The Real Reason for Chronic Fatigue in Mono?

February 2, 2009

A recent article in the New York Times reports on the widespread incidence of mononucleosis in teens and young adults. The Epstein-Barr virus is thought to be the cause, with most Americans infected by their 30s. It’s thought that up to 50% of people infected develop severe fatigue or other symptoms. The article points out the fact that "mono," or "the kissing disease" has been trivialized due to it’s widespread nature and that trials of new drugs and vaccines are lacking.
 
My take on this article: Most people who are infected with mono experience little more than your typical cold symptoms, but there are a small, but significant number of people who suffer a variety of potentially life-threatening complications, if not extreme fatigue that can be quite debilitating. Mononucleosis infects your body’s lymphoid system, most of which are found in your lymph nodes and spleen. These lymph glands educate your body about any infections and respond appropriately by making more immune cells. As a result, the glands can swell to various degrees—sometimes, to dangerous levels. 
 
Besides the many lymph glands in your neck, your tonsils (and adenoids) are also made of lymphoid tissue. So if you are a teen or a young adult and still have relatively large tonsils, then being infected with mono will cause your tonsils to swell. 
 
As I’ve stated before, anything that causes either temporary or permanent narrowing in your throat will cause your throat structures to obstruct when you are sleeping, especially when you are on your back (due to gravity), and when in deeper levels of sleep (due to muscle relaxation). Even a simple cold can aggravate temporary sleep-breathig problems, causing you to toss and turn all night long. Once your cold goes away, you’re fine again. 
 
However, if you have larger tonsils than normal, then the enlarged tonsils will cause you to stop breathing more often, and in certain people, the vacuum effect created in the throat causes a suctioning of stomach juices into your throat, which causes more swelling. This irritates your tonsils further and the vicious cycle continues. 
 
One little appreciated piece of information is that if you have large tonsils (or eve if you’ve had your tonsils taken out), you could still have lingual tonsils remaining. Lingual tonsils are lymphoid tissue at the base of the tongue in the midline, just above your voice box. So any degree of swelling will narrow the space behind the tongue significantly. It’s also been shown recently that persistently enlarged lingual tonsils are associated with laryngopharyngeal reflux disease. 
 
I’ve also alluded to my sleep-breathing paradigm (in my book Sleep, Interrupted: A physician reveals the #1 reason why so many of us are sick and tired) where many people with sleep-breathing problems have relatively narrow jaws and dental crowding, which leads to chronic low-grade obstructions preventing deep sleep, and constant low-grade inflammation of the throat from microscopic stomach contents. 
 
In my practice, every time I see someone with severe mono, their tonsils are infected and extremely large, sometimes almost touching in the midline. Antibiotics usually don’t work (because it’s a viral infection), and in fact, is not recommended due to a potential reaction to certain antibiotics. The one medication that usually helps patients feel better is a short course of oral steroids, like prednisone. It’s thought to be due to its’ anti-inflammatory effects, significantly reducing swelling. 
 
Anytime there is inflammation in the throat, by definition, there will also be inflammation in the nose. This occurs via a combination of gastric juice regurgitation into the nose, ears and sinuses, as well as through an imbalance of the involuntary nervous system. People with narrows jaws will also have narrow nasal side-walls, since the the width of the nasal cavity follows the width of the upper jaw.
 
If there is any degree of nasal congestion, then vacuum forces are created downstream, aggravating even more throat or tongue narrowing and collapse. 
 
The well-known residual symptoms of severe chronic fatigue after mono can last from weeks to months. Sometimes, the fatigue doesn’t go away at all. Eventually, some of these people will be diagnosed with chronic fatigue syndrome. 
 
The chronic physiologic stress state that’s created can lead to metabolic and hormonal changes. For example, elevated cortisol levels due to stress can suppress thyroid function and raise glucose levels. 
 
It can even affect reproductive hormones adversely. In women, stress can suppress progesterone, elevating the estrogen to progesterone ratio. Interestingly, progesterone is known to promote upper airway muscle tone, so the lower the level of progesterone, the more your tongue is likely to fall back and obstruct, leading to less efficient sleep.
 
