History and exam
Key diagnostic factors
common
presence of risk factors
Risk factors include sexual activity and kissing.
fever
Ranges from 37.8°C (100°F) to 41.1°C (106°F); usually <38.9°C (102°F).
Lasts 1 to 2 weeks; rarely up to 5 weeks.
Occurs in 76% of cases.[34]
pharyngitis
Can be exudative or non-exudative.
Often resembles Streptococcus pyogenes pharyngitis.
Subsides by the second week.
Petechiae may be present on the soft palate.
Occurs in 84% of patients.[34]
cervical or generalised lymphadenopathy
Nodes typically tender, non-erythematous, and discrete.
Most prominent after second week of illness.
Occurs in 94% of cases.[34]
malaise
Occurs in 82% of cases.[34]
Other diagnostic factors
common
splenomegaly
uncommon
rash
Occurs in 10% of adults, but may present in up to one third of paediatric patients.[34]
Appears in the first days of illness; lasts for 1 week. Can be erythematous, maculopapular, or morbilliform.
A maculopapular pruritic rash is typically seen in adults with IM after starting treatment with ampicillin, amoxicillin, or beta-lactam antibiotics for pharyngitis.[45]
Mucosal rash and eyelid oedema more common in adults.
signs of hepatitis (hepatomegaly, jaundice)
Liver involvement is present in over 90% of IM cases, but it is often subclinical and self-limited. Jaundice is seen in a small minority (<5%) of patients.[46] Hepatomegaly is more common in young children, and occurs in 12% of cases.[34]
Systemic symptoms of IM are typically present when Epstein-Barr virus infection involves the liver, but in some cases hepatic involvement can also occur in isolation. Severe or fatal hepatitis has also been observed, especially in immunocompromised patients.[46]
jaundice
Adults are less likely to have sore throat and lymphadenopathy, but more likely to have hepatomegaly and jaundice (due to hepatitis).[37] Liver involvement in acute EBV infection represents mild hepatitis with predominantly cholestatic features, but does not always manifest itself as a clinical jaundice.[47] The overall frequency of jaundice in adolescents and adults is about 9%.[34]
myalgia
Seen in 28% of patients at the time of initial presentation.[35]
Risk factors
weak
kissing
Epstein-Barr virus (EBV) is most commonly transmitted through saliva, hence the name ''kissing'' disease. In one study, all patients with EBV-caused IM shed virus from the oropharynx for 6 months after the disease onset.[23] In a prospective study, 22 out of 24 healthy individuals with past history of EBV infection shed virus in saliva for 15 months.[24]
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