The rash

The rash of EBM is almost always related to antibiotics given for tonsillitis. The primary rash, most often non-specific, pinkish and maculopapular (similar to that of rubella), occurs in about 5% of cases only.

The secondary rash is most often precipitated by one of the penicillins, especially ampicillin or amoxycillin. About 90-100% of patients prescribed ampicillin or amoxycillin will be affected; up to 50% of those given penicillin will develop the rash. It can be extensive and sometimes has a purplish tinge. The complications of EB mononucleosis are presented in Table 25.3 and the differential diagnoses in Table 25.4.

Laboratory diagnosis

The following confirm the diagnosis of EB mononucleosis.

• White cell count shows absolute lymphocytosis.

• Blood film shows atypical lymphocytes.

• Paul Bunnell test for heterophil antibody is positive (although positivity can be delayed or absent in 10% of cases).

• Diagnosis confirmed (if necessary) by EBV- specific antibodies, viral capsule antigen (VCA) antibodies—IgM, IgG.

Table 25.3 Complications of EB mononucleosis 1


• antibiotic-induced skin rash

• prolonged debility

• depression



• myocarditis

• pericarditis


• agranulocytosis

• haemolytic anaemia


Respiratory tract

• upper airway obstruction (lymphoid hypertrophy)


• ruptured spleen


• cranial nerve palsies, especially facial palsy

• Guillain-Barre syndrome

• meningoencephalitis

• transverse myelitis

Source: World Health Organisation 1995 figures Table 25.4 Differential diagnoses of EB mononucleosis 1

Other agents that cause typical EBM syndrome

• HIV infection (acute initial illness)


• toxoplasmosis

Exudative tonsillitis resembling EBM

• acute streptococcal pharyngitis

• adenovirus infection

• diphtheria (unlikely in Australia)

Hepatitis A,B,C,D,E

Lymphadenopathy, fever and splenomegaly

Complications of EBM without other manifestations

• encephalitis


• drug reaction

Source: World Health Organisation 1995 figures

However culture for Epstein-Barr virus and tests for specific virus antibodies are not done routinely. False positives for Paul Bunnell test:


• Hodgkin's disease

• acute leukaemia


EBM usually runs an uncomplicated course over 6-8 weeks. Major symptoms subside within 2-3 weeks. Patients should be advised to take about 4 weeks off work.


• supportive measures (no specific treatment)

• rest (the best treatment) during the acute stage, preferably at home and indoors

• aspirin or paracetamol to relieve discomfort

• gargle soluble aspirin or 30% glucose to soothe the throat

• advise against alcohol, fatty foods, continued activity especially contact sports (risk of splenic rupture)

• ensure adequate hydration

• corticosteroids for:

o neurological involvement o thrombocytopenia o threatened airway obstruction

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