Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Infectious mononucleosis in adults and adolescents

Mark D Aronson, MD
Paul G Auwaerter, MD, MBA, FIDSA
Section Editors
Martin S Hirsch, MD
Sheldon L Kaplan, MD
Deputy Editor
Jennifer Mitty, MD, MPH


Infectious mononucleosis (IM) is characterized by a triad of fever, tonsillar pharyngitis, and lymphadenopathy [1]. It was initially described as "Drusenfieber" or glandular fever in 1889, but the term "infectious mononucleosis" was later used in 1920 to describe six college students with a febrile illness characterized by absolute lymphocytosis and atypical mononuclear cells in the blood [2,3]. The relationship between Epstein-Barr virus (EBV) and IM was established when a laboratory worker was infected with EBV and developed IM and a newly positive heterophile test [4].

Infectious mononucleosis in adults and adolescents will be reviewed here. A complete description of EBV and other clinical manifestations of EBV infection (including malignancy) are discussed separately. (See "Clinical manifestations and treatment of Epstein-Barr virus infection" and "Virology of Epstein-Barr virus".)


Epstein-Barr virus (EBV) is a widely disseminated herpesvirus that is spread by intimate contact between susceptible persons and EBV shedders. The virus has not been recovered from environmental sources, suggesting that humans are the major reservoir.

Antibodies to EBV have been demonstrated in all population groups with a worldwide distribution; approximately 90 to 95 percent of adults are eventually EBV-seropositive. By age four, EBV seroprevalence is close to 100 percent in developing countries and ranges from 25 to 50 percent in lower socioeconomic groups in the United States. Many attribute this finding to intense personal contact and poor personal hygiene among children, which provide opportunities for early acquisition and subsequent spread of EBV.

EBV acquired during childhood years is often subclinical; less than 10 percent of children develop clinical infection despite the high rates of exposure. The incidence of symptomatic infection begins to rise in adolescent through adult years [5]. Large studies of infectious mononucleosis are now decades old, but traditionally the peak incidence of infection has been described in the 15 to 24-year age range [6]. Some data derived in the United Kingdom suggest that infectious mononucleosis (IM) cases may be occurring later in life with increasing severity, requiring hospitalization [7]. IM is relatively uncommon in adults, accounting for less than two percent of pharyngitis in adults [8]. The vast majority of adults are not susceptible to this infection because of prior exposure.

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Jul 10, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Evans AS, Niederman JC, Cenabre LC, et al. A prospective evaluation of heterophile and Epstein-Barr virus-specific IgM antibody tests in clinical and subclinical infectious mononucleosis: Specificity and sensitivity of the tests and persistence of antibody. J Infect Dis 1975; 132:546.
  2. Evans AS. The history of infectious mononucleosis. Am J Med Sci 1974; 267:189.
  3. Sprunt TP, Evans FA. Mononucleosis leukocytosis in reaction to acute infections (infectious mononucleosis). John Hopkins Hosp Bull 1920; 31:409.
  4. Henle G, Henle W, Diehl V. Relation of Burkitt's tumor-associated herpes-ytpe virus to infectious mononucleosis. Proc Natl Acad Sci U S A 1968; 59:94.
  5. Evans A, Niederman J. Epstein-Barr virus. In: Viral Infections of Human Epidemiology and Control, Evans A (Ed), Plenum Publishing, New York 1989. p.265.
  6. Heath CW Jr, Brodsky AL, Potolsky AI. Infectious mononucleosis in a general population. Am J Epidemiol 1972; 95:46.
  7. Morris MC, Edmunds WJ. The changing epidemiology of infectious mononucleosis? J Infect 2002; 45:107.
  8. Aronson MD, Komaroff AL, Pass TM, et al. Heterophil antibody in adults with sore throat: frequency and clinical presentation. Ann Intern Med 1982; 96:505.
  9. Nye FJ. Social class and infectious mononucleosis. J Hyg (Lond) 1973; 71:145.
  10. Rostgaard K, Wohlfahrt J, Hjalgrim H. A genetic basis for infectious mononucleosis: evidence from a family study of hospitalized cases in Denmark. Clin Infect Dis 2014; 58:1684.
