Although depression is well known as a sequel to influenza, mania is not. We describe a patient with a severe psychotic illness who first showed features of a confusional state but then developed a manic psychosis. The occurrence of functional affective psychoses during or following systemic physical illness has been well described (Bonhoeffer, 1909; Kraepelin, 1921; Kiloh, 1961; Post, 1965), but the nature of the relationship has never been clear. In some instances, the physical illness may simply act as a form of non-specific stress precipitating the mental disorder; evidence for a more direct patho-physiological relationship has been lacking. When, in addition to a background of physical illness, a patient shows disorientation and clouding of consciousness together with signs of a manic psychosis, the diagnostic problem is especially difficult, particularly so since a confusional state can occur as part of a severe manic illness (Maudsley, 1895; Kraepelin, 1921). Conversely, hypomanic symptoms can occur in an organic psychosis (Bonhoeffer, 1909).

Complement-fixing antibodies against an antigen prepared from the EB3 line of cultured Burkitt tumour cells were studied in various groups of patients and control individuals. Higher antibody titres were observed in patients with Burkitt's tumour than in African patients with other diagnoses. Significantly more medical students and nurses with a history of infectious mononucleosis possessed antibodies than those with no such history. Low levels of antibody were observed in patients during the acute phase of infectious mononucleosis and these levels were significantly lower than those in patients admitted to the same hospital with other diagnoses.During the early months following the acute phase of illness, EB complement-fixing antibodies remained stationary or apparently declined in titre but, in patients tested one or more years later, significantly higher antibody levels were observed.

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Positive Paul-Bunnell-Davidsohn reactions in sera from healthy individuals, usually blood donors (where the incidence may be 0-9 to 1 6%), have been described on several occasions (Barratt, 1941;Hobson, Lawson, and Wigfield, 1958;Virtanen, 1962). The significance of these observations is obscure and whether such heterophile antibodies represent subclinical infectious mononucleosis or are chance findings, to be dismissed as 'false-positive reactions', is not clear. The association of the EB virus with infectious mononucleosis (Henle, Henle, and Diehl, 1968;Evans, Niederman, and McCollum, 1968) sheds some light upon this problem, for the high incidence of antibodies to this virus in the community showed that asymptomatic infection with the probable causative agent of infectious mononucleosis was widespread. Holborow, Hemsted, and Mead (1973) have recently observed that a high proportion of patients with active infectious mononucleosis possessed antibodies to smooth muscle. Our own unpublished data support this observation but we were surprised that some of our control medical students and nurses also had smooth muscle antibodies. These antibodies are usually found in patients with some degree of liver damage (Johnson, Holborow, and Glynn, 1965) but our medical students and nurses were, apparently, quite healthy. Their sera were therefore tested for EB virus antibodies and, in the following report, we outline our findings and suggest that subclinical EB virus infection, associated with the development of smooth muscle antibodies, may be not uncommon in young adults.

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