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<div class="noeditbox">Welcome to [[Pathophysiology of Complex Patient Problems|PT 635 Pathophysiology of Complex Patient Problems]] This is a wiki created by and for the students in the School of Physical Therapy at Bellarmine University in Louisville KY. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div><div class="editorbox">
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'''Original Editors '''- Nicole Clark [[Pathophysiology of Complex Patient Problems|from Bellarmine University's&nbsp;Pathophysiology of Complex Patient Problems project.]]  


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== Definition/Description  ==


[[Image:Throat.jpg|thumb|right|typical gland presentation]]Mononucleosis, also known as the "kissing disease," is a&nbsp;viral infection spread through the passing of saliva that causes&nbsp;fever, sore throat, and swollen lymph glands. Since the virus that causes Mono is transmitted through the sharing of saliva&nbsp;you can get it through kissing, but people are also if not more likely to contract Mono through the sharing of&nbsp;utensils, drinking glasses, or interaction through someone with Mono who coughs or sneezes. <span style="font-size: 13px" class="Apple-style-span"><ref name="one">http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001617/</ref></span> However, mononucleosis isn't as contagious as some infections, such as the common cold.
== Introduction  ==
[[File:Mononucleosis.png|right|frameless|350x350px]]
Infectious mononucleosis is an acute infectious disease associated with Epstein-Barr virus that is characterized especially by fever, sore throat, swelling of lymph nodes, fatigue, and lymphocytosis and occurs primarily in adolescents and young adults.<ref>Merriam Webster [https://www.merriam-webster.com/dictionary/infectious%20mononucleosis infectious mononucleosis] Available from: https://www.merriam-webster.com/dictionary/infectious%20mononucleosis ( last ccessed 5.8.2020) </ref> It is usually a clinical diagnosis, with confirmation by serum testing, but may have suggestive findings on imaging
* Mononucleosis classically presents with fever, lymphadenopathy, and tonsillar pharyngitis. See image R 
* It was originally called "mononucleosis" after abnormal mononuclear cells were found in patients with the clinical syndrome.<ref name=":1" /> 
* Later Epstein-Barr virus (EBV) was established as the cause of mononucleosis after an exposed healthcare worker developed a positive heterophile test (a rapid test which detects infectious mononucleosis that is caused by the Epstein Barr Virus)<ref name=":0">Mohseni M, Boniface MP, Graham C. [https://www.ncbi.nlm.nih.gov/books/NBK470387/ Mononucleosis.] April 27 2020 Available from:https://www.ncbi.nlm.nih.gov/books/NBK470387/ (last accessed 3.8.2020)</ref>


<br>
== Etiology  ==
The cause of mononucleosis is the Epstein-Barr virus (EBV), a type of herpesvirus spread by contact, typically with salivary secretions.
* Transmission is generally person-to-person, but EBV is not considered a highly contagious disease<ref name=":0" />.
* It is thought to be spread primarily through a person-to-person route through salivary secretions. The EBV virus infects B-cells in the [[Lymphatic System|lymphoid]] tissue. Like other herpes viruses, it becomes a lifelong chronic infection with periodic shedding of virus<ref name=":1" />.
* The duration of oral shedding is not entirely clear, but high levels of shedding can continue for a median of 6 months after illness onset.<ref name=":0" />
== Epidemiolgy  ==
It is estimated that up to 95% of adults in the world are eventually seropositive to EBV  (widely disseminated in all population groups).
* Exposure to EBV, but often a subclinical infection, especially in children. Young adults (15-24) are more likely to be symptomatic<ref name=":1">Radiopedia [https://radiopaedia.org/articles/infectious-mononucleosis-1?lang=us Mononucleosis] Available from:https://radiopaedia.org/articles/infectious-mononucleosis-1?lang=us (last accessed 3.8.2020)</ref>.
* Mononucleosis is uncommon in adults:  approximately 2% of all pharyngeal disease in adults is attributable to this disease.
* Adults are generally not susceptible to clinical illness because of previous exposure.
* In the United States, clinically evident infection occurs at rates estimated at 30 times higher in whites than in blacks (possibly because if acquired at a young (childhood) age, EBV is often subclinical ie earlier EBV exposures in blacks, and a higher frequency of asymptomatic infection as young children).
* After exposure, the EBV infects the epithelial cells of the salivary glands and the oropharynx. Lymphocytes residing in the tonsils get exposed to the virus and then enter the bloodstream. Lymphoid hyperplasia is common and may be seen as generalized lymphadenopathy, tonsillitis, and hepatosplenomegaly.
* The infection of the B-lymphocytes results in the production of immunoglobulins (heterophile antibodies)<ref name=":0" />.