  11. Cohen JI, Dropulic L, Hsu AP, et al. Association of GATA2 Deficiency With Severe Primary Epstein-Barr Virus (EBV) Infection and EBV-associated Cancers. Clin Infect Dis 2016; 63:41.
  12. Balfour HH Jr, Holman CJ, Hokanson KM, et al. A prospective clinical study of Epstein-Barr virus and host interactions during acute infectious mononucleosis. J Infect Dis 2005; 192:1505.
  13. Balfour HH Jr, Odumade OA, Schmeling DO, et al. Behavioral, virologic, and immunologic factors associated with acquisition and severity of primary Epstein-Barr virus infection in university students. J Infect Dis 2013; 207:80.
  14. Vetsika EK, Callan M. Infectious mononucleosis and Epstein-Barr virus. Expert Rev Mol Med 2004; 6:1.
  15. Sawyer RN, Evans AS, Niederman JC, McCollum RW. Prospective studies of a group of Yale University freshmen. I. Occurrence of infectious mononucleosis. J Infect Dis 1971; 123:263.
  16. Fafi-Kremer S, Morand P, Brion JP, et al. Long-term shedding of infectious epstein-barr virus after infectious mononucleosis. J Infect Dis 2005; 191:985.
  17. Fleisher GR, Pasquariello PS, Warren WS, et al. Intrafamilial transmission of Epstein-Barr virus infections. J Pediatr 1981; 98:16.
  18. Junker AK, Thomas EE, Radcliffe A, et al. Epstein-Barr virus shedding in breast milk. Am J Med Sci 1991; 302:220.
  19. Kusuhara K, Takabayashi A, Ueda K, et al. Breast milk is not a significant source for early Epstein-Barr virus or human herpesvirus 6 infection in infants: a seroepidemiologic study in 2 endemic areas of human T-cell lymphotropic virus type I in Japan. Microbiol Immunol 1997; 41:309.
  20. Näher H, Gissmann L, Freese UK, et al. Subclinical Epstein-Barr virus infection of both the male and female genital tract--indication for sexual transmission. J Invest Dermatol 1992; 98:791.
  21. Sixbey JW, Lemon SM, Pagano JS. A second site for Epstein-Barr virus shedding: the uterine cervix. Lancet 1986; 2:1122.
  22. Israele V, Shirley P, Sixbey JW. Excretion of the Epstein-Barr virus from the genital tract of men. J Infect Dis 1991; 163:1341.
  23. Higgins CD, Swerdlow AJ, Macsween KF, et al. A study of risk factors for acquisition of Epstein-Barr virus and its subtypes. J Infect Dis 2007; 195:474.
  24. Anagnostopoulos I, Hummel M, Kreschel C, Stein H. Morphology, immunophenotype, and distribution of latently and/or productively Epstein-Barr virus-infected cells in acute infectious mononucleosis: implications for the interindividual infection route of Epstein-Barr virus. Blood 1995; 85:744.
  25. Balfour HH Jr, Holman CJ, Hokanson KM, et al. A prospective clinical study of Epstein-Barr virus and host interactions during acute infectious mononucleosis. J Infect Dis 2005; 192:1505.
  26. Thorley-Lawson DA, Mann KP. Early events in Epstein-Barr virus infection provide a model for B cell activation. J Exp Med 1985; 162:45.
  27. Paul JR, Bunnell WW. The presence of heterophile antibodies in infectious mononucleosis. Am J Med Sci 1932; 183.
  28. Paul JR, Bunnell WW. Classics in infectious diseases. The presence of heterophile antibodies in infectious mononucleosis by John R. Paul and W. W. Bunnell. American Journal of the Medical Sciences, 1932. Rev Infect Dis 1982; 4:1062.
  29. Corsi MM, Ruscica M, Passoni D, et al. High Th1-type cytokine serum levels in patients with infectious mononucleosis. Acta Virol 2004; 48:263.
  30. Tomkinson BE, Wagner DK, Nelson DL, Sullivan JL. Activated lymphocytes during acute Epstein-Barr virus infection. J Immunol 1987; 139:3802.