It’s been suggested that there are many different reasons for chronic fatigue syndrome, but upper airway narrowing due to to anatomic reasons and swelling is one logical explanation that encompasses all other explanations. Ultimately, swelling of the upper airway structures can be from anything that causes inflammation, from the common cold to allergies, to acid reflux. The tonsils are one dramatic example of swelling due to infection or inflammation, but other areas of the throat can become swollen, such as the soft palate and tongue. If you look at mono from a sleep-breathing perspective, the chronic fatigue that results sometimes makes a lot more sense.
 

27 Responses to “The Real Reason for Chronic Fatigue in Mono?”

  1. Nicholas Scott on June 8th, 2009 4:14 pm

    Alright heres my story. I was diagnosed with Mono around 2-3 years ago, and I’m not sure if I have felt right ever since. I don’t know if my fatigue is from the need for more sleep or lack of diet according to how I work out every day. When they said I had mono I didnt even know if I believed them. Because the week they told me I did they said then was the time I will experience contagious symptoms and shouldn’t go to work at least for another week or so. But the whole time I never felt any different than I did the past couple months and I thought it was bull crap when after two weeks they said I wasn’t carrying any symptoms any longer, but I still felt the same? I never had to sleep for 3 days straight or anything like that, I’ve just noticed I’ve always been tired ever since, like my body is sleepy but I’m not. It makes lifting weights a little more difficult than it should be. I’m working on my diet and trying to get at least 8-10 hours of sleep everyday. But anyways here are some facts about me. I’m an 18 year old male who gets good daily exercise and gains muscle weight, I’m improving my diet and Im wondering if I ever really had mono and if I do could it still be affecting me. I’m never satisfied with my sleep by the way, I never recouperate that groggy feeling you feel when you get up, but my mind stays active so I generally am distracted. Its not too bad Im not like walking arouind like a drunk person but I feel I deserve more energy than this.

  2. Steven Park on June 8th, 2009 6:44 pm

    Nicholas,

    Did your doctor do blood tests to confirm that you had a new case of mono? They would have tested for Epstein-Barr Virus markers. Do you have large tonsils? If so, did they get larger when you suddenly got infected?

    It’s hard to say without examining you, but since mono infects lymphoid tissues, if you have relatively large tonsils to begin with, then further enlargement of your tonsils can worsen sleep-breathing problems. By definition, you won’t be able to get deep, efficient sleep. That’s why despite sleeping up to 10 hours every day, you never feel completely refreshed. Of course there are other medical problems that can cause similar features, so you’ll need to undergo a complete physical and labwork with your medical doctor first.

    Do you eat dinner or drink alcohol close to bedtime? If so, leave 3-4 hours after either before you go to bed. Do you prefer to sleep on your side or stomach? If so, you may have a sleep-breathing problem.

    I just responded to a similar question on my forum / Ask Dr. Park area: http://doctorstevenpark.com/forum/ask-dr-park/monoallergies-and-allergic-rhinitis

    It’s an interesting discussion. Good luck on finding an answer.

  3. Darla Cross on June 29th, 2009 1:28 pm

    here’s my story. I’m 45 years old. I had my tonsils removed when I was 7. Last year I went from a very active and healthy woman to all of a sudden very weak and tired. After a possible heart attack I had an angiogram done then my kidneys started hurting and my blood sugar level started dropping into the low 30′s. I was finally diagnosed with mono. It has been almost a year in that time I have been diagnosed with chronic mono. I just had my gall bladder out 25 days ago and am still having complications and new symptoms from one thing or another. It is hard to even strip my bed and wash my bedding or clean my house. I went from working 60 to 80 hours a week and having enough energy to chasing and playing with my nieces and nephew and animals to trying to have enough energy just to take a shower. My one doctor wants me to go to an infectious disease specialist because I ran a high fever for 6 days straight and am experiencing pain in my abdomen that shouldn’t be there as well as all the fatigue. I want my life back. I am tired of hearing that it’s just mono or we can’t find anything to explain your pains. This is so old and I am still young.

  4. Steven Park on June 29th, 2009 7:45 pm

    Darla,

    Sorry to hear about all your health problems. Your situation sounds complicated. It sounds like you’re currently having issues related to your gall bladder surgery.

