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Author: Dr Sarah Hill, Dermatology Registrar, Waikato Hospital, Hamilton, New Zealand, 2007. Updated by Dr Catherine Tian, House Officer Auckland City Hospital. DermNet New Zealand Editor in Chief: Associate A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand. Medical Editor: Dr Helen Gordon, Auckland, New Zealand. Copy edited by Gus Mitchell. August 2020.
Infectious mononucleosis is a common infectious disease caused by Epstein-Barr virus (EBV). It is also more commonly known as glandular fever.
Infectious mononucleosis typically affects young adults aged 15–25 years . It is equally common in both sexes and affects all races [1–2]. Up to nearly 95% of people have had EBV infection by the time they are adults. The disease occurs worldwide with no seasonal predilection .
EBV is a human herpes type 4 DNA virus. EBV is implicated in a wide range of human diseases, many of which have mucocutaneous manifestations that can be acute or chronic.
EBV is passed from person to person by saliva through intimate contacts such as kissing, or via objects such as a toothbrush or drinking glass. The virus survives on an object while it remains moist. EBV can also be spread through blood and semen during sexual contact, blood transfusion, organ transplantation, and other procedures .
The clinical manifestations of infection are dependent on the interaction between virus and host immune system. The incubation period from contact until symptoms is usually 1–2 months .
Primary infection with EBV starts with a prodromal phase of low-grade fever, malaise, arthralgia, and myalgia. Tonsillitis and pharyngitis (frequently accompanied by enlarged tonsils with pus), cervical lymphadenopathy, fever, leukocytosis, and hepatosplenomegaly may follow 4–6 weeks later.
Infectious mononucleosis can cause wide-ranging symptoms (see below), which can persist for up to 4 months [4–7].
The typical exanthem of mononucleosis is an acute and generalised maculopapular eruption.
A more intense and extensive cutaneous eruption arises in 27–90% of patients with infectious mononucleosis 2–10 days after starting antibiotics . These include ampicillin, amoxicillin, cephalosporins, tetracyclines, and macrolides such as erythromycin [7–15]
The exact mechanisms of antimicrobial rash in infectious mononucleosis remain unclear. The virus is thought to induce loss of tolerance by the immune system, resulting in a hypersensitivity reaction to the drug [9,10]. Drug allergy is usually transient . However, re-exposure to the antibiotic may sometimes result in recurrence of rash years later .
Skin signs of EBV infection
Following the acute symptomatic phase, EBV persists in memory B cells in the tonsils and peripheral circulation of the infected host in a latent non-lethal carrier state throughout life [2,3].
The clinical features and a positive heterophile test are usually sufficient to diagnose infectious mononucleosis.
Abdominal ultrasonography can evaluate splenomegaly.
The main differential diagnoses of acute infectious mononucleosis are :
Treatment options for infectious mononucleosis are typically supportive in nature, such as:
Less common treatment options include:
There is currently no vaccine to protect against EBV infection. Prevention involves social hygiene, avoiding sharing drinks, food, or personal items.
Recovery from the acute phase of the initial EBV infection in healthy and immunocompetent individuals is generally complete in a few weeks, but it can take up to several months to feel completely well again. Prolonged lethargy and tiredness are common [1,2].
EBV causes life-long infection as the virus remains dormant in B lymphocytes. Intact immune response prevents progressive disease due to EBV. However, immune suppression or another illness has the potential to reactivate the virus causing vague and subclinical symptoms and, rarely, aggressive disease. During this phase, the virus can be spread to others.
Other skin manifestations of EBV infection include [4–6]:
Other diseases associated with EBV include:
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