Glandular fever

Glandular fever (infectious mononucleosis) is an infection commonly found in adolescents and young adults. It is usually caused by the Epstein–Barr virus (Turabelidze, 2021). The annual incidence in the general population of glandular fever is approximately 5 cases per 1000 persons (National Institute for Health and Care Excellence (NICE), 2021). Although glandular fever is often mild, rare but potentially life-threatening complications may occur (NHS, 2020).

In early childhood, Epstein–Barr virus may cause very mild symptoms or no symptoms at all. The symptoms may be difficult to differentiate from other common childhood viral illnesses. 

Young adults and adolescents who develop glandular fever may experience the following:

• fever
• severe sore throat (pharyngitis)
• anorexia
• malaise and fatigue
• headaches
• enlarged lymph nodes (lymphadenopathy)
• low mood
• non-specific rash

These symptoms may last for several weeks.

Glandular fever is rare in people older than 40 years of age and may present atypically in this age group, without sore throat and lymphadenopathy. Older adults may experience:

• unexplained fever of more than 2 weeks duration
• jaundice (NHS, 2020; Turabelidze, 2021; Longmore et al, 2014)

A person with complications of glandular fever may have the following symptoms:

• stridor
• respiratory difficulty
• dehydration or difficulty swallowing fluids
• neurological symptoms
• abdominal pain
• jaundice (NICE, 2021).

Epstein–Barr virus is a DNA herpes virus which infects B-lymphocytes. The virus is spread mainly through saliva. It can also be transmitted by other body secretions, including blood and semen (The Ohio State University, 2022).

Although the virus itself is not particularly contagious, the incubation period is usually around 4–7 weeks. Patients are infectious during the incubation period and while symptoms are present. Some people may be contagious for up to 18 months after initial infection (NICE, 2021).

The virus replicates in the cells of the nasopharynx and the infected B-lymphocytes spread through the lymphatic system, spleen and liver. The inflammatory response brings about fever, and pharyngitis is caused by the B-lymphocytes within the oropharynx lymphatic tissue (The Ohio State University, 2022). Rarely, the viral replication and subsequent immunological response can lead to hepatitis, splenomegaly, upper airway obstruction and neurological complications (Figure 1).

Following resolution of acute illness, the virus remains in

Diagnosis should be made by clinical history, examination and investigation. Glandular fever should be suspected when a patient has:

• a fever lasting 1 to 2 weeks, rarely up to 5 weeks
• pharyngitis, usually described as a severe sore throat that is not improving or worsening after several days. The clinical examination may reveal features similar to streptococcus pharyngitis
• tonsillitis which may be indicated by tonsillar enlargement on examination. There may be a ‘whiteash’ appearance to the tonsils. Palatal petechiae are common (1–2 mm in diameter, in crops lasting 3–4 days)
• mildly tender, mobile, non-erythematous cervical or general lymphadenopathy
• This occurs in 82% of cases. Patients may report other prodromal symptoms such as anorexia and headache
• an enlargement of the spleen (splenomegaly). Enlargement begins in the first week and reaches maximum size at the beginning of the second week. This occurs in 52% of cases
• a non-specific rash. This occurs in 10% of adults and

Glandular fever has no specific medical treatment. Glandular fever infections are usually self-limiting and mild. Self-management strategies are recommended such as:

• analgesia: paracetamol and ibuprofen
• fluid intake
• rest
• alcohol avoidance.

Control measures to limit the spread of infection include:

• avoidance of kissing others
• hand washing
• avoidance of sharing utensils and towels.

Patients should be advised that they can return to school or work as soon as they feel well enough, and that bed rest is not normally required. Patients are advised that symptoms may last for 2–4 weeks or longer and that fatigue is usually the final symptom to resolve.

Signs of complications and safety measures should be explained to the patient. These include:

• avoidance of heavy lifting and collision sports for 1 month because of the risk of splenic rupture
• seeking urgent medical advice in the case of difficulty breathing or swallowing fluids
• seeking urgent medical advice in the case of

Common complications of glandular fever are:

• hepatitis and abnormal liver function tests results
• haematological complications
• chronic fatigue.

Hepatitis is a common and self-limiting complication. 90% of patients with glandular fever will have deranged liver function test results. However, life-threatening, fulminant hepatitis rarely develops.

Haematological complications, such as mild thrombocytopenia (low platelets), occur in 25–50% of patients with glandular fever. Mild neutropenia (low neutrophils) is also common. Rarely neutropenia may lead to neutropenic sepsis, which can be a medical emergency.

Chronic fatigue affects 10% of people with glandular fever and may occur when fatigue lasts for several months after the initial infection. Being female and pre-morbid mood disorders are risk factors for chronic fatigue.

Rarer, long-term complications include:

• cancer – Epstein-Barr virus is associated with several cancers, including stomach, nasal and lymphoma
• multiple sclerosis – glandular fever is thought to be a risk factor linked to genetic susceptibility
• neurological conditions

Dojcinov SD, Pugh MR. The pathology of epstein-barr virus lymphoproliferations. Hemasphere. 2019;3(Suppl):70-73. https://doi.org/10.1097/HS9.0000000000000227.

Longmore M, Wilkinson I, Baldwin A, Wallin E. Oxford Handbook of Clinical Medicine. (9th edn). Oxford: Oxford University Press; 2014

National Institute for Health and Care Excellence. Sore throat (acute): antimicrobial prescribing. 2018. https://www.nice.org.uk/guidance/ng84/resources/sore-throat-acute-antimicrobial-prescribing-pdf-1837694694085 (accessed 4 December 2022)

National Institute for Health and Care Excellence. Glandular fever. 2021 https://cks.nice.org.uk/topics/glandular-fever-infectious-mononucleosis/ (accessed 13th October 2022)

NHS. Glandular Fever. 2020. https://www.nhs.uk/conditions/glandular-fever/ (accessed 13 October 2022)

The Ohio State University. Infectious mononucleosis (IM): Pathophysiology and clinical presentation. 2022. https://u.osu.edu/infectiousmononucleosis2/pathophysiology-and-clinical-presentation-correct-diagnosis/ (accessed 14 October 2022)

Turabelidze G. BMJ Best Practice: Infectious mononucleosis. 2021. https://bestpractice.bmj.com/topics/en-gb/123 (accessed 13 October 2022)