Infectious Mononucleosis (Mono, Kissing Disease, Glandular Fever)

A Disease That Can Be Transmitted Through Kissing - Mono

Infectious Mononucleosis, IM, Mono, Kissing Disease, Glandular Fever

Infectious Mononucleosis (IM, mono, Pfeiffer's disease, Filatov's disease, kissing disease), known as kissing disease or a disease that can be transmitted by kissing, is a disease caused by the Epstein-Barr Virus (EBV). Another name is "glandular fever". EBV causes infections by being transmitted from person to person primarily through close contact with oral, throat fluids and body secretions and is usually seen frequently in childhood. It is called "kissing disease" because it is most commonly transmitted from mouth to saliva. Depending on the disease, lymphadenopathies in the neck, which can reach larger sizes than other upper respiratory tract infections, can occur, and this situation can scare families as if it were a cancerous disease. It usually occurs frequently in children and adolescents, but can be seen at any age. Many people get kissing disease around the age of 1. Since the disease can progress with very mild symptoms in young children, it may not be noticed by families and in most cases, it cannot be diagnosed. Since permanent immunity occurs once the disease is passed, it does not recur throughout life. People with kissing disease usually have symptoms such as high fever, painful swollen lymph nodes in the neck and under the jaw, and sore throat. While the symptoms are similar to a simple upper respiratory tract infection, the resulting lymph node enlargement in the neck can be large and can sometimes be alarming for families. Some patients may develop an enlarged spleen, and spleen problems may occur during sports injuries. Clinically, the symptoms are mild in most patients, and the symptoms completely disappear within 1-2 months.

What is kissing disease?

Kissing disease is an infectious disease transmitted through body secretions in the mouth caused by the Epstein-Barr virus (EBV). It is also called infectious mononucleosis, glandular fever, or simply mono disease. The active virus is often spread through saliva during kissing, which is why it is called "kissing disease". The disease is most common in children and young adults. Blood tests can be used to determine whether people who have this disease have it. Most patients have symptoms that gradually decrease over a period of up to 1 month. In general, symptomatic supportive treatment, nutrition that will increase body resistance, and rest are recommended for treatment.

What causes kissing disease?

Infectious Mononucleosis, IM, Mono, Kissing Disease, Glandular Fever
Kissing disease is caused by an Epstein-Barr virus (EBV). EBV is a member of the herpes virus family, which also includes the herpes virus, also known as the cold sore virus. This virüs is a γ-herpesvirus that infects at least 90% of the population worldwide. The EBV virus is spread through direct contact with body fluids, such as the mouth and blood of an infected person. Mononucleosis can also be transmitted through sexual contact and organ transplantation, which involves close body contact. Coughing, sneezing, kissing, or sharing food or drinks with someone who is infected can easily spread the virus from person to person. It can spread easily after close contact in patients who have not previously been exposed to the virus.

What are the symptoms of kissing disease?

After contact with the virus, it can take up to 4-8 weeks for the virus to infect and for symptoms to appear. In other words, if your child has quite large and slightly painful swellings on their neck, there may be someone among their schoolmates who had similar symptoms 4-8 weeks ago! This period of time between the virus that causes the disease entering the body and the symptoms of the disease starting to appear is called the incubation period. While the disease does not cause very serious symptoms in young children, it can cause obvious symptoms in 35 to 50% of patients in young people and adults. It is estimated that only 10% of children infected with EBV have obvious symptoms and are noticed by their families. In adults, the probability of having kissing disease is low due to the developing immune response, since the rate of having had this infection before is high. Most cases of infectious mononucleosis are seen in the 15-24 age group. Symptoms typically last 1-2 months, and the first symptoms often include:
  • General body malaise
  • Weakness
  • Loss of appetite
  • Chilling
  • Persistent fever
  • Sore and redness in the throat
  • Swollen tonsils
  • Swollen lymph nodes in the armpit and neck (this may be the symptom that worries families the most!)
  • Headache
  • Night sweating
If the virus infects the liver and causes enlargement, abnormalities in liver function tests and enzyme levels may be detected. In some patients, a blotchy skin rash that looks like a measles rash may appear on the body. In the early stages of the disease, which include the first few days, a temporary edema may occur in the upper eyelids.

In 1/3 of cases, the tonsils may be covered with a whitish membrane. Kissing disease can sometimes present itself with a more severe picture, with swelling in the spleen or liver. In some patients, lymphadenopathy may reach up to 7 cm in size (source >> Prevalence and Clinical Characteristics of Primary Epstein–Barr Virus Infection Among Children Presented with Cervical Lymphadenopathy). This situation may cause concern for parents of children. Lymph nodes in the neck may enlarge in simple upper respiratory tract infections and usually reach a maximum size of 25-28 mm; however, when there is a lymph node larger than these sizes, malignancy is suspected. In kissing disease, lymph node enlargements that can be confused with malignancies can be seen.