    In general, since you don’t have your tonsils anymore, the link between large tonsils and mono is not as important an issue. However, due to other areas of narrowing in the throat, chronic fatigue symptoms can occur. One question I have for you is this: Are you normally a side or stomach sleeper? If so, we’re you forced to sleep only on your back just after the operation? If you are normally a side or stomach sleeper, then a sleep-breathing problem can definitely aggravate whatever other problems you may currently be having. By definition, you’re also in the premenopausal age, and this is the time when your sleep quality can also begin to diminish. Do you snore? If not, do either of your parents snore heavily?

  5. Jon on July 7th, 2009 11:30 am

    Darla please read A More Excellent Way about your CFS…. I remeber just being able to take a shower a day, but I found the root to my fatigue in this book.

  6. kiara on October 13th, 2009 10:56 am

    i was diagnosed with mono around the beginning of june. Im only 16, and of course, was terrified. But when i first had it, the back of my throat was inflammed with white patches on them. I know it’s normal, but it’s been 4 months now and the inflammation still hasn’t went away (the patches have though). im wondering if anything is wrong. ive been trying to research, but nothing has came up. ive given oral sex around a month ago, and i’m wondering if this could have something to do with it. Can someone please help me. i dont know what is wrong.=(

  7. Dr. Steven Y. Park on October 13th, 2009 7:10 pm

    Klara,

    Regardless of what caused your tonsil infection, now they’re chronically swollen, which is probably preventing you from sleeping efficiently at night due to obstructed breathing. You may want to see an ENT about it.

  8. Dee on October 24th, 2009 9:28 am

    I was diagnosed with mono 8 years ago. I am 42 years old. I had my tonsils out at 22. I have never felt the same. I have had all kinds of lab work done. Every test has came back neg. I try to suck it up and do my daily activities. I feel bad all the time. I don’t want to seem like a hypochondriac. Every DR. ask me if I am depressed and want to put me on antidepressants,(which I have tried to satisfy them and they didn’t work.) I am tired all the time. I feel like I have no energy. I want to work in my yards, I want to play tennis, I want to go to the gym. There are so many things I wish I could do, But after work all I can do is come home and lay around. I was wondering is it normal for this to be happening still after 8 years. I just want to feel good again. I want my life back. I have tried everything and will try anything. I am desperate to feel better.

  9. marie on February 9th, 2010 7:26 pm

    I am a 25 year old female and i have suffer with mono for 2 years it has never left.I have taken all kinds of test and they are neg.I sleep al ay and am nausea 4 seven.what can i do .when will this mono run its course. i get plenty of rest and water.help me pleas  have 2 young kids.

  10. Steven Park on February 10th, 2010 7:43 am

    If you can’t sleep on your back, and have one or both parents that snore, you may have a sleep-breathing problem. Take a look at my book, Sleep, Interrupted, to see if what I’m describing fits your condition. If so, you may need to see a sleep specialist.

  11. Lauren on May 15th, 2011 5:25 pm

    I had mono a year and a half ago and was very sick and in bed for 4 months. After that I was so exhausted I did nothing but work 3 hours a day and come home and sleep. I am doing better now but still feel this weird “in a dream” feeling all day. I just feel dazed even after 8-9 hours of sleep and a healthy diet. I am 21 years old and a female. I was told that this daze feeling was anxiety but I do not seem to be anxious.
    Thank you.

  12. Steven Park on May 15th, 2011 5:57 pm

    Lauren,

    As I discussed in my article, anyone with your symptoms after mono should be checked for obstructive sleep apnea or large tonsils.

  13. Joe Graham on July 9th, 2011 9:46 pm

    I had a really bad case of mono when I was 17. I missed almost 3 months of school my senior year. To this day 11 years later I feel so wore out all the time. I have never had the energy levels since before I got Mono.. Is there anything I should be doing? As well as I get sick really easily seems. I get whatever going around and I get really sick. most people might the cold lasts a couple days. For me a week. Did mono somehow wreck my immune system and my energy level for the rest of my life? Should I get blood work done? Is there some kind of specialist I should be seeing? Thanks. Tired of being sick and tired.

