Medical Care

Closely monitor patients with extreme tonsillar enlargement for airway obstruction. Steroids are indicated for impending or established airway obstruction in individuals with Epstein-Barr virus (EBV) infectious mononucleosis.

Surgical Care

Surgery is necessary for spontaneous splenic rupture, which occurs in rare patients with EBV infectious mononucleosis and may be the initial manifestation of the condition.

Consultations

Consult an infectious disease specialist in all but the most straightforward cases of EBV infectious mononucleosis.

Consulting a hematologist may be necessary if unusual hematologic manifestations of EBV infectious mononucleosis are present (eg, in anemia to determine the cause of the patient's anemia).

Consulting a neurologist is advised for patients with potential CNS involvement.

Consultation with a cardiologist is advised for the rare patients with EBV infectious mononucleosis who have presumed myocarditis.

Consult a gastroenterologist for patients with EBV-induced acalculous cholecystitis or if anicteric hepatitis is in the differential diagnoses.

Diet

Normal diet is appropriate.

Activity

Patients with acute EBV mononucleosis should be advised to refrain from active physical activity for 3 weeks.

Medication

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Table 1. Differential Diagnoses of Infectious Mononucleosis

Clinical Parameters		Epstein-Barr Virus	Cyto-megalovirus	Toxoplasmosis	Viral Hepatitis
Symptoms	Fatigue	+++	+	+/-	+
	Malaise	++	+	-	+
	Mild sore throat	+	+	+/-	+/-
	Early maculopapular rash	±	-	-	+/-
Signs	Early bilateral upper eyelid edema	±	-	-	-
	Unilateral localized adenopathy	-	-	+	-
	Bilateral posterior cervical adenopathy	+	+	-	+/-
	Tender hepatomegaly	+/-	+/-	-	+
	Splenomegaly	+	+/-	+/-	-
Laboratory abnormalities	WBC count	N*/-	N/-	N	¯
	Elevated SGOT^†/SGPT^‡	++	+	+/-	+++
	Atypical lymphocytes (≥ 10%)	+	+	-	-
	Thrombocytopenia	+/-	+/-	-	+/-
	Elevated IgM^§ CMV titer	-	+	-	-
	Elevated IgM EBV VCA^II titer	+	-	-	-
	Elevated IgM toxoplasmosis titer	-	-	+	-
	Positive hepatitis (eg, A, B, D) test	-	-	-	+
*Normal ^† Serum glutamic-oxaloacetic transaminase ^‡ Serum glutamic-pyruvic transaminase ^§ Immunoglobulin M ^II Viral capsid antigen

Table 2. EBV Serologic Responses in EBV-Associated Diseases

EBV Diseases	EBV Antibody Responses
	Anti-VCA			Anti-EA
	IgM Monospot/ Heterophile	IgM	IgG	Diffuse EA	Restricted EA	Anti-EBNA
Acute EBV mononucleosis	+	+	+	+	-	-
Past EBV infection	-	-	+	-	-	+
Chronic active EBV infection	-	-	+++	+	+	+
Burkitt lymphoma	-	-	+++	+/-	+	+
Nasopharyngeal carcinoma	-	-	+++	+	+/-	+

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Author

Kartika Shetty, MD, FACP Program Director, Internal Medicine Residency Program, Sunrise GME; Facility Medical Director, TEAMHealth, Mountain View Hospital

Kartika Shetty, MD, FACP is a member of the following medical societies: American College of Physicians, Association of Program Directors in Internal Medicine, Medical Council of India

Disclosure: Nothing to disclose.

Coauthor(s)

Elizabeth Benge, MD Resident Physician, Department of Internal Medicine, Sunrise Health GME Consortium

Elizabeth Benge, MD is a member of the following medical societies: American College of Physicians, American Medical Women's Association

Disclosure: Nothing to disclose.

Vanessa E Josef, MD, MS Fellow in Pulmonary Disease and Critical Care Medicine, University of New Mexico School of Medicine

Vanessa E Josef, MD, MS is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Thoracic Society

Disclosure: Nothing to disclose.

Reza Vaghefi, MD Infectious Disease Physician, Infectious Disease Partners of Nevada (IDPN), Sunrise Health GME Consortium

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

John W King, MD Professor of Medicine, Chief, Section of Infectious Diseases, Director, Viral Therapeutics Clinics for Hepatitis, Louisiana State University School of Medicine in Shreveport; Consultant in Infectious Diseases, Overton Brooks Veterans Affairs Medical Center

John W King, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Association of Subspecialty Professors, Infectious Diseases Society of America, Sigma Xi, The Scientific Research Honor Society

Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America; Fellow of the Royal College of Physicians, London

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Medical Association, Association of Professors of Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Additional Contributors

Burke A Cunha, MD Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Charles S Levy, MD Associate Professor, Department of Medicine, Section of Infectious Disease, George Washington University School of Medicine

Charles S Levy, MD is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America, Medical Society of the District of Columbia

Disclosure: Nothing to disclose.