What are the risk factors for kissing disease?

Kissing disease can occur more frequently in individuals who have never been exposed to this virus and who work in crowded environments that require close physical contact. Individuals at risk for kissing disease include:
  • Young people and students between the ages of 15-30
  • Medical interns, nurses and doctors
  • Other hospital workers and caregivers
  • Patients who are taking chemotherapy or post-organ transplant medications that suppress the immune system
  • People with diseases that suppress the immune system, such as HIV or cancer
  • People who regularly work in crowded environments and are in close contact with people, such as bus drivers

Complications that can be seen due to kissing disease

Kissing disease usually does not cause permanent health problems in patients. In patients with suppressed immune systems, this disease can cause more widespread and long-lasting infection. The following complications can be seen in some patients with kissing disease:
  • Spleen enlargement (may increase the risk of spleen rupture)
  • Hepatitis (Liver inflammation, may cause increased liver enzymes and changes in liver function tests)
  • Inflammation in heart tissues (may cause heart palpitations and heart rhythm changes)
  • Anemia
  • Meningitis (Inflammation of the membranes surrounding the brain, may cause serious headaches)
These above are not seen in most patients, but, unlike simple upper respiratory tract infection, the presence of additional symptoms such as increased lymph node enlargement in the neck and liver-sac enlargement constitute the different clinical features of the disease.

How is kissing disease diagnosed?

Infectious Mononucleosis, IM, Mono, Kissing Disease, Glandular Fever
Your doctor can make a diagnosis based on symptoms of kissing disease, a physical examination, and blood tests. Although there is no specific finding that distinguishes this disease; clinically, the presence of abnormally enlarged neck lymph nodes, signs of prolonged upper respiratory tract infection, and sometimes the presence of spleen or liver enlargement may be distinctive symptoms. If patients present with acute symptoms characterized by sore throat, cervical lymphadenopathy, fever, and fatigue, infectious mononucleosis due to EBV should be suspected, especially in adolescents and young adults. If the presence of exudative pharyngitis with swelling of the uvula and tonsils is seen on oral examination; if there is periorbital and eyelid edema and symmetrical cervical and postauricular lymphadenopathy, the diagnosis can be approached further.

After a detailed physical examination and for diagnosis, blood tests are requested. In the early stages of kissing disease, an increase in the number of a type of white blood cell called lymphocytes can be seen in blood tests. Some of these increased lymphocytes appear to have an unusual appearance when examined under a microscope. These are known as atypical lymphocytes.

More specific blood tests, such as the monospot and heterophile antibody tests, may be preferred to confirm the diagnosis of mononucleosis. These tests are based on the measurement of antibodies produced by the body's immune system against EBV. However, these antibodies may not be detected until the second or third weeks of the disease. A typical clinical picture with a positive heterophile antibody test is usually sufficient to make the diagnosis, but heterophile antibodies are nonspecific and do not develop in some patients. Young children, especially those under the age of 4, may not develop a positive heterophile antibody response during primary EBV infection, and the diagnosis may be missed if specific EBV tests are not performed. A heterophile test using one of the commercially available antibody kits is often performed to support the clinical diagnosis. Although heterophile tests are the most commonly used tests to diagnose infectious mononucleosis, the US Centers for Disease Control and Prevention recently recommended against their use for “general use” because of their lack of specificity, especially in young children, and the possibility of false-negative results (Centers for Disease Control and Prevention 2014).

Treatment of  kissing disease 

Infectious Mononucleosis, IM, Mono, Kissing Disease, Glandular Fever
Although there is no specific treatment option for the disease, general supportive treatments and symptomatic medications that can be arranged according to the signs and symptoms can be used. Even if no treatment is given, the symptoms usually improve on their own within 1-2 months, even if the patient does not receive any treatment. In the event of complications or in severe cases, other medical specialists such as an infectious disease specialist, hematologist, cardiologist, gastroenterologist or neurologist may need to be involved due to the effects on other organs. In cases such as rupture of the spleen, a surgeon will undertake the treatment of the patient. Treatment is often aimed at relieving the symptoms. The following methods that can be applied at home help to speed up recovery:
  • Bed rest, limiting active exercises
  • Plenty of fluid intake by mouth
  • Use of antipyretic and anti-inflammatory drugs
  • Use of drugs to relieve sore throat
In patients with an enlarged spleen, it is necessary to avoid sports that require strong contact during the disease and recovery phase to prevent rupture of the spleen. Antibiotics are not necessary in the first place for viral infections.

The long-term prognosis is good for most patients with kissing disease, and serious complications are rare.


Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon

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