Editing Infectious mononucleosis (section)

==Signs and symptoms==
[[File:Main symptoms of Infectious mononucleosis.png|thumb|upright=1.3|Main symptoms of infectious mononucleosis<ref name=MedicineNet2011>{{cite web|last1=Stöppler|first1=Melissa Conrad|title=Infectious Mononucleosis (Mono)|editor1-last=Shiel|editor1-first=William C. Jr.|url=http://www.medicinenet.com/infectious_mononucleosis/article.htm|work=[[MedicineNet]]|publisher=medicinenet.com|access-date=18 June 2013|date=7 September 2011|url-status=live|archive-url=https://web.archive.org/web/20130618184041/http://www.medicinenet.com/infectious_mononucleosis/article.htm|archive-date=18 June 2013}}</ref>]]
[[File:Mononucleosis.JPG|upright=1.3|thumb|[[Exudative]] [[pharyngitis]] in a person with infectious mononucleosis]]
[[File:Cross Reaction Rash.JPG|thumb|upright=1.3|alt=Cross reaction rash|Rash from using penicillin while infected with IM<ref name=Harrison/>]]
[[File:Rash of amoxicillin use during EBV infection.jpg|thumb|alt=Maculopapular rash from amoxicillin use during EBV infection|Maculopapular rash from amoxicillin use during EBV infection]]
The [[Medical sign|sign]]s and [[symptoms]] of infectious mononucleosis vary with age.

===Children===
Before puberty, the disease typically only produces [[flu]]-like symptoms, if any at all.<ref>{{Cite journal |last1=Sumaya |first1=C. V. |last2=Ench |first2=Y. |date=June 1985 |title=Epstein-Barr virus infectious mononucleosis in children. I. Clinical and general laboratory findings |url=https://pubmed.ncbi.nlm.nih.gov/2987784/#:~:text=Children%20with%20infectious%20mononucleosis,%20in,been%20reported%20in%20adult%20patients. |journal=Pediatrics |volume=75 |issue=6 |pages=1003–1010 |doi=10.1542/peds.75.6.1003 |issn=0031-4005 |pmid=2987784}}</ref> When found, symptoms tend to be similar to those of common [[sore throat|throat infections]] (mild [[pharyngitis]], with or without [[tonsillitis]]).<ref name=Harrison/>

===Adolescents and young adults===
In [[adolescence]] and young adulthood, the disease presents with a characteristic triad:<ref name=Cohen2005>{{cite book|last=Cohen|first=Jeffrey I.|title=Epstein-Barr Virus|year=2005|publisher=Horizon Scientific Press|isbn=978-1-904455-03-5|pages=35–42|chapter-url=https://books.google.com/books?id=TRO-wXto8hcC&q=epstein-barr+jeffrey+I.+cohen+abstract|editor=Robertson, Erle S.|access-date=18 June 2013|chapter=Clinical Aspects of Epstein-Barr Infection|url-status=live|archive-url=https://web.archive.org/web/20140224131627/http://books.google.com/books?id=TRO-wXto8hcC&printsec=frontcover#v=onepage&q=epstein-barr%20jeffrey%20I.%20cohen%20abstract&f=false|archive-date=24 February 2014}}</ref>
* [[Fever]]&nbsp;–&nbsp;usually lasting 14 days;<ref>{{cite book|last1=Cohen|first1=Jonathan|last2=Powderly|first2=William G.|last3=Opal|first3=Steven M.|title=Infectious Diseases|date=2016|publisher=Elsevier Health Sciences|isbn=978-0-7020-6338-1|page=79|url=https://books.google.com/books?id=Dhq3DAAAQBAJ&pg=PA79|language=en|url-status=live|archive-url=https://web.archive.org/web/20170911003200/https://books.google.com/books?id=Dhq3DAAAQBAJ&pg=PA79|archive-date=2017-09-11}}</ref> often mild.<ref name=Harrison/>
* [[acute pharyngitis|Sore throat]]&nbsp;–&nbsp;usually severe for 3–5 days, before resolving in the next 7–10 days.<ref>{{cite book|last1=Bennett|first1=John E.|last2=Dolin|first2=Raphael|last3=Blaser|first3=Martin J.|title=Principles and Practice of Infectious Diseases|date=2014|publisher=Elsevier Health Sciences|isbn=978-1-4557-4801-3|page=1760|url=https://books.google.com/books?id=BseNCgAAQBAJ&pg=PA1760|language=en|url-status=live|archive-url=https://web.archive.org/web/20170911003200/https://books.google.com/books?id=BseNCgAAQBAJ&pg=PA1760|archive-date=2017-09-11}}</ref>
* [[lymphadenopathy|Swollen glands]]&nbsp;–&nbsp; mobile; usually located around the back of the neck (posterior [[cervical lymph nodes]]) and sometimes throughout the body.<ref name=JAMA2016/><ref name=Harrison/><ref name="Benign lymphadenopathy">{{cite journal |last1=Weiss |first1=LM|last2=O'Malley|first2=D|title=Benign lymphadenopathies|journal=Modern Pathology|volume=26 |issue=Supplement 1 |pages=S88–S96 |year=2013|pmid=23281438|doi=10.1038/modpathol.2012.176|doi-access=free}}</ref>