  14. Ariel on September 28th, 2011 11:52 pm

    I am 22 years old, I have just graduated college and I have been dealing with chronic mono since i was 18. I did have to go away about 2.5 years after I was diagnosed but it came back again 6 months later with a vengeance. I have seen countless doctors and for some reason my body won’t get rid of it. I usually sleep fine it just seems that my body can’t get enough. My newest doctor put me on a bunch of supplements and vitamins and they seem to be helping a little bit. I eat very healthy, and I usually try to exercise ~5 days/week. My immunologist actually referred my to a rheumatologist cause she thinks i might have chronic fatigue. I just want to know what the outlook is for chronic mono/CFS. I’ve googled a lot but its hard to get a straight answer. Am i destined to feel this way forever?

  15. Steven Park on October 2nd, 2011 6:45 am

    In my experience, you may have upper airway resistance syndrome, which can be triggered by the EBV virus that causes enlarged tonsils. With persistently enlarged tonsils, your upper airway may be narrowed, preventing you from getting deep sleep. You may consider seeing an ENT physician about this. Good luck.

  16. Kendra on February 20th, 2012 8:01 pm

    So far I feel like you’re the only doctor actually addressing the full problems related to mono/EBV, so hopefully you can help me figure out what to do.

    I am a 22 year old female with a healthy weight and documented orthostatic hypotension with syncopal episodes. I have a family history of depression and have been treated since I turned 17.

    I write to you because I have had mono 3 times. The first time I was 6, the second I was 19, and the most recent incident occurred when I was ~21. The beginning of my sleep issues coincide with the most recent occurrence–I began snoring. Over the past 1.5 years, I have had numerous awful sore throats which only seem to resolve with administration of steroids (usually prednisone). I noticed some reduction in snoring when I took singulair daily, but it prevents me from concentrating during the day. This past Christmas (Dec. 2011) I once again became very ill with the worst sore throat I’ve ever experienced–literally cringed and cried out every time I swallowed. Since then, my boyfriend noted I’ve developed sleep apnea.

    I saw an ENT today, and they suggested a tonsilectomy but only as part of a uvulopalatopharyngoplasty as my tonsils are not “that swollen” (it should be noted I have a very small palate and mouth). This seems a bit extreme to me so I’m interested in your opinion as you seem to grasp the impact of this combination of symptoms.

    On a side note, I tend to have very bad allergies to just about everything. I’m currently getting allergy shots but as it is without antihistamines for ~24 hours my skin becomes extremely red and itchy. I include this due to concern that there’s an underlying immune issue.

    Thanks for taking the time to read all of this! I really appreciate your dedication.

  17. Steven Park on February 20th, 2012 9:07 pm

    Kendra,

    Thanks for sharing your story. Your statement that you have a small mouth implies that your tongue is relatively too large for your mouth. Taking out your small tonsils and shrinking your soft palate has little chance of resolving your condition. I’ve addressed these issues in my book and teleseminars. Unfortunately, I can’t recommend anything specific for you in particular situation without examining you. It sounds like you may need something to either enlarge your jaws or shrink your tongue, regardless of whether or not you have obstructive sleep apnea. Good luck.

  18. Jay Wells on May 22nd, 2012 2:30 pm

    I had Mononucleosis in June 1965 and was ok for a fue months
    by Dec.1965 started having problems with fatigue.
    At that time they looked at my thyroid. (reading was high)
    I was told went back to normal.
    Three years later it was low. I was given .3 Levothytroxine.
    They dropped it to .175 ten years ago and all the old problems stated.
    Fatigue and sugar problem. No one beleives me.

    This is my question; Were can I get more information?
    Thanks Jay

  19. Jay Wells on May 24th, 2012 12:14 pm

    I am 65 years old and had monon at 20. bad enough I was not able to stand. I was getting better for a fue months and for no know reason started having attacks of fatigue. My throat enlarged. They checked my Thyroids because reading high but dismissed it and said no reason for it. Five years later another doctor looked at my Thyroid. It was low stared me on .3 levothyroxine . I did better for 10 years Then another attack. Another Doctor found nothing I fought fatigue for 20 years. I see another doctor who lower the Thyroid and I found myself unable to work more than a fue hours.

