Infectious Mononucleosis in a Young Athlete
MS3: The patient is a 20-year-old male college student who plays goalie for the soccer team. He presents complaining of a sore throat for the past 2 to 3 days. He does not relate a fever, though he does indicate that he has been really tired since the sore throat started.
Dr C: What did you find on physical examination?
MS3: On physical exam, he has both anterior and posterior cervical adenopathy. His oropharynx was mildly erythematous but without any exudate. Otherwise, I didn’t see anything significant on his physical exam.
Dr C: OK. Anything else?
MS3: Before he was put in the exam room, the nurse sent him to the lab for a Rapid Strep test. She told me the test was negative. So, I think that he probably has a viral pharyngitis and just requires symptomatic care.
Dr C: That sounds reasonable. In this age group, which specific viral illness should you suspect?
MS3: Um—you mean rhinovirus?
Dr C: Maybe. But I was thinking about mono. Think of mono in patients between 10 to 30 years old with sore throat, fever, fatigue, and cervical adenopathy. If you look, you can find adenopathy elsewhere—in the inguinal areas or axillae. According to one study, palatal petechiae or splenomegaly are very specific. So, if a finding is specific, it helps to . . . ?
MS3: To rule in the diagnosis. SpIn: Specific test to rule In.
Dr C: And to rule out the diagnosis?
Dr C: Fatigue or adenopathy are the most sensitive findings. So the absence of fatigue or adenopathy helps to rule out mono. Good. Any lab tests that would help?
MS3: There’s the mono test or Monospot?
Dr C: Right. The heterophile test. What can you tell me about that test?
MS3: Well, on pediatrics, they said that the test can be a false negative.
Dr C: That’s right. You can repeat the test in a week, if you think it was falsely negative, and the patient is still sick. But if we really need an answer in the next day or so, we may want to consider ordering a more sensitive test, the Viral Capsid Antigen (VCA)-IgM. What’s one big deal related to mono and this patient?
Dr C: Great. Why?
MS3: It can rupture. So the patient is not supposed to play football or contact sports?
Dr C: For how long?
MS3: I don’t know.
Dr C: Almost all ruptures occur in the first 3 weeks of illness. So patients should be kept out of athletic activity for at least 3 to 4 weeks, and they are asymptomatic. Some researchers have recommended using ultrasound at 3 weeks to determine whether or not the athlete can return to play. But this strategy increases the cost of care substantially—and so is not automatically done. I’ll give you a good article (Ebell M. Epstein-Barr virus infectious mononuclesis. Am Fam Physician 2004;70:1279-87, 1289-90) that reviews the evidence on mono. Let’s go finish up with this patient.
Peter Carek, MD, MS, Medical University of South Carolina, Author
Alec Chessman, MD, Medical University of South Carolina, Editor
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