Another major symptom is [[Fatigue (medical)|feeling tired]].<ref name=CDC2014Eb/> [[Headache]]s are common, and [[abdominal pain]]s with [[nausea]] or [[vomiting]] sometimes also occur.<ref name=Cohen2005/> Symptoms most often disappear after about 2–4 weeks.<ref name=CDC2014Eb/><ref name=Johannsen2009/> However, fatigue and a general feeling of being unwell ([[malaise]]) may sometimes last for months.<ref name=Harrison/> Fatigue lasts more than one month in an estimated 28% of cases.<ref>{{cite book|last1=Robertson|first1=Erle S.|title=Epstein-Barr Virus|date=2005|publisher=Horizon Scientific Press|isbn=978-1-904455-03-5|page=36|url=https://books.google.com/books?id=TRO-wXto8hcC&pg=PA36|language=en|url-status=live|archive-url=https://web.archive.org/web/20170911003200/https://books.google.com/books?id=TRO-wXto8hcC&pg=PA36|archive-date=2017-09-11}}</ref> Mild fever, swollen neck glands and [[Myalgia|body aches]] may also persist beyond 4 weeks.<ref name=Harrison/><ref name=Luzuriaga2010>{{cite journal|last=Luzuriaga|first=K|author2=Sullivan, JL|title=Infectious mononucleosis|journal=The New England Journal of Medicine|date=May 27, 2010|volume=362|issue=21|pages=1993–2000|pmid=20505178|doi=10.1056/NEJMcp1001116}}</ref><ref name=Ebell2004/> Most people are able to resume their usual activities within 2–3 months.<ref name=Luzuriaga2010/>

The most prominent sign of the disease is often [[pharyngitis]], which is frequently accompanied by [[tonsillitis|enlarged tonsils]] with [[pus]]—an [[exudate]] similar to that seen in cases of [[strep throat]].<ref name=Harrison/> In about 50% of cases, small reddish-purple spots called [[petechia]]e can be seen on the [[roof of the mouth]].<ref name=Ebell2004>{{cite journal | author = Ebell MH | title = Epstein-Barr virus infectious mononucleosis | journal = American Family Physician | volume = 70 | issue = 7 | pages = 1279–87 |date=November 2004| pmid = 15508538}}</ref> Palatal [[enanthem]] can also occur, but is relatively uncommon.<ref name=Harrison/>

A small minority of people spontaneously present a [[rash]], usually on the arms or trunk, which can be [[macular]] ([[morbilliform]]) or [[papule|papular]].<ref name=Harrison/> Almost all people given [[amoxicillin]] or [[ampicillin]] eventually develop a generalized, itchy maculopapular rash, which however does not imply that the person will have [[adverse reaction]]s to [[penicillin]]s again in the future.<ref name=Harrison/><ref name=Johannsen2009>{{cite book|last=Johannsen|first=EC|title=Mandell, Douglas, and Bennett's principles and practice of infectious disease|year=2009|publisher=Churchill Livingstone|location=Philadelphia|isbn=978-0-443-06839-3|edition=7th|author2=Kaye, KM|editor=Mandell, GL |editor2=Bennett, JE |editor3=Dolin, R|chapter=Epstein-Barr virus (infectious mononucleosis, Epstein-Barr virus-associated malignant disease, and other diseases)}}</ref> Occasional cases of [[erythema nodosum]] and [[erythema multiforme]] have been reported.<ref name=Harrison/> Seizures may also occasionally occur.<ref>{{cite book|last1=Shorvon|first1=Simon D.|last2=Andermann|first2=Frederick|last3=Guerrini|first3=Renzo|title=The Causes of Epilepsy: Common and Uncommon Causes in Adults and Children|date=2011|publisher=Cambridge University Press|isbn=978-1-139-49578-3|page=470|url=https://books.google.com/books?id=BUs-AYMBbC0C&pg=PA470|language=en|url-status=live|archive-url=https://web.archive.org/web/20180104013750/https://books.google.ca/books?id=BUs-AYMBbC0C&pg=PA470|archive-date=2018-01-04}}</ref>