  31. Giuliano VJ, Jasin HE, Ziff M. The nature of the atypical lymphocyte in infectious mononucleosis. Clin Immunol Immunopathol 1974; 3:90.
  32. Johnsen HE, Madsen M, Kristensen T, Kissmeyer-Nielsen F. Lymphocyte subpopulations in man. Expression of HLA-DR determinants on human T cells in infectious mononucleosis. Acta Pathol Microbiol Scand C 1978; 86C:307.
  33. Niedobitek G, Herbst H, Young LS, et al. Patterns of Epstein-Barr virus infection in non-neoplastic lymphoid tissue. Blood 1992; 79:2520.
  34. Williams H, McAulay K, Macsween KF, et al. The immune response to primary EBV infection: a role for natural killer cells. Br J Haematol 2005; 129:266.
  35. Hjalgrim H, Askling J, Rostgaard K, et al. Characteristics of Hodgkin's lymphoma after infectious mononucleosis. N Engl J Med 2003; 349:1324.
  36. Hjalgrim H, Smedby KE, Rostgaard K, et al. Infectious mononucleosis, childhood social environment, and risk of Hodgkin lymphoma. Cancer Res 2007; 67:2382.
  37. Thacker EL, Mirzaei F, Ascherio A. Infectious mononucleosis and risk for multiple sclerosis: a meta-analysis. Ann Neurol 2006; 59:499.
  38. Poole BD, Scofield RH, Harley JB, James JA. Epstein-Barr virus and molecular mimicry in systemic lupus erythematosus. Autoimmunity 2006; 39:63.
  39. Auwaerter PG. Recent advances in the understanding of infectious mononucleosis: are prospects improved for treatment or control? Expert Rev Anti Infect Ther 2006; 4:1039.
  40. Sokal EM, Hoppenbrouwers K, Vandermeulen C, et al. Recombinant gp350 vaccine for infectious mononucleosis: a phase 2, randomized, double-blind, placebo-controlled trial to evaluate the safety, immunogenicity, and efficacy of an Epstein-Barr virus vaccine in healthy young adults. J Infect Dis 2007; 196:1749.
  41. Luzuriaga K, Sullivan JL. Infectious mononucleosis. N Engl J Med 2010; 362:1993.
  42. Hoagland RJ. Infectious mononucleosis. Prim Care 1975; 2:295.
  43. Rea TD, Russo JE, Katon W, et al. Prospective study of the natural history of infectious mononucleosis caused by Epstein-Barr virus. J Am Board Fam Pract 2001; 14:234.
  44. Peter J, Ray CG. Infectious mononucleosis. Pediatr Rev 1998; 19:276.
  45. Macsween KF, Higgins CD, McAulay KA, et al. Infectious mononucleosis in university students in the United kingdom: evaluation of the clinical features and consequences of the disease. Clin Infect Dis 2010; 50:699.
  46. Monem SA, O'Connor PF, O'Leary TG. Peritonsillar abscess and infectious mononucleosis: an association or a different presentation of the same condition. Ir Med J 1999; 92:278.
  47. Yoda K, Sata T, Kurata T, Aramaki H. Oropharyngotonsillitis associated with nonprimary Epstein-Barr virus infection. Arch Otolaryngol Head Neck Surg 2000; 126:185.
  48. Klemola E, Von Essen R, Henle G, Henle W. Infectious-mononucleosis-like disease with negative heterophil agglutination test. Clinical features in relation to Epstein-Barr virus and cytomegalovirus antibodies. J Infect Dis 1970; 121:608.
  49. Gaines H, von Sydow M, Pehrson PO, Lundbegh P. Clinical picture of primary HIV infection presenting as a glandular-fever-like illness. BMJ 1988; 297:1363.
  50. Horwitz CA, Henle W, Henle G, et al. Heterophil-negative infectious mononucleosis and mononucleosis-like illnesses. Laboratory confirmation of 43 cases. Am J Med 1977; 63:947.
  51. Steeper TA, Horwitz CA, Ablashi DV, et al. The spectrum of clinical and laboratory findings resulting from human herpesvirus-6 (HHV-6) in patients with mononucleosis-like illnesses not resulting from Epstein-Barr virus or cytomegalovirus. Am J Clin Pathol 1990; 93:776.
