A 16-year-old boy comes to the office due to fever, fatigue, and myalgia that started 10 days ago. He has felt too tired and achy to get out of bed. His throat is sore, and he has decreased food and fluid intake. The patient has no significant medical history and does not take medications. He does not use tobacco, alcohol, or illicit drugs. He is sexually active. The patient is an excellent student and actively involved in music and sports. Temperature is 38.6 C (101.5 F), blood pressure is 100/60 mm Hg, and pulse is 104/min. Physical examination shows a tired adolescent male. There is no rhinorrhea, tympanic membranes are clear, the lips are dry and cracked, and the tonsils are enlarged and erythematous bilaterally with white exudate. There is bilateral anterior and posterior cervical lymphadenopathy. Cardiopulmonary examination reveals regular tachycardia with normal S1 and S2 as well as clear lungs. The abdomen is soft and nontender; there is no palpable hepatosplenomegaly. Of the following recommendations, which will most reduce the risk of sequelae from this condition?

Question

A 16-year-old boy comes to the office due to fever, fatigue, and myalgia that started 10 days ago.  He has felt too tired and achy to get out of bed.  His throat is sore, and he has decreased food and fluid intake.  The patient has no significant medical history and does not take medications.  He does not use tobacco, alcohol, or illicit drugs.  He is sexually active.  The patient is an excellent student and actively involved in music and sports.  Temperature is 38.6 C (101.5 F), blood pressure is 100/60 mm Hg, and pulse is 104/min.  Physical examination shows a tired adolescent male.  There is no rhinorrhea, tympanic membranes are clear, the lips are dry and cracked, and the tonsils are enlarged and erythematous bilaterally with white exudate.  There is bilateral anterior and posterior cervical lymphadenopathy.  Cardiopulmonary examination reveals regular tachycardia with normal S1 and S2 as well as clear lungs.  The abdomen is soft and nontender; there is no palpable hepatosplenomegaly.  Of the following recommendations, which will most reduce the risk of sequelae from this condition?

Quizplus · Accepted Answer

Explanation: This patient has infectious mononucleosis (IM), a viral illness most frequently caused by Epstein-Barr virus. Common features of IM include prolonged fever, severe fatigue, exudative pharyngitis, lymphadenopathy, and hepatosplenomegaly. A rare but potentially dangerous sequela of IM is splenic rupture. Although the spleen is not palpable in this patient, physical examination is not a reliable indicator of splenomegaly, as it is frequently undetectable until the spleen is 2-3 times its normal size. Therefore, to prevent possible complications, a patient highly suspected of having IM should avoid all sports for a minimum of 3 weeks since symptom onset (contact sports for a minimum of 4 weeks), regardless of physical examination findings. (Choice B) Pregnant women should avoid exposