Glandular fever – patient advice and red flags

See below for an evidence-based overview of information that should be given to patients with glandular fever along with a summary of potential complications and red flags. You can also access our more in-depth course to update your knowledge on glandular fever symptoms and diagnosis.

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As glandular fever has an underlying viral cause, medically there is little a clinician can offer. Information should be provided to patients on this so they can self-manage their symptoms as much as possible.

Two separate Cochrane systematic reviews concluded that there was a lack of evidence for the effectiveness of antivirals and oral steroids in the management of glandular fever, therefore neither are recommended.1.2

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Table 1:
Glandular fever management summary: information to give to patients.3,4

Explain the expected course of the illness. Although symptoms usually last for 2–3 weeks, tiredness may persist after the other symptoms have resolved, sometimes for months.

Advise patients

  • that exclusion from work or school is not necessary.
  • to take analgesics such as paracetamol or ibuprofen to relieve pain and fever symptoms, but that aspirin should not be given to children under 16.
  • to drink plenty of fluids.
  • to avoid alcohol during the course of the illness as the liver may be under stress.
  • to initially rest and sleep but to gradually increase their activity when their energy starts to come back. If they are tired, they should tailor their activities to what they can manage comfortably. Bed rest is not normally needed.
  • to limit the spread of the disease, by avoiding kissing and sharing eating or drinking utensils, and to thoroughly clean all items that may have been contaminated by saliva. Wash hands regularly.
  • to avoid contact/collision sports, heavy lifting, or any activities that might increase the risk of falls, for the first month of the illness, to reduce the risk of splenic rupture.

Advise patients to seek urgent medical advice if they:3

  • develop stridor or respiratory difficulty
  • have difficulty swallowing fluids or have signs of dehydration, such as reduced urine output
  • become systemically very unwell
  • develop abdominal pain (may indicate splenic rupture)

Although glandular fever is in many cases a self-limiting illness there are complications associated with it. Providing or signposting to patient information leaflets can inform patients of complications to be aware of.

Table 2: Glandular fever complications and red flags.3,5,6

  • Dehydration
  • Maculopapular rash
  • Peritonsillar abscess
  • Upper airways obstruction: due to gross enlargement of the tonsils or a peritonsillar abscess
  • Massive splenomegaly
  • Splenic rupture (rare, less than 1%): usually occurs in the first three to four weeks of the acute illness. About 50% of cases of splenic rupture are spontaneous, and 50% follow trauma.
  • Neurological complications: occur in 1–5% of people and the majority (85%) make a full recovery. Conditions include encephalitis or aseptic meningitis, facial nerve palsy, Guillain-Barré syndrome, optic neuritis, retrobulbar neuritis, and mononeuritis multiplex, brachial plexus neuropathy and hemiplegia.
  • Haematological complications: include autoimmune haemolytic anaemia occurring in 3% of people. Mild thrombocytopenia is common (25–50%) but severe neutropenia can cause neutropenic sepsis, pneumonia or death.
  • Cardiac complications: including pericarditis and myocarditis (rare), cardiac conduction abnormalities.
  • Renal complications: such as acute interstitial nephritis.
  • Abnormal liver function tests are seen in about 90% of people.
  • Hepatitis
  • Necrotic hepatitis (rare)
  • Fatigue lasting longer than six months may develop in a minority of people. It should be noted that post-infection fatigue and malaise can continue for one to two years in some patients with acute IM. This should not be confused with chronic fatigue syndrome.5
  • In immunocompromised people, infection with EPV may result in malignancies such as lymphoproliferative disorders, primary central nervous system lymphoma, Hodgkin's lymphoma, and nasopharyngeal carcinoma.
  • In people with HIV, EBV infection has also been associated with oral hairy leukoplakia and diffuse interstitial pneumonitis.
  • Pancreatitis
  • Pneumonia
  • Interstitial lung disease

When is secondary care referral indicated in glandular fever?

Glandular fever can be mainly managed in primary care.

However, the Clinical Knowledge Summaries advise, based on SIGN guidance and textbook recommendations that referral into secondary care should be for immediate admission if a patient with suspected or confirmed glandular fever presents with stridor, dehydration or difficulty swallowing fluids, suspected splenic rupture or a suspected potentially serious complication, as outlined above.3

Glandular fever: patient advice and red flags References

  1. De Paor M, et al. Antiviral agents for infectious mononucleosis (glandular fever). Cochrane Database of Systematic Reviews, 2016.
  2. Rezk E, et al. Steroids for symptom control in infectious mononucleosis. Cochrane Database of Systematic Reviews, 2015.
  3. Glandular fever (infectious mononucleosis). Clinical Knowledge Summaries, 2020
  4. Glandular fever. NHS website, 2020
  5. Rogers ME. Acute Infectious Mononucleosis: A Review for Urgent Care Physicians. American Journal of clinical medicine2012, 9(2), 88-91.
  6. Epstein-Barr Virus and Infectious Mononucleosis. For Healthcare Providers. Centers for Disease Control and Prevention, 2020.


Editorial team, Wilmington Healthcare

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