Glandular fever
Glandular fever, known in medical notes as infectious mononucleosis, is put together in a misleading way.
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Glandular fever, known in medical notes as infectious mononucleosis, is put together in a misleading way. It starts like an ordinary case of tonsillitis, the antibiotic does nothing, the temperature is still there in the second week, the neck swells and there is not enough energy to reach the kitchen. None of that needs to be frightening: glandular fever clears up by itself, with no treatment at all. But it brings two things worth knowing about in advance, an enlarged spleen that puts sport out of bounds for well over a month, and a rash caused by the world's most prescribed antibiotic that afterwards gets written down, wrongly, as an allergy for life.
How it spreads, and whether others can be protected
The culprit is the Epstein-Barr virus, one of the herpes family. It lives in saliva, so it passes on through kissing and through a shared glass, spoon, bottle, toothbrush or cigarette, and occasionally through transfused blood. It does not travel across a room in the air, through a handshake or from a seat on the bus.
Around six weeks pass between catching the virus and the first complaints, which is why working out where you picked it up is nearly always impossible.
Almost everyone meets this virus at some point. In small children the encounter goes unnoticed or passes for a mild cold, so by adulthood most people have long been protected. The visible illness falls to those who meet the virus later, chiefly teenagers and people in their early twenties, which explains both the age of the patients and the nickname.
Cutting off transmission altogether is neither possible nor a realistic aim: the virus is shed in saliva for months after recovery and, in healthy carriers, on and off for life. What is sensible is different: while you are ill and for a while afterwards, no kissing, no drinking from anyone else's glass and no offering your own, and keep a toothbrush to yourself. Blood donation is off the table for some months, and the blood service will give the exact interval. Going back to work or classes is fine as soon as the energy is there, with no need to wait for any test result. There is no vaccine against glandular fever.
What it looks like
It usually opens with a few days of feeling off-colour and slightly feverish, and then unfolds:
- a severe sore throat, with large tonsils covered in a greyish-white coating that looks exactly like bacterial tonsillitis;
- a temperature that lasts one to two weeks and responds poorly to medicines that bring fever down;
- swollen glands, particularly at the back of the neck and below the hairline, tender to touch, with a neck that looks thicker than usual;
- a draining tiredness that sleep does not fix and that bothers people more than the throat does;
- puffy eyelids in the first few days, an understated sign but a recognisable one;
- headache, aching muscles, no appetite;
- a rash, small red spots on the palate and sometimes a yellow tinge to the eyes and a heavy feeling under the left ribs.
The throat generally eases within a week and the fever within one or two, while the glands take longer to go down. Weakness is what drags on longest: in some people it lasts a month or two, occasionally more, and that is part of the ordinary course of the illness rather than a complication.
When an ambulance is needed
Glandular fever is almost always got through at home, but there are three situations where you ring the emergency number (112 across Europe) without waiting for morning:
- A blocked airway. Very large tonsils and swelling can occasionally close off the throat. The warning signs are being unable to swallow your own saliva so that it dribbles out, struggling to breathe, breathing that has turned noisy and wheezy, a changed voice, and finding it easier to sit up than to lie down.
- A ruptured spleen. Sudden severe pain high on the left side of the abdomen spreading to the left shoulder, together with pallor, cold sweat, dizziness or fainting. It happens rarely, but it is life-threatening and it is dealt with in an operating theatre.
- A sharp deterioration. The person cannot be woken or is confused, has a fit or a severe headache with a stiff neck, or cannot keep fluids down because of vomiting and is showing signs of dehydration.
In that state do not drive and do not take anyone in a car: call for help. Being seen the same day through the ordinary route is needed if the fever passes two weeks, if the eyes turn yellow, if the throat gets worse after the first week, if pain makes drinking impossible, or if a rash has spread over the body after starting an antibiotic.
What the doctor does, and why an antibiotic will not help
The diagnosis rests on a blood test. The blood count shows plenty of unusual-looking lymphocytes, the mononuclear cells the illness is named after, and antibodies specific to the Epstein-Barr virus are looked for separately. In the first week the quick test can come back negative in an obvious case, so it is sometimes repeated. Liver enzymes are checked at the same time: in most people they are mildly raised, because the liver joins in almost every time, and they settle without any treatment.
Other infections run a similar course, so with an atypical picture a doctor will think about cytomegalovirus, toxoplasmosis and, most importantly, the acute stage of HIV infection, which begins in exactly the same way with fever, sore throat, swollen glands and a rash. If there has been unprotected sex or another exposure in recent weeks, say so at the outset: an HIV test is not a formality here but the most valuable part of the work-up, because starting treatment early changes a great deal.
Antibiotics do nothing to viruses and glandular fever is not treated with them. There is also a very specific trap: give someone with glandular fever a penicillin antibiotic, usually amoxicillin, and within days most will erupt in a widespread itchy rash. It is not a true penicillin allergy, yet it stays in the records for good and deprives that person of the simplest, most convenient antibiotics for the rest of their life. So with a sore throat that will not settle and comes with swollen glands and exhaustion, the sensible order is blood test first, treatment second. And if the antibiotic had already been started when the rash appeared, say so, because that allergy label is worth sorting out later.
Steroids are used rarely and only for particular problems, such as swelling that threatens the airway. They are not given routinely, since there is nothing to be gained from it.
The spleen and getting back to exertion
Around half of those affected have an enlarged spleen. It sits on the left under the ribs and, stretched, it becomes fragile: a blow to the side, a sudden wrench, a barbell, a wrestling bout or a fall off a bicycle can tear it. Ruptures are rare, but they are the most dangerous thing that can happen in this illness and nearly all of them occur in the first weeks.
Hence a simple rule: for as long as the illness lasts, and for at least a month from when it began, no contact sport, no martial arts, no heavy lifting and no explosive effort. For contact sports and weight training the break is usually longer, and going back is best done after a doctor has examined you. Walking, stairs and ordinary household life are not covered by the ban: spending whole days in bed does not help and drags the weakness out.
Alcohol is also better left alone for those first weeks, while the liver is busy with the infection.
Getting through these weeks at home
Nothing shortens the illness, so everything done at home is aimed at making it easier to bear.
- Rest as much as the body asks for, but get up and move a little every day.
- Drink often and in small amounts. If swallowing hurts, cool drinks go down better than hot ones, and ice cream counts too.
- Soft food, soup, yoghurt or something puréed, is tolerated better than dry or spicy meals.
- For pain and fever, ordinary over-the-counter painkillers help; which one to choose is a question for a doctor or pharmacist. Children and teenagers are not given aspirin.
- Gargling with warm salty water eases the throat for a while.
- Go back to school or work gradually, and do not be surprised to tire more easily for the first few weeks. Arrange a lighter timetable if that can be done.
If a month or two on the energy still has not returned, it is worth raising: most often it is simply a recovery taking its time, but other causes of fatigue such as a low haemoglobin or a thyroid problem get ruled out at the same time.
Online consultation
Several questions in this illness are handled well at a distance. The first is whether tonsillitis that will not end might be glandular fever, and which tests will settle it instead of guessing; the doctor will go through how long the fever has run, what the throat looks like, where the glands are swollen and how effort is tolerated. The second is what to make of a blood test already done in which the lymphocytes or the liver enzymes look alarming. The third, and the most practical, is when training and studying can resume, and this is where a remote appointment saves the most time. It is also the right place to discuss a rash that appeared with an antibiotic, so that it is not filed away as an allergy for no reason. Difficulty breathing, an inability to swallow saliva and severe abdominal pain cannot be judged on a screen: those mean calling an ambulance straight away.
This material is for information only and does not replace medical advice.
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