When should I consider referring a patient with glandular fever for specialist evaluation?

For a patient with a suspected or confirmed diagnosis of glandular fever, you should consider referring for specialist evaluation in several scenarios, ranging from emergency admissions to urgent reviews for complications or persistent symptoms.

• Arrange emergency hospital admission if the patient has signs of upper airway obstruction, such as stridor and respiratory distress ¹,². This includes suspected upper airway obstruction with symptoms like stridor, signs of superior vena cava obstruction, or dysphagia with aspiration ³.
• Arrange emergency hospital admission if the patient has signs of severe dehydration that cannot be managed in primary care ¹,². This may include extreme tonsillar hypertrophy and dehydration ².
• Arrange emergency hospital admission if there is a suspected serious or life-threatening complication, such as peritonsillar abscess, splenic rupture, or sepsis ¹,².

Advise the patient to seek urgent medical review if they develop clinical features of a potentially serious complication, such as:

• Signs of upper airway obstruction ¹,².
• Difficulty swallowing fluids or signs of severe dehydration ¹,².
• Severe systemic illness ¹,².
• Acute upper abdominal pain, which may indicate acute hepatitis or splenic rupture ¹,².

Consider specialist referral if:

• Lymphadenopathy persists or grows progressively after 7 days, as this may indicate non-infective swelling or abscess formation ³.
• Lymphadenopathy has not resolved after 2–4 weeks, in which case an urgent referral to an ear, nose, and throat (ENT) surgeon for further investigation may be appropriate ³.
• There are clinical features of a malignant primary tumour of the head and neck; arrange urgent referral using a 2-week suspected cancer pathway ³.
• There is unexplained generalised lymphadenopathy in children and young people; offer a very urgent full blood count (within 48 hours) to assess for leukaemia ³,⁴.
• There is unexplained lymphadenopathy or splenomegaly; consider arranging referral using a 2-week suspected cancer pathway to exclude a diagnosis of lymphoma, particularly for adults aged 25 years or more, or within 48 hours for children and young people up to and including 24 years of age ³,⁴.
• For children and young people with unexplained lymphadenopathy or splenomegaly accompanied by fever, night sweats, pruritus, or weight loss, consider a very urgent referral (within 48 hours) for specialist assessment for non-Hodgkin's lymphoma or Hodgkin's lymphoma ⁴.
• For children and young people with persistent fatigue, unexplained fever, or unexplained persistent infection, offer a very urgent full blood count (within 48 hours) to assess for leukaemia ⁴.