What you have not heard about Mono By Mark B. Levin, M.D. and Louis J. Tesoro, M.D. The Pediatric Group, P.A., Princeton

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What we have all heard of acute Infectious Mononucleosis, or Mono, typically causes dread. None of us want our adolescent to miss a semester of school, be ostracized by their friends or be too tired to participate in life. Most people, however, have not heard the whole story! Infectious Mononucleosis, aka The Kissing Disease or Glandular Fever, may infect people at any age and is usually so benign an illness that most people do not even recognize that they have had it.

The cause of Mono is Epstein-Barr Virus (EBV). This virus is acquired through close contact with respiratory secretions from an infected individual. The name, "The Kissing Disease" reflects a common mode of transmission. Sharing utensils for eating and drinking, sharing food, water bottles and inanimate objects, such as writing implements that someone else has mouthed are also considered vectors for this virus. Prevention of spread by avoiding respiratory transmission (kissing, sharing food or eating/drinking utensils, etc.) and frequent hand-washing is imperative. Once the virus is contracted, it may take from 30 to 50 days to cause symptoms. Therefore, it is often difficult to ascertain the source of the infection for an individual. EBV is not considered contagious during this incubation period. The contagion period is about two weeks from the start of symptoms. There is no seasonal pattern of infection with EBV. Humans are the only known host for this virus and nearly all humans are infected by adulthood even without recalling having had mono.

Clinical symptoms vary from one individual to the next. The symptom that usually stirs the belief that Mono may be present is fatigue. On the other hand, the actual most common symptom is rhinitis (a runny nose) in young children. Adolescents and adults display the most adverse symptoms due to EBV infections. The combination of fever, lassitude, pharyngitis (with pus on the tonsils), enlarged lymph glands and enlarged liver and spleen is the symptom complex that gives Mono the name "Glandular Fever." EBV has been blamed as a causative agent of Chronic Fatigue Syndrome and Fibromyositis, but scientific scrutiny has refuted this claim.

Two curiosities are characteristic of EBV infections. If a person with EBV takes penicillin, a rash may often develop. The rash can lead people to mistakenly believe that they are allergic to the penicillin. Knowing that Mono is caused by a virus (and thus unresponsive to antibiotics), the temptation to institute antibiotics in such a patient (even if the symptoms are quite bothersome) must be resisted. The instances where antibiotics may be of benefit are a co-infection with streptococcal germs or a peri-tonsillar abscess. Your physician must be consulted to discern these complications. In these cases, it may be wise to use an antibiotic other than a penicillin derivative.

The other oddity of Mono is the predominance in the blood stream of cells called "monocytes." These normal blood cells are one of the body's soldiers against viral infection. Histologically, a monocyte's nucleus is one large, irregular blob. Since this shape differs from other blood cells that have multiple lobes in the nucleus, they are termed mononuclear cells. This is how the name of the disease became "mononucleosis."

Once the diagnosis is suspected by history and clinical findings, blood testing can confirm it. In adolescence and adulthood, the screening heterophile mono test (sometimes called a "monospot") is rapid and very sensitive. In preadolescence, however, the sensitivity of the test is limited. Diagnosis in this group is confirmed best by a specific antibody test called an EBV titer. This test can determine if the infection is currently present or has been acquired in the past. Contrary to folklore, an immunologically healthy person only gets Mono once. Although the virus persists indefinitely in host cells and other viruses that can mimic the symptoms of Mono, clinical relapse is not believed to occur.

As mentioned above, antibiotics have no effect on EBV, so treatment, as in other viral diseases, is aimed at relief of symptoms. Pain relievers, assurance of fluid and calorie intake and rest according to personal need are the mainstays of treatment. Forced activity does not seem to affect the course of the illness or complication rate. Likewise, forced bed rest does not ameliorate the condition or prevent complications. The one restriction that is imperative is avoidance of contact sports if the liver or spleen are enlarged. These blood-filled organs are normally protected behind the rib cage in the upper portion of the abdomen. If the spleen or liver are enlarged, an abdominal injury could cause them to rupture - a potentially life-threatening event. Once these organs recede to their normal size, contact sports may be resumed, provided the patient has the energy for this activity. Complete resolution of the lassitude associated with Mono can take several weeks. Most physicians and parents recommend devoting the energy to schoolwork before the resumption of sports.

Once the diagnosis is confirmed, oral corticosteroids may be used in special circumstances. This therapy does not cure the disease or shorten its course, but can have a salutatory effect on some of the clinical findings of Mono. Corticosteroids should only be given after careful consideration by the patient's physician. Mild symptoms of Mono do not justify the potential side effects of cortisone therapy.

Dr. Mark B. Levin 

Dr. Levin has been a member of the staff at The Pediatric Group since 1977. Currently an attending Pediatrician at the Medical Center at Princeton, he has been Chairman, Department of Pediatrics, Medical Center at Princeton, 1984 to 1986, 1989 to 1992, and past President, Medical and Dental Staff, Medical Center at Princeton, 1987 to 1988. Dr. Levin has served on numerous Departmental and hospital committees. He has published original articles both while at Upstate Medical Center in Syracuse and at The Pediatric Group. He has a wife and three children. Dr. Levin enjoys alpine skiing, jogging, hiking and camping, travel, computers and racquetball.

Dr. Louis J. Tesoro

Dr. Tesoro has been a member of the staff at The Pediatric Group since 1988. Dr. Tesoro is Attending Pediatrician, Medical Center at Princeton, 1988 to present. He has served on several Departmental and hospital committees and was Chairman, Department of Pediatrics, Medical Center at Princeton from 1996 - 2000. He has lectured at the Universiy of Pennsylvania and has published original articles both while at The Children's Hospital of Philadelphia and at The Pediatric Group.

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