Lisa is a vivacious 16-year-old student who is active in cheerleading, sports and all honor classes. It is to her dismay that she awoke ill this morning, the first day of semester exams, with the following symptoms: severely painful sore throat, fever, chills, headache, fatigue, and lack of energy. She arrives at her pediatrician’s office and her doctor’s exam is positive for enlarged inflamed tonsils with exudate, swollen tender neck glands, fever of 103F, and pain in the upper left abdomen. She has no energy and wants to go back to bed, which is a definite behavioral change from her normal energetic self.
Her clinician orders a rapid strep test which is negative, a backup throat culture which takes 24 hours before the results will be available, and a white blood cell count with differential which is elevated above the normal range. Her parents want an antibiotic prescribed since there are some of her peers with strep throat as well as flu this month. Her doctor suggested ordering a mono spot test on the previous blood sample and will check the throat culture before starting an antibiotic. The mono test is positive and the throat culture the next day is negative. Further school history is obtained which is significant for several members of the football team having the diagnosis of mono over the past two months including her boyfriend.
Mononucleosis, (“Kissing Disease”, “Glandular Fever”) is an illness caused by the Epstein-Barr virus (human herpesvirus 4). This virus infects more than three million people in the United States. It is spread by sharing of infected saliva thru kissing or drinking or eating after someone who is infected. Four to six weeks after exposure, the symptoms as described in Mono Lisa’s history become apparent. Though the worst symptoms usually occur between the ages 15-24 yrs, young children may have only fever as a symptom. 95% of all adults have been infected by the virus but not everyone infected has symptoms.
The most common symptoms and physical signs are as follows: 1) Sore throat with exudative tonsillitis (extremely red throat with pus on enlarged tonsils which may interfere with swallowing and breathing); 2) Swollen lymph nodes in the neck and all over the body; 3) Enlarged spleen; 4) Liver Inflammation (hepatitis from the Epstein- Bar virus); Systemic symptoms (headache, fever, chills, body aches, loss of appetite, abdominal pain, extreme fatigue).
The laboratory work up of a patient suspected of having mono will always include a mono spot test with sometimes a complete blood count and rapid strep/throat culture to exclude group A beta hemolytic strep. Sometimes the mono spot test is negative and there still may be concern about the Epstein-Bar virus as an etiology of the throat infection. Usually in these cases an Epstein-Barr antibody titer is drawn to clarify the diagnosis. This test will not only detect a recent infection, but also determine if there has been exposure with this virus in the past.
The treatment of mononucleosis is mainly supportive since there are no antiviral drugs currently approved for Epstein-Bar infection in a normal host. No antibiotics are indicated since this is a viral infection and antibiotics do not kill viruses. In fact sometimes a patient who has this viral infection may be placed on an antibiotic and will develop an itchy red rash all over his body. This rash is unique to having an Epstein- Barr infection combined with giving Amoxicillin. When the antibiotic is discontinued the rash disappears. The patient does not have a penicillin allergy. Rest and good hydration along with acetaminophen or ibuprofen for fever and body aches is indicated. Sometimes a corticosteroid may be prescribed in an effort to shrink the tonsils and possible enlarged spleen. No contact sports or heavy lifting should be done for several weeks after being diagnosed. Sometimes there may be an enlarged spleen which could rupture while playing contact sports. Since there is extreme fatigue associated with this infection, returning to school should only involve the essential courses without extracurricular activities. Plenty of time should be devoted to rest and quality of sleep. Most of these patients resolve these symptoms within two months. If symptoms persist beyond this time consult your physician.