(Photo available at&nbsp;[http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001617/figure/A000591.B2936/?report=objectonly http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001617/figure/A000591.B2936/?report=objectonly])
==  Characteristics/Clinical Presentation  ==
 
* Fever
== Prevalence ==
* Tonsillitis
 
* Lymphadenopathy and splenomegaly
Current statistics on mononucleosis are only as recent as 2002, as non could be found from the CDC. The following are the latest reportings:
* Occasionally hepatosplenomegaly
 
* Fatigue
*In the research conducted in 2005, it was found that Epstein-Barr Virus (EBV) infects more than 98 percent of the world's population.
* Occasionally: rash
*Epstein-Barr Virus (EBV) causes infectious mononucleosis in 90 percent of the cases." <ref name="three">http://www.tarunaoils.com/articles/mononucleosis-causes-mononucleosis-statistics.asp</ref>
Complications
 
* Splenic rupture: may be spontaneous
<br>According to the latest statistics in 2005&nbsp;95% of people in the United States over the age 30&nbsp;have been infected with EBV at some point, but may&nbsp;not have known. People&nbsp;in the 20's who have been infection will only present with symptoms 35-50% of the time. For those in their 20's that have lived in dorms or other close quarter housing the chance of infection increases.<ref name="Patho Book">Goodman C, Fuller K. Pathology. Implications for the Physical Therapist. St. Louis, MO: Saunders Elseveir: 2009</ref>&nbsp;Mono occurs most commonly between the ages of 15 to 17, however you many develop mono at any age.<ref name="one" /><br>
* Splenic infarction <ref name=":1" />
 
== <br>Characteristics/Clinical Presentation  ==
 
&nbsp;
 
Typical Patient Presentation [[Image:Monosymptoms.jpg|http://www.healthcentral.com/sleep-disorders/000548.html]] <ref>http://www.healthcentral.com/sleep-disorders/000548.html</ref>
 
Common Symptoms - these symptoms usually resolve in a few days<ref name="five">http://www.webmd.com/a-to-z-guides/infectious-mononucleosis-topic-overview</ref><ref name="four">http://www.mayoclinic.com/health/mononucleosis/DS00352/METHOD</ref>&nbsp;
 
*Drowsiness
*Fever  
*General discomfort
*Loss of appetite
*Muscle aches/stiffness
*Rash
*Sore Throat
*Swollen lymph nodes
*Swollen spleen Fatigue
 
Less Uncommon - may be signs of rare but serious condition. Patient's should be instructed to contact physician immediately.
 
*Chest pain
*Cough
*Headache
*Hives
*Jaundice
*Neck stiffness
*Nosebleed
*Rapid heart rate
*Sensitivity to light
*Shortness of Breath


== Associated Co-morbidities  ==
== Associated Co-morbidities  ==


While there are very few co-morbidities associated with mono, a select group of studies as shown a correlation between [http://www.cdc.gov/cfs/ Chronic Fatigue Syndrome] (CFS) and Mononucleosis. According to research the [http://www.cdc.gov/ncidod/diseases/ebv.htm Epstein Barr Virus] has many similar clinical features. It has yet to be determined whether or not the conditions are synonymous or just present with similar symptoms due to their viral nature of transmision. <ref name="six">Straus, S., The Chronic Mononucleosis Syndrome. The Journal of Infectious Diseases, Vol. 157, No. 3 (Mar., 1988) pp. 405-412. Oxford University Press. http://www.jstor.org/stable/30136640</ref><br>
While there are very few co-morbidities associated with mono, a select group of studies as shown a correlation between [http://www.cdc.gov/cfs/ Chronic Fatigue Syndrome] (CFS) and Mononucleosis. According to research the [http://www.cdc.gov/ncidod/diseases/ebv.htm Epstein Barr Virus] has many similar clinical features. It has yet to be determined whether or not the conditions are synonymous or just present with similar symptoms due to their viral nature of transmision. <ref name="six">Straus, S., The Chronic Mononucleosis Syndrome. The Journal of Infectious Diseases, Vol. 157, No. 3 (Mar., 1988) pp. 405-412. Oxford University Press. http://www.jstor.org/stable/30136640</ref>


