The classic initial presentation of mononucleosis include: fever, lymphadenopathy, pharyngitis, rash and/or periorbital oedema. Occasionally, patients infected with EBV may also display splenomegaly, with subsequent life-threatening complication of splenic rupture and/or hepatomegaly.

• Bradycardia is a rare and inconsistent finding

• Maculopapular rash which is generalized, non-itchy, faint and disappears rapidly may be observed during the early phase of the disease.

• Jaundice: varies with the age of presentation. Among young adults with mono ~5% of cases present with jaundice; however, among the elderly age group, ~30% present with anicteric viral hepatitis

• Anemia is uncommon, even though EBV infection induces antibodies to RBC-membranes

• Hoagland sign: Transient bilateral supra-orbital oedema that is observed during the early stages of infection.

• Tender lymphadenopathy is present; in particular, the posterior cervical lymph nodes on both sides of the neck are involved.

• Pharyngitis secondary to mono may be either be exudative or non-exudative. Either type of pharyngitis is colonized by group A strep.

• White patches may also observed in the tonsils associated with massive tonsilar enlargement which may lead to fatal airway obstruction.

• Petechial hemorrhages may be observed in the posterior oropharynx; particularly involving the palate.

• Tender splenomegaly is a late-feature. Following recovery from initial illness, spleen returns to normal or near normal size.
• Hepatomegaly

• The course of the disease can also be chronic presenting with chronic fatigue syndrome which is a variant of mononucleosis. However, the findings need to be present for months or years to be classified as chronic EBV syndrome or chronic fatigue syndrome.

• Physical findings include:

• Significantly lower level of activity in comparison to baseline
• Impaired cognitive dysfunction,
• Tender cervical or axillary lymph nodes

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