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Does glandular fever relapse or cause a chronic illness?

Dr Gavin Spickett, consultant clinical immunologist, Royal Victoria Infirmary, Newcastle upon Tyne

Normally Epstein-Barr virus (EBV) infection leads to a self-limiting, and sometimes inapparent, disease that resolves spontaneously over three to six weeks, although the initial infection can be severe and can in rare cases lead to neurological complications (Guillain Barré syndrome, encephalitis), acute hepatitis, autoimmune thrombocytopenia and haemolytic anaemia.

Once infected, the patient remains infected for life in a chronic asymptomatic carrier state, shedding virus intermittently in pharyngeal secretions and hence remaining infective lifelong. Reactivation of the infection may occur, with increased viral shedding and a rise in antibody titres. Prolonged mal-aise may be reported for up to six months even in patients with no evidence of abnormal serological responses.

Chronic active EBV infection is reported, with a severe illness usually lasting untreated for six or more months, usually characterised by recurrent pyrexias, hepatitis and other organ damage. The serological markers show high levels of antibody to early antigen (EA) and viral capsid antigen (VCA) but no antibody to Epstein Barr Virus Nuclear Antigen (EBNA).

There may be persistence of IgM anti-EBV antibodies beyond the normal three-month period. This is rare (one in 2,000 cases of EBV infection), and reflects a very abnormal immunological response to EBV. Similar problems may be seen in the genetic primary immunodeficiency, X-linked lymphoprolifer- ative (Duncan's) syndrome, due to deficiency of SAP protein, and in patients who are seriously immunosuppressed, for example AIDS patients, bone marrow transplant patients, and solid organ transplant patients.

In these conditions, EBV-driven lymphoproliferation is seen. This is usually due to the escape of the patient's own virus from immunological control. A past history of EBV infection is also a risk factor for Hodgkin's disease, where the characteristic Reed-Sternberg cells can be shown to be EBV+.

Where there is serological and virological evidence of ongoing viral activity, with an abnormal humoral response, treatment with aciclovir in high doses (up to 800mg five times daily orally) may be tried with suitable monitoring of liver and renal function. Adequate hydration is essential.

Chronic EBV (or CMV/toxoplasma) infection is often blamed for chronic fatigue syndrome (post-viral syndrome).

Glandular fever usually resolves completely but sometimes there are

long-term complications

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