== Medications  ==
== Medications  ==
 
Symptomatic therapy is usually sufficient.
Since Mono is not a bacterial infection, anti-biotics are not typically prescribed to help fight off the infection. Viral infections, such as mono are more typically managed with over the counter medications such as Tylenol and Ibuprofen (Advile). In more complex cases patients may be prescribed corticosteriods to help control any systemic effects occuring from the virus. <ref name="five" /><br>
* Athletes are encouraged to discontinue sports during the acute phase (<3-4 weeks) to lower the risk of splenic rupture.<ref name=":1" />
 
* Antipyretics and anti-inflammatory medications help to treat fever, sore throat, and the general fatigue seen in this illness.
&nbsp;  
* Hydration, rest, and good nutritional intake should be encouraged.
 
* Corticosteroids are not generally recommended in the routine treatment of mononucleosis because of concerns with immunosuppression; however, in cases of airway obstruction, corticosteroids (and possible otolaryngology consultation) are indicated along with appropriate airway management<ref name=":0" />.
[[Image:Antibody.jpg|thumb|right|http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001617/figure/A000591.B9069/?report=objectonly]]


== Diagnostic Tests/Lab Tests/Lab Values  ==
== Diagnostic Tests/Lab Tests/Lab Values  ==


A combination of clinical examination, lab tests, and positive [http://www.webmd.com/skin-problems-and-treatments/mononucleosis-tests Monospot test] are used to diagnosis Mononucleosis. Antibodies in the serum are elevated during the acute phase of the illness and can last for 3-4 weeks. This must be differentiated from Chronic Fatigue because these same antibody levels were at one time shown to be increased with CFS as well.<ref name="Patho Book" /> In the initial clinical evaluation a strep test should also be performed to rule that out as a possible cause for the fever and swollen glands. Elevated white blood cell count will be noted during lab work and may remain this way for up to 4 months. <ref name="CDC">http://www.cdc.gov/ncidod/diseases/ebv.htm</ref>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <br>
The diagnostic test of choice for mononucleosis is the heterophile antibody (monospot) test (occasionally falsely negative in early disease and require repeat testing later in the course of the illness).
 
== Etiology/Causes  ==
 
Mono is caused by the [http://www.cdc.gov/ncidod/diseases/ebv.htm Epstein-Barr virus], a form of herpesvirus. EBV is one of the most common virus in the United States and does not disappear once symptoms supposide like some viruses. Some of the EBV cells remain dormant in their host for the rest of the patient's life. The virus is passed through saliva and close contact. It has also been shown that mono can be caused from other viral organisms such as cytomegalovirus. Mononucleosis is spread sharing beverages, utensils, lip balm, and most commonly known is kissing.<ref name="one" />&nbsp;Infectious mononucleosis can be caused from [http://www.nlm.nih.gov/medlineplus/ency/article/000568.htm Acute Cytomegalovirus (CMV) infection], condition caused by a member of the herpes virus family. Once symptoms have subsided the individual is still caring the virus, it has just become dormant. A few of the viral cells will remain permanently and the person may have an acute flare up years down the road.<ref name="CDC" /><br><br>


== Systemic Involvement  ==
The most important entity to exclude from the differential diagnosis is primary [[Human Immunodeficiency Virus (HIV)|HIV]] infection.


Enlargement of the spleen is the most serious systemic complication that can arise from Mono. In very rare, extreme cases the spleen may rupture if not treated properly. This would be evident by sudden, sharp, stabbing pain in the left side of the upper abdomen.  
[[Ruptured Spleen|Splenic rupture]] is a rare complication in mononucleosis but can be potentially life-threatening if not diagnosed in a timely fashion<ref name=":0" />. 