    Now at 65 I am looking for answers – I’ve always know there was a conection
    Where can I get more infor on this – Thanks for any help’ Jay

  20. Craig on July 13th, 2012 12:22 am

    Mono suffering continues 16 years and counting. in 1996 I became sick with mono. I was 18. Today I am 35, I am still sick, can not sleep, severe insomnia, geographic tounge, sore swallon glands in neck, (tonsils normal). lack of energy, blood shot eyes, just plain tired all the time, unrefreshing sleep even when I can sleep. Before mono I could sleep with no problem, perfectly healthy. It has ruined my life and no doctors can help. They either strait out dont belive me, or they want to give me depression meds, thats when I walk out.

  21. Sol on March 20th, 2013 5:58 pm

    I had mono the past July 2012. I was coming out from a surgery and after 5 th week mono develop. I tough the were really bad allergie due to whether change. I went to my allergist and also shown him my enlarge and painfull lymph nodes and he said it was just inflammation. He prescribe me dulera for 3 months, nasal sprays steroids and prednisone. I felt all side effects right away…I end up at the ER several times, once for severe sinuses, another for anxiety, and last one for dehidration…I had Palpitation, I was losing potassium all the time, and super hyper due to dulera. I mention this to all doctors many times and nobody pay attention an treat me as I was crazy. Went to specialist for nose and throat because I lose my voice and he says” you look fine to me, you just have terrible allergies!”
    I went to so many doctor cuz I knew something was wrong with me and I was very stress !! I even went to Mexico because I develop really bad Ibs and acid reflux on top of everything.
    Finally this past January a friend of mine ” an ex doctor from Argentina’ help me to view my whole blood test and I once again mention my lymph nodes and chills with fatigue and he run away ask me to do an Epstein Barr test and I did finally found out I had mono all those months last year.
    Now I am dealing with a bad fatigue, join pain, back pain, Ibs, acid reflux due to my nerve system and thyroid last month came out a little low, white blood cells low as well.
    My question i guess be… Is my body going to be normal? I am almost 30 and the surgery I had last year was a robotic myomectomy. I was planning to conceive this past November and my life is in whole completely! I felt very depress becouse of lack of the good food, avoiding pregnancy until I get better and some bad anxiety which I do not want to go out and travel anymore. My doctor think I had fibromalgia and prescribe me that medicine but my body cant deal with medications no more.

  22. Sol c on March 20th, 2013 6:01 pm

    I had mono the past July 2012. I was coming out from a surgery and after 5 th week mono develop. I tough the were really bad allergie due to whether change. I went to my allergist and also shown him my enlarge and painfull lymph nodes and he said it was just inflammation. He prescribe me dulera for 3 months, nasal sprays steroids and prednisone. I felt all side effects right away…I end up at the ER several times, once for severe sinuses, another for anxiety, and last one for dehidration…I had Palpitation, I was losing potassium all the time, and super hyper due to dulera. I mention this to all doctors many times and nobody pay attention an treat me as I was crazy. Went to specialist for nose and throat because I lose my voice and he says” you look fine to me, you just have terrible allergies!”
    I went to so many doctor cuz I knew something was wrong with me and I was very stress !! I even went to Mexico because I develop really bad Ibs and acid reflux on top of everything.
    Finally this past January a friend of mine ” an ex doctor from Argentina’ help me to view my whole blood test and I once again mention my lymph nodes and chills with fatigue and he run away ask me to do an Epstein Barr test and I did finally found out I had mono all those months last year.
    Now I am dealing with a bad fatigue, join pain, back pain, Ibs, acid reflux due to my nerve system and thyroid last month came out a little low, white blood cells low as well.
    My question i guess be… Is my body going to be normal? I am almost 30 and the surgery I had last year was a robotic myomectomy. I was planning to conceive this past November and my life is in whole completely! I felt very depress becouse of lack of the good food, avoiding pregnancy until I get better and some bad anxiety which I do not want to go out and travel anymore. My doctor think I had fibromalgia and prescribe me that medicine but my body cant deal with medications no more.

  23. Margot on March 21st, 2013 5:11 am

    I am 16 years old, in November 2011 I was diagnosed with Mono. My doctor retired this year and has told me that during his entire career he had never seen anyone with such a severe case. First i took 3 months off of school, after going back my mono came back 2 times and i had to take more time off of school. My spleen was so swollen that i had to sleep on my back for a solid month to prevent it from rupturing. I went from 137lbs to 103lbs within the first 2 months and slept an average of 22 hours a day. My doctor putme on a smoothie diet with protein powder and vitamins to help make sure my body was getting the proper nutrients. It has now been over 2 years and I still dont fully have my energy back. It’s gotten to the point that i’ve missed so mucu school that im on the verge of getting kicked out. But i really can’t help it my body starts shutting down halfway through the school day.

  24. Carolyn Reichert on May 10th, 2013 11:17 pm

    17 yo son chronically sick x 10 mo with occ. vomiting, diarrhea, abd pain. Did better when eliminated gluten & dairy initially, but over past month has been having N/V and diarrhea every other day or so. He takes
    Concerta 18mg, Celexa 10mg, Abilify 15mg. 4/26 had EGD which showed gastritis, duodenitis, nodules. Biopsy report later revealed suspected Barrett’s. Saw pediatrician frequently for URI symptoms. 5/3 throat swab was done and negative for strept. No treatment given because thought son had viral infection. Continued to complain of extremely painful throat. 5/5 Went to Urgent Care and test for mono was positive. Started on steriod pack & Z-pack. (Decreased Celexa to 5 mg on our own to see effect on NV x 1 wk. 5/6 Call from ped’s office, throat cultre was positive for human metapneumovirus, MRSA, Streptococcu pneumoniae. Changed antibiotic to Septra DS. Weight has dropped 12 pounds in 2 wks. As of today 5/10, feels better, normal to low-grade temp, taking frequent naps.
    Do you think the culture for MRSA could be incorrect? He’s athletic, but I would expect to see skin lesions, not URI from working out at gym. He does have acne.
    Naturally, we are concerned and will f/u with Urgent Care Center this wkd as scheduled. How will we know if he actually has MRSA? His big concern is when will he be able to kiss his girlfriend. If he has MRSA, will he be able to get rid of it? Should he be hospitalized for IV antibiotics?
    Thanks so much!
    Nervous mom

  25. Rebecca on May 22nd, 2013 6:54 pm

    I had mono when I was 7 for three weeks, it was horrible. I am now 27. I have allergies to all pollen and dander’s, acid reflux, exhaustion, weakness, vitamin B12 deficiency, I am anemic, low red blood count, swollen nodes, severe TMJ dysfunction, constant headaches, stomach pains, nausea, diahrrea, cramping, numbness in extremeties, shooting pains throughout limbs and recently my joints started hurting to the point of limping, and I am also getting “stuck” or stiff in positions. I feel 27 going on 67. I am currently seeing a doctor, he is doing blood work for autoimmune disorders. I am waiting for the results. I am afraid I am going to go to get the results and they haven’t found the cause. Any advice?

  26. Joanna on June 30th, 2013 8:43 pm

    i was diagnosed with mono 4 weeks ago. i ended up getting a blood infection as well i was admitted to the hospital and had to have a breathing tube put down mynose and into my throat because my throat was going to close. i got tonsilitis and strep at the same time in the hospital., i was on the ventilater for 5 days. now i have been home 2 weeks and i feel pretty good and am doing a lot the only thing is my muscles arent very strong now. i used to be able to lift 130 pounds and now i cant lift more than 30 pounds. and my legs give out if i try and run. its really weird to me and i can’t find and information to help me. any advice would be wonderful.

  27. Veronica on August 1st, 2013 10:01 pm

    Hello Dr. Park,
    I know this is a very old article, but I was diagnosed with mono in september of last year and it is now august and I still have severely inflamed tonsils. I have also been diagnosed with acid reflux since having the inflamed tonsils. I always thought the two conditions had a causal relationship but this is the first explanation i’ve read that really puts the two together, so thank you for that!
    Also, i have had a few doctors tell me that it is not advisable to have my tonsils taken out since I am still symptomatic. How do you suggest I treat this condition? I don’t feel that the acid reflux or the tonsil swelling will decrease unless the enlarged tonsils get treated first.
    Hope you read this, thanks!

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