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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.


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