  52. Kawa-Ha K, Tanaka K, Inoue M, et al. Isolation of human herpesvirus 7 from a child with symptoms mimicking chronic Epstein-Barr virus infection. Br J Haematol 1993; 84:545.
  53. Auwaerter PG. Infectious mononucleosis in middle age. JAMA 1999; 281:454.
  54. Horwitz CA, Henle W, Henle G, et al. Infectious mononucleosis in patients aged 40 to 72 years: report of 27 cases, including 3 without heterophil-antibody responses. Medicine (Baltimore) 1983; 62:256.
  55. Infectious Mononucleosis, Carter RL, Penman HG (Eds), Blackwell Scientific Publication, Oxford and Edinburgh 1969. p.47-62.
  56. Aldrete JS. Spontaneous rupture of the spleen in patients with infectious mononucleosis. Mayo Clin Proc 1992; 67:910.
  57. Bartlett A, Williams R, Hilton M. Splenic rupture in infectious mononucleosis: A systematic review of published case reports. Injury 2016; 47:531.
  58. Gayer G, Zandman-Goddard G, Kosych E, Apter S. Spontaneous rupture of the spleen detected on CT as the initial manifestation of infectious mononucleosis. Emerg Radiol 2003; 10:51.
  59. Asgari MM, Begos DG. Spontaneous splenic rupture in infectious mononucleosis: a review. Yale J Biol Med 1997; 70:175.
  60. Naviglio S, Abate MV, Chinello M, Ventura A. Splenic Infarction in Acute Infectious Mononucleosis. J Emerg Med 2016; 50:e11.
  61. Schissel DJ, Singer D, David-Bajar K. Azithromycin eruption in infectious mononucleosis: a proposed mechanism of interaction. Cutis 2000; 65:163.
  62. Paily R. Quinolone drug rash in a patient with infectious mononucleosis. J Dermatol 2000; 27:405.
  63. LeClaire AC, Martin CA, Hoven AD. Rash associated with piperacillin/tazobactam administration in infectious mononucleosis. Ann Pharmacother 2004; 38:996.
  64. McCloskey GL, Massa MC. Cephalexin rash in infectious mononucleosis. Cutis 1997; 59:251.
  65. Long CM, Kerschner JE. Parotid mass: Epstein-Barr virus and facial paralysis. Int J Pediatr Otorhinolaryngol 2001; 59:143.
  66. Joki-Erkkilä VP, Hietaharju A, Numminen J, et al. Multiple cranial nerve palsies as a complication of infectious mononucleosis due to inflammatory lesion in jugular foramen. Ann Otol Rhinol Laryngol 2000; 109:340.
  67. Johns MM, Hogikyan ND. Simultaneous vocal fold and tongue paresis secondary to Epstein-Barr virus infection. Arch Otolaryngol Head Neck Surg 2000; 126:1491.
  68. Schellinger PD, Sommer C, Leithäuser F, et al. Epstein-Barr virus meningoencephalitis with a lymphoma-like response in an immunocompetent host. Ann Neurol 1999; 45:659.
  69. Tselis A, Duman R, Storch GA, Lisak RP. Epstein-Barr virus encephalomyelitis diagnosed by polymerase chain reaction: detection of the genome in the CSF. Neurology 1997; 48:1351.
  70. Marrie RA, Wolfson C, Sturkenboom MC, et al. Multiple sclerosis and antecedent infections: a case-control study. Neurology 2000; 54:2307.
  71. Hernán MA, Zhang SM, Lipworth L, et al. Multiple sclerosis and age at infection with common viruses. Epidemiology 2001; 12:301.
  72. Devereaux CE, Bemiller T, Brann O. Ascites and severe hepatitis complicating Epstein-Barr infection. Am J Gastroenterol 1999; 94:236.
  73. Ghosh A, Ghoshal UC, Kochhar R, et al. Infectious mononucleosis hepatitis: report of two patients. Indian J Gastroenterol 1997; 16:113.