===Complications===
[[Splenomegaly|Spleen enlargement]] is common in the second and third weeks, although this may not be apparent on [[physical examination]]. Rarely the spleen may rupture.<ref>{{cite web | title = Infectious Mononucleosis | date = 19 November 2019 | publisher = Johns Hopkins Medicine | url = https://www.hopkinsmedicine.org/health/conditions-and-diseases/infectious-mononucleosis | access-date = 23 Sep 2020 | archive-date = 15 August 2020 | archive-url = https://web.archive.org/web/20200815055115/https://www.hopkinsmedicine.org/health/conditions-and-diseases/infectious-mononucleosis | url-status = live }}</ref> There may also be some [[Hepatomegaly|enlargement of the liver]].<ref name=Ebell2004/> [[Jaundice]] occurs only occasionally.<ref name=Harrison/><ref>{{cite journal|last1=Evans|first1=Alfred S.|title=Liver involvement in infectious mononucleosis|journal=Journal of Clinical Investigation|date=1 January 1948|volume=27|issue=1|pages=106–110|doi=10.1172/JCI101913|pmc=439479|pmid=16695521}}</ref>

It generally gets better on its own in people who are otherwise healthy.<ref name="pmid29885408"/> When caused by EBV, infectious mononucleosis is classified as one of the [[Epstein–Barr virus–associated lymphoproliferative diseases]]. Occasionally the disease may persist and result in a chronic infection. This may develop into systemic EBV-positive T cell [[lymphoma]].<ref name="pmid29885408">{{cite journal | vauthors = Rezk SA, Zhao X, Weiss LM | title = Epstein-Barr virus (EBV)-associated lymphoid proliferations, a 2018 update | journal = Human Pathology | volume = 79 | pages = 18–41 | date = September 2018 | pmid = 29885408 | doi = 10.1016/j.humpath.2018.05.020 | s2cid = 47010934 }}</ref>

===Older adults===
Infectious mononucleosis mainly affects younger adults.<ref name=Harrison/> When older adults do catch the disease, they less often have characteristic signs and symptoms such as the sore throat and lymphadenopathy.<ref name=Harrison/><ref name=Ebell2004/> Instead, they may primarily experience prolonged fever, fatigue, malaise and body pains.<ref name=Harrison/> They are more likely to have liver enlargement and [[jaundice]].<ref name=Ebell2004/> People over 40 years of age are more likely to develop serious illness.<ref name=Odumade2011/>

===Incubation period===
The exact length of [[incubation period|time between infection and symptoms]] is unclear. A review of the literature made an estimate of 33–49 days.<ref name=Richardson2001>{{cite journal|last=Richardson|first=M|author2=Elliman, D |author3=Maguire, H |author4=Simpson, J |author5= Nicoll, A |title=Evidence base of incubation periods, periods of infectiousness and exclusion policies for the control of communicable diseases in schools and preschools|journal=The Pediatric Infectious Disease Journal|date=April 2001|volume=20|issue=4|pages=380–91|pmid=11332662|doi=10.1097/00006454-200104000-00004|s2cid=7700827}}</ref> In adolescents and young adults, symptoms are thought to appear around 4–6 weeks after initial infection.<ref name=Harrison>{{cite book |last=Cohen|first=Jeffrey I.| veditors=Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL, Loscalzo J |title=Harrison's principles of internal medicine |pages=380–91|publisher=McGraw-Hill Medical Publishing Division |location=New York |year=2008 |edition=17th |chapter=Epstein-Barr Infections, Including Infectious Mononucleosis|isbn=978-0-07-146633-2}}</ref> Onset is often gradual, though it can be abrupt.<ref name=Odumade2011>{{cite journal | vauthors = Odumade OA, Hogquist KA, Balfour HH | title = Progress and problems in understanding and managing primary Epstein-Barr virus infections | journal = Clin. Microbiol. Rev. | volume = 24 | issue = 1 | pages = 193–209 | date = January 2011 | pmid = 21233512 | pmc = 3021204 | doi = 10.1128/CMR.00044-10 }}</ref> The main symptoms may be [[prodrome|preceded]] by 1–2 weeks of fatigue, feeling unwell and body aches.<ref name=Harrison/>