The liver may also become involved in some cases. Hepatitis, or inflammation can occur in some cases or the patient may experience jaundice which is characterized by yellowing of the skin and whites of the eyes. If any abdominal pain or yellowing of the skin occurs medical attention should be sought immediately.<ref name="four" /><br>
== Physical Therapy Management ==
 
Infectious Mononucleosis:  PREFERRED PRACTICE PATTERNS 6B:
<br>
* Impaired [[Aerobic Exercise|Aerobic]] Capacity/Endurance Associated with Deconditioning  
 
* Infectious mononucleosis is probably contagious before symptoms develop until the fever subsides and the oral and pharyngeal lesions disappear. Although infectious mononucleosis appears to be only mildly contagious, adherence to standard precautions, especially good [[Hand Hygiene|handwashing]] and avoidance of shared dishware or food items with other people.
<br>[[Image:2011-infectious-mononucleosis.jpg|frame|center|http://www.medicinenet.com/infectious_mononucleosis/article.htm]]&nbsp;
* The person with infectious mononucleosis should be cautioned against engaging in excessive activity, especially contact sports, which could result in splenic rupture or lowered resistance to infection. Usually this guideline is appropriate for a period of at least 1 month.
 
* Any sign of splenic rupture (e.g., abdominal or upper quadrant pain, Kehr's sign, sudden left shoulder pain, or shock) requires immediate medical evaluation.  
<br>
* Any soft tissue mobilization or [[Myofascial Release|myofascia]]<nowiki/>l techniques necessary in the left upper quadrant, especially up and under the [[Ribs|rib]] cage, must take into consideration the enlarged liver and/or spleen; indirect techniques away from the spleen are indicated.
 
* In rare cases mononucleosis impairs the CNS. Any change in neurologic status must be evaluated and reported to the physician.  
== Medical Management (current best evidence)  ==
* Changes in respiration or signs and symptoms of airway obstruction may require emergency intervention.<ref name="Patho Book">Goodman C, Fuller K. Pathology. Implications for the Physical Therapist. St. Louis, MO: Saunders Elseveir: 2009</ref>
 
See also relevant section in [[Medical Related Issues in Sports Medicine]]
Usually the medical management for mononucleosis is self-treatment. Normally, all symptoms&nbsp;are resp;ved&nbsp;within a month but can last for up to four months.<ref name="one" /> Your doctor will advise you to get plenty of rest, gargle with salt water to sooth sore throat, take Tylenol or Ibuprofen for any present fever or headache, and avoid sports or heavy lifting in the event of an enlarged spleen. In more severe cases corticosteroids maybe prescribed to reduce swelling of throat, tonsils, or spleen. Patients with mono should avoid contact with other individuals if running a fever to reduce the risk of contamination. If in contact with others while the virus is active, avoid sharing utensils or drinking after others to minimize the risk of spreading the virus. <ref name="five" /><br>
 
== Physical Therapy Management (current best evidence) <ref name="Patho Book" /> ==
 
 
 
{| style="width: 685px; height: 350px" border="1" cellspacing="1" cellpadding="1" width="685"
|-
| ''Infectious Mononucleosis''
|-
| <u>PREFERRED PRACTICE PATTERNS 6B:</u>
|-
| Impaired Aerobic Capacity/Endurance Associated with Deconditioning <br>Infectious mononucleosis is probably contagious before symptoms develop until the fever subsides and the oral and pharyngeal lesions disappear. Although infectious mononucleosis appears to be only mildly contagious, adherence to standard precautions, especially good handwashing and avoidance of shared dishware or food items with other people, is essential in preventing the HCW from contracting this condition.<br>The person with infectious mononucleosis should be cautioned against engaging in excessive activity, especially contact sports, which could result in splenic rupture or lowered resistance to infection. Usually this guideline is appropriate for a period of at least 1 month.<br>Any sign of splenic rupture (e.g., abdominal or upper quadrant pain, Kehr's sign, sudden left shoulder pain, or shock) requires immediate medical evaluation. Any soft tissue mobilization or myofascial techniques necessary in the left upper quadrant, especially up and under the rib cage, must take into consideration the enlarged liver and/or spleen; indirect techniques away from the spleen are indicated.<br>In rare cases mononucleosis impairs the CNS. Any change in neurologic status must be evaluated and reported to the physician. Changes in respiration or signs and symptoms of airway obstruction may require emergency intervention.
<br>
 
|}
 
'''With permission from Elsevier <br>'''
 
== Alternative/Holistic Management (current best evidence)  ==
 
While medical management for Mono is limited to rest, over the&nbsp;counter pain/fever reducers,&nbsp;and avoidance of aggrevating activities,&nbsp;unless an extreme case presents, there are some sources that advocate the use of specific diets and natural cures if the virus is to arise. <ref name="home remedies">http://www.home-remedies-for-you.com/remedy/Mononucleosis.html</ref>  


== Differential Diagnosis  ==
== Differential Diagnosis  ==
 
Many other viral and some rickettsial illnesses have characteristics similar to EBV.  
Since Mono is caused by a strand of herpevirus there are other conditions that may present with similar symptoms. It is always important for patient to consult with M.D. to rule out possibilty of any of the following: <ref name="emed">http://emedicine.medscape.com/article/784513-differential</ref>
* The differential includes:
 
* [[Cytomegalovirus (CMV) Infection|cytomegalovirus]]  
*[http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002575/ Diphtheria]
* human immunodeficiency virus (HIV)
*[http://www.ncbi.nlm.nih.gov/pubmedhealth/?term=Herpes%20simplex Herpes Simplex]
* human [[Herpes Zoster|herpes]] <nowiki/>virus type 6
*[http://www.physio-pedia.com/index.php5?title=HIV/AIDS HIV Infection and AIDS]  
* EBV hepatitis - this is an uncommon diagnosis and causes a self‐limiting hepatitis<ref>Vine LJ, Shepherd K, Hunter JG, Madden R, Thornton C, Ellis V, Bendall RP, Dalton HR. Characteristics of Epstein–Barr virus hepatitis among patients with jaundice or acute hepatitis. Alimentary pharmacology & therapeutics. 2012 Jul;36(1):16-21.</ref>  
*[http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002524/ Mumps]  
* [[Hepatitis A, B, C|hepatitis]] B
*[http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001975/ Roseola Infantum]
* tick-borne illnesses such as [[Lyme Disease|Lyme]] disease.  
*[http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002541/ Rubella]
* Primary HIV may present with mucocutaneous ulcerations; furthermore, skin rash is frequently seen in primary HIV and is far less common in mononucleosis.<ref name=":0" />
*[http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001981/ Peritonsillar Abscess]  
*[http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002367/ Pharyngitis]  
*[http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001979/ Retropharyngeal Abscess]
*[http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001969/ Scarlet Fever]
 
<br>
 
Also, there are several complications that can occur if patient's are not taking care of themselves once sypmtoms are present. Many&nbsp;of these condition are rare but dangerous:&nbsp;<ref name="one" />  
 
*[http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001597/ Hemolytic anemia]
*[http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0003727/ Hepatitis with jaundice] (more common in patients older than 35)
*[http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002259/ Inflammation of the testicles] (orchitis)
*[http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001704/ Guillain-Barre syndrome]
*[http://www.physio-pedia.com/index.php5?title=Meningitis Meningitis]  
*[http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0003684/ Seizures]  
*[http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001777/ Bell's Palsy]
*[http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0003682/ Uncoordinated movements]
*[http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001663/ Strep Throat]
*Spleen rupture (rare)


== Case Reports/ Case Studies  ==
== Case Reports/ Case Studies  ==
Line 148: Line 85:
*Buchwald DS, Rea TD, Katon WJ, Russo JE, Ashley RL.&nbsp;[http://www.ncbi.nlm.nih.gov/pubmed/11063953 Acute infectious mononucleosis: characteristics of patients who report failure to recover.]&nbsp;Department of Medicine, University of Washington, Seattle, Washington, USA.&nbsp;Am J Med. 2000 Nov;109(7):531-7.
*Buchwald DS, Rea TD, Katon WJ, Russo JE, Ashley RL.&nbsp;[http://www.ncbi.nlm.nih.gov/pubmed/11063953 Acute infectious mononucleosis: characteristics of patients who report failure to recover.]&nbsp;Department of Medicine, University of Washington, Seattle, Washington, USA.&nbsp;Am J Med. 2000 Nov;109(7):531-7.


== Resources <br> ==
== Resources   ==


[http://www.cdc.gov/ Center for Disease Control]  
[http://www.cdc.gov/ Center for Disease Control]  
Line 156: Line 93:
[http://www.mayoclinic.com/ MayoClinic]  
[http://www.mayoclinic.com/ MayoClinic]  


[http://www.merckmanuals.com/professional/sec14/ch189/ch189f.html Merck Manual]  
[http://www.merckmanuals.com/professional/sec14/ch189/ch189f.html Merck Manual]
 
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
 
&nbsp;
<div class="researchbox"><rss>http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1nGQFE-05Nk25h_6W7FmyLHg9Q505qt5xdk4aGGVcGFLsadg_l|charset=UTF-8|short|max=10</rss></div>
<br>
 
<br>
 
== References  ==
== References  ==
see [[Adding References|adding references tutorial]].


<references />
<references />


[[Category:Bellarmine]]
[[Category:Bellarmine_Student_Project]]
[[Category:Communicable Diseases]]

Latest revision as of 05:47, 31 May 2022

Original Editors - Nicole Clark

Top Contributors - Nicole Clark, Lucinda hampton, Admin, Elaine Lonnemann, Kim Jackson, WikiSysop and Wendy Walker  

Introduction[edit | edit source]

Mononucleosis.png

Infectious mononucleosis is an acute infectious disease associated with Epstein-Barr virus that is characterized especially by fever, sore throat, swelling of lymph nodes, fatigue, and lymphocytosis and occurs primarily in adolescents and young adults.[1] It is usually a clinical diagnosis, with confirmation by serum testing, but may have suggestive findings on imaging

  • Mononucleosis classically presents with fever, lymphadenopathy, and tonsillar pharyngitis. See image R
  • It was originally called "mononucleosis" after abnormal mononuclear cells were found in patients with the clinical syndrome.[2]
  • Later Epstein-Barr virus (EBV) was established as the cause of mononucleosis after an exposed healthcare worker developed a positive heterophile test (a rapid test which detects infectious mononucleosis that is caused by the Epstein Barr Virus)[3]

Etiology[edit | edit source]

The cause of mononucleosis is the Epstein-Barr virus (EBV), a type of herpesvirus spread by contact, typically with salivary secretions.

  • Transmission is generally person-to-person, but EBV is not considered a highly contagious disease[3].
  • It is thought to be spread primarily through a person-to-person route through salivary secretions. The EBV virus infects B-cells in the lymphoid tissue. Like other herpes viruses, it becomes a lifelong chronic infection with periodic shedding of virus[2].
  • The duration of oral shedding is not entirely clear, but high levels of shedding can continue for a median of 6 months after illness onset.[3]

Epidemiolgy[edit | edit source]

It is estimated that up to 95% of adults in the world are eventually seropositive to EBV (widely disseminated in all population groups).

  • Exposure to EBV, but often a subclinical infection, especially in children. Young adults (15-24) are more likely to be symptomatic[2].
  • Mononucleosis is uncommon in adults:  approximately 2% of all pharyngeal disease in adults is attributable to this disease.
  • Adults are generally not susceptible to clinical illness because of previous exposure.
  • In the United States, clinically evident infection occurs at rates estimated at 30 times higher in whites than in blacks (possibly because if acquired at a young (childhood) age, EBV is often subclinical ie earlier EBV exposures in blacks, and a higher frequency of asymptomatic infection as young children).
  • After exposure, the EBV infects the epithelial cells of the salivary glands and the oropharynx. Lymphocytes residing in the tonsils get exposed to the virus and then enter the bloodstream. Lymphoid hyperplasia is common and may be seen as generalized lymphadenopathy, tonsillitis, and hepatosplenomegaly.
  • The infection of the B-lymphocytes results in the production of immunoglobulins (heterophile antibodies)[3].

Characteristics/Clinical Presentation[edit | edit source]

  • Fever
  • Tonsillitis
  • Lymphadenopathy and splenomegaly
  • Occasionally hepatosplenomegaly
  • Fatigue
  • Occasionally: rash

Complications

  • Splenic rupture: may be spontaneous
  • Splenic infarction [2]

Associated Co-morbidities[edit | edit source]

While there are very few co-morbidities associated with mono, a select group of studies as shown a correlation between Chronic Fatigue Syndrome (CFS) and Mononucleosis. According to research the Epstein Barr Virus has many similar clinical features. It has yet to be determined whether or not the conditions are synonymous or just present with similar symptoms due to their viral nature of transmision. [4]

Medications[edit | edit source]

Symptomatic therapy is usually sufficient.

  • Athletes are encouraged to discontinue sports during the acute phase (<3-4 weeks) to lower the risk of splenic rupture.[2]
  • Antipyretics and anti-inflammatory medications help to treat fever, sore throat, and the general fatigue seen in this illness.
  • Hydration, rest, and good nutritional intake should be encouraged.
  • Corticosteroids are not generally recommended in the routine treatment of mononucleosis because of concerns with immunosuppression; however, in cases of airway obstruction, corticosteroids (and possible otolaryngology consultation) are indicated along with appropriate airway management[3].

Diagnostic Tests/Lab Tests/Lab Values[edit | edit source]

The diagnostic test of choice for mononucleosis is the heterophile antibody (monospot) test (occasionally falsely negative in early disease and require repeat testing later in the course of the illness).

The most important entity to exclude from the differential diagnosis is primary HIV infection.

Splenic rupture is a rare complication in mononucleosis but can be potentially life-threatening if not diagnosed in a timely fashion[3]. 

Physical Therapy Management[edit | edit source]

Infectious Mononucleosis: PREFERRED PRACTICE PATTERNS 6B:

  • Impaired Aerobic Capacity/Endurance Associated with Deconditioning
  • Infectious mononucleosis is probably contagious before symptoms develop until the fever subsides and the oral and pharyngeal lesions disappear. Although infectious mononucleosis appears to be only mildly contagious, adherence to standard precautions, especially good handwashing and avoidance of shared dishware or food items with other people.
  • The person with infectious mononucleosis should be cautioned against engaging in excessive activity, especially contact sports, which could result in splenic rupture or lowered resistance to infection. Usually this guideline is appropriate for a period of at least 1 month.
  • Any sign of splenic rupture (e.g., abdominal or upper quadrant pain, Kehr's sign, sudden left shoulder pain, or shock) requires immediate medical evaluation.
  • Any soft tissue mobilization or myofascial techniques necessary in the left upper quadrant, especially up and under the rib cage, must take into consideration the enlarged liver and/or spleen; indirect techniques away from the spleen are indicated.
  • In rare cases mononucleosis impairs the CNS. Any change in neurologic status must be evaluated and reported to the physician.
  • Changes in respiration or signs and symptoms of airway obstruction may require emergency intervention.[5]

See also relevant section in Medical Related Issues in Sports Medicine

Differential Diagnosis[edit | edit source]

Many other viral and some rickettsial illnesses have characteristics similar to EBV.

  • The differential includes:
  • cytomegalovirus
  • human immunodeficiency virus (HIV)
  • human herpes virus type 6
  • EBV hepatitis - this is an uncommon diagnosis and causes a self‐limiting hepatitis[6]
  • hepatitis B
  • tick-borne illnesses such as Lyme disease.
  • Primary HIV may present with mucocutaneous ulcerations; furthermore, skin rash is frequently seen in primary HIV and is far less common in mononucleosis.[3]

Case Reports/ Case Studies[edit | edit source]

Resources[edit | edit source]

Center for Disease Control

WebMD

MayoClinic

Merck Manual

References[edit | edit source]

  1. ↑ Merriam Webster infectious mononucleosis Available from: https://www.merriam-webster.com/dictionary/infectious%20mononucleosis ( last ccessed 5.8.2020)
  2. ↑ 2.0 2.1 2.2 2.3 2.4 Radiopedia Mononucleosis Available from:https://radiopaedia.org/articles/infectious-mononucleosis-1?lang=us (last accessed 3.8.2020)
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 Mohseni M, Boniface MP, Graham C. Mononucleosis. April 27 2020 Available from:https://www.ncbi.nlm.nih.gov/books/NBK470387/ (last accessed 3.8.2020)
  4. ↑ Straus, S., The Chronic Mononucleosis Syndrome. The Journal of Infectious Diseases, Vol. 157, No. 3 (Mar., 1988) pp. 405-412. Oxford University Press. http://www.jstor.org/stable/30136640
  5. ↑ Goodman C, Fuller K. Pathology. Implications for the Physical Therapist. St. Louis, MO: Saunders Elseveir: 2009
  6. ↑ Vine LJ, Shepherd K, Hunter JG, Madden R, Thornton C, Ellis V, Bendall RP, Dalton HR. Characteristics of Epstein–Barr virus hepatitis among patients with jaundice or acute hepatitis. Alimentary pharmacology & therapeutics. 2012 Jul;36(1):16-21.
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