  74. Chen J, Konstantinopoulos PA, Satyal S, et al. Just another simple case of infectious mononucleosis? Lancet 2003; 361:1182.
  75. Kottanattu L, Lava SA, Helbling R, et al. Pancreatitis and cholecystitis in primary acute symptomatic Epstein-Barr virus infection - Systematic review of the literature. J Clin Virol 2016; 82:51.
  76. Lei PS, Lowichik A, Allen W, Mauch TJ. Acute renal failure: unusual complication of Epstein-Barr virus-induced infectious mononucleosis. Clin Infect Dis 2000; 31:1519.
  77. Kitayama Y, Honda S, Sugimura H. Epstein-Barr virus-related gastric pseudolymphoma in infectious mononucleosis. Gastrointest Endosc 2000; 52:290.
  78. Hudson LB, Perlman SE. Necrotizing genital ulcerations in a premenarcheal female with mononucleosis. Obstet Gynecol 1998; 92:642.
  79. Avgil M, Diav-Citrin O, Shechtman S, et al. Epstein-Barr virus infection in pregnancy--a prospective controlled study. Reprod Toxicol 2008; 25:468.
  80. Avgil M, Ornoy A. Herpes simplex virus and Epstein-Barr virus infections in pregnancy: consequences of neonatal or intrauterine infection. Reprod Toxicol 2006; 21:436.
  81. Horwitz CA, Moulds J, Henle W, et al. Cold agglutinins in infectious mononucleosis and heterophil-antibody-negative mononucleosis-like syndromes. Blood 1977; 50:195.
  82. Maquiera E, Yañez S, Fernández L, et al. Mononucleosis-like illness as a manifestation of carbamazepine-induced anticonvulsant hypersensitivity syndrome. Allergol Immunopathol (Madr) 1996; 24:87.
  83. Lupton JR, Figueroa P, Tamjidi P, et al. An infectious mononucleosis-like syndrome induced by minocycline: a third pattern of adverse drug reaction. Cutis 1999; 64:91.
  84. Brown M, Schubert T. Phenytoin hypersensitivity hepatitis and mononucleosis syndrome. J Clin Gastroenterol 1986; 8:469.
  85. Hurt C, Tammaro D. Diagnostic evaluation of mononucleosis-like illnesses. Am J Med 2007; 120:911.e1.
  86. Ebell MH. Epstein-Barr virus infectious mononucleosis. Am Fam Physician 2004; 70:1279.
  87. Ebell MH, Call M, Shinholser J, Gardner J. Does This Patient Have Infectious Mononucleosis?: The Rational Clinical Examination Systematic Review. JAMA 2016; 315:1502.
  88. Brigden ML, Au S, Thompson S, et al. Infectious mononucleosis in an outpatient population: diagnostic utility of 2 automated hematology analyzers and the sensitivity and specificity of Hoagland's criteria in heterophile-positive patients. Arch Pathol Lab Med 1999; 123:875.
  89. Axelrod P, Finestone AJ. Infectious mononucleosis in older adults. Am Fam Physician 1990; 42:1599.
  90. Seitanidis B. A comparison of the Monospot with the Paul-Bunnell test in infectious mononucleosis and other diseases. J Clin Pathol 1969; 22:321.
  91. Basson V, Sharp AA. Monospot: a differential slide test for infectious mononucleosis. J Clin Pathol 1969; 22:324.
  92. Linderholm M, Boman J, Juto P, Linde A. Comparative evaluation of nine kits for rapid diagnosis of infectious mononucleosis and Epstein-Barr virus-specific serology. J Clin Microbiol 1994; 32:259.
  93. Schumacher HR, Austin RM, Stass SA. False-positive serology in infectious monoucleosis. Lancet 1979; 1:722.
  94. Marshall-Andon T, Heinz P. How to use … the Monospot and other heterophile antibody tests. Arch Dis Child Educ Pract Ed 2017; 102:188.
  95. Tetrault G. Infections in heterophile-negative patients. Arch Pathol Lab Med 2001; 125:858.
  96. Bruu AL, Hjetland R, Holter E, et al. Evaluation of 12 commercial tests for detection of Epstein-Barr virus-specific and heterophile antibodies. Clin Diagn Lab Immunol 2000; 7:451.
