Diseases).  Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases: Elsevier BV; 2010:1989-2010. 
6. Rosenberg ES, Caliendo AM, Walker BD. Acute HIV Infection among Patients Tested for Mononucleosis. New England Journal of Medicine 1999;340:969-. 
7. Tynell E, Aurelius E, Brandell A, et al. Acyclovir and Prednisolone Treatment of Acute Infectious Mononucleosis: A Multicenter, Double-Blind, Placebo-Controlled Study. Journal of Infectious Diseases 1996;174:324-31.