  97. Obel N, Høier-Madsen M, Kangro H. Serological and clinical findings in patients with serological evidence of reactivated Epstein-Barr virus infection. APMIS 1996; 104:424.
  98. Bhaduri-McIntosh S, Landry ML, Nikiforow S, et al. Serum IgA antibodies to Epstein-Barr virus (EBV) early lytic antigens are present in primary EBV infection. J Infect Dis 2007; 195:483.
  99. Weinberger B, Plentz A, Weinberger KM, et al. Quantitation of Epstein-Barr virus mRNA using reverse transcription and real-time PCR. J Med Virol 2004; 74:612.
  100. Fafi-Kremer S, Brengel-Pesce K, Barguès G, et al. Assessment of automated DNA extraction coupled with real-time PCR for measuring Epstein-Barr virus load in whole blood, peripheral mononuclear cells and plasma. J Clin Virol 2004; 30:157.
  101. Pitetti RD, Laus S, Wadowsky RM. Clinical evaluation of a quantitative real time polymerase chain reaction assay for diagnosis of primary Epstein-Barr virus infection in children. Pediatr Infect Dis J 2003; 22:736.
  102. Evans AS. Infectious mononucleosis and related syndromes. Am J Med Sci 1978; 276:325.
  103. Cameron D, MacBean LM. A clinical study of infectious mononucleosis and toxoplasmosis, Williams & Wilkins, Baltimore 1973. p.18.
  104. Thami GP, Kanwar AJ, Goyal A. Heterophil negative infectious mononucleosis like syndrome due to hepatitis B virus. J Assoc Physicians India 2000; 48:921.
  105. Niu MT, Stein DS, Schnittman SM. Primary human immunodeficiency virus type 1 infection: review of pathogenesis and early treatment intervention in humans and animal retrovirus infections. J Infect Dis 1993; 168:1490.
  106. Rosenberg ES, Caliendo AM, Walker BD. Acute HIV infection among patients tested for mononucleosis. N Engl J Med 1999; 340:969.
  107. Vidrih JA, Walensky RP, Sax PE, Freedberg KA. Positive Epstein-Barr virus heterophile antibody tests in patients with primary human immunodeficiency virus infection. Am J Med 2001; 111:192.
  108. Walensky RP, Rosenberg ES, Ferraro MJ, et al. Investigation of primary human immunodeficiency virus infection in patients who test positive for heterophile antibody. Clin Infect Dis 2001; 33:570.
  109. Klemola E, Kääriäinen L. Cytomegalovirus as a possible cause of a disease resembling infectious mononucleosis. Br Med J 1965; 2:1099.
  110. Jordan MC, Rousseau W, Stewart JA, et al. Spontaneous cytomegalovirus mononucleosis. Clinical and laboratory observations in nine cases. Ann Intern Med 1973; 79:153.
  111. Straus SE. The chronic mononucleosis syndrome. J Infect Dis 1988; 157:405.
  112. Okano M, Kawa K, Kimura H, et al. Proposed guidelines for diagnosing chronic active Epstein-Barr virus infection. Am J Hematol 2005; 80:64.
  113. Kimura H, Morishima T, Kanegane H, et al. Prognostic factors for chronic active Epstein-Barr virus infection. J Infect Dis 2003; 187:527.
  114. Tynell E, Aurelius E, Brandell A, et al. Acyclovir and prednisolone treatment of acute infectious mononucleosis: a multicenter, double-blind, placebo-controlled study. J Infect Dis 1996; 174:324.
  115. Rezk E, Nofal YH, Hamzeh A, et al. Steroids for symptom control in infectious mononucleosis. Cochrane Database Syst Rev 2015; :CD004402.
  116. Wohl DL, Isaacson JE. Airway obstruction in children with infectious mononucleosis. Ear Nose Throat J 1995; 74:630.
  117. Thompson SK, Doerr TD, Hengerer AS. Infectious mononucleosis and corticosteroids: management practices and outcomes. Arch Otolaryngol Head Neck Surg 2005; 131:900.
  118. van der Horst C, Joncas J, Ahronheim G, et al. Lack of effect of peroral acyclovir for the treatment of acute infectious mononucleosis. J Infect Dis 1991; 164:788.
  119. Torre D, Tambini R. Acyclovir for treatment of infectious mononucleosis: a meta-analysis. Scand J Infect Dis 1999; 31:543.
  120. Kinderknecht JJ. Infectious mononucleosis and the spleen. Curr Sports Med Rep 2002; 1:116.
  121. Johnson MA, Cooperberg PL, Boisvert J, et al. Spontaneous splenic rupture in infectious mononucleosis: sonographic diagnosis and follow-up. AJR Am J Roentgenol 1981; 136:111.
  122. Maki DG, Reich RM. Infectious mononucleosis in the athlete. Diagnosis, complications, and management. Am J Sports Med 1982; 10:162.
  123. Haines JD Jr. When to resume sports after infectious mononucleosis. How soon is safe? Postgrad Med 1987; 81:331.
  124. Friman G, Wesslén L. Special feature for the Olympics: effects of exercise on the immune system: infections and exercise in high-performance athletes. Immunol Cell Biol 2000; 78:510.
  125. Auwaerter PG. Infectious mononucleosis: return to play. Clin Sports Med 2004; 23:485.
  126. Tamayo SG, Rickman LS, Mathews WC, et al. Examiner dependence on physical diagnostic tests for the detection of splenomegaly: a prospective study with multiple observers. J Gen Intern Med 1993; 8:69.
  127. Ali J. Spontaneous rupture of the spleen in patients with infectious mononucleosis. Can J Surg 1993; 36:49.
  128. Dommerby H, Stangerup SE, Stangerup M, Hancke S. Hepatosplenomegaly in infectious mononucleosis, assessed by ultrasonic scanning. J Laryngol Otol 1986; 100:573.
  129. Burroughs KE. Athletes resuming activity after infectious mononucleosis. Arch Fam Med 2000; 9:1122.
  130. McIntyre OR, Ebaugh FG Jr. Palpable spleens in college freshmen. Ann Intern Med 1967; 66:301.
  131. Hosey RG, Mattacola CG, Kriss V, et al. Ultrasound assessment of spleen size in collegiate athletes. Br J Sports Med 2006; 40:251.
  132. Waninger KN, Harcke HT. Determination of safe return to play for athletes recovering from infectious mononucleosis: a review of the literature. Clin J Sport Med 2005; 15:410.
  133. Noffsinger J. Physical activity considerations in children and adolescents with viral infections. Pediatr Ann 1996; 25:585.
  134. Buchwald DS, Rea TD, Katon WJ, et al. Acute infectious mononucleosis: characteristics of patients who report failure to recover. Am J Med 2000; 109:531.
  135. Hickie I, Davenport T, Wakefield D, et al. Post-infective and chronic fatigue syndromes precipitated by viral and non-viral pathogens: prospective cohort study. BMJ 2006; 333:575.
  136. Katz BZ, Shiraishi Y, Mears CJ, et al. Chronic fatigue syndrome after infectious mononucleosis in adolescents. Pediatrics 2009; 124:189.
  137. Petersen I, Thomas JM, Hamilton WT, White PD. Risk and predictors of fatigue after infectious mononucleosis in a large primary-care cohort. QJM 2006; 99:49.
  138. Vernon SD, Whistler T, Cameron B, et al. Preliminary evidence of mitochondrial dysfunction associated with post-infective fatigue after acute infection with Epstein Barr virus. BMC Infect Dis 2006; 6:15.
  139. Vernon SD, Nicholson A, Rajeevan M, et al. Correlation of psycho-neuroendocrine-immune (PNI) gene expression with symptoms of acute infectious mononucleosis. Brain Res 2006; 1068:1.
  140. White PD. What causes prolonged fatigue after infectious mononucleosis: and does it tell us anything about chronic fatigue syndrome? J Infect Dis 2007; 196:4.
  141. Jackman WT, Mann KA, Hoffmann HJ, Spaete RR. Expression of Epstein-Barr virus gp350 as a single chain glycoprotein for an EBV subunit vaccine. Vaccine 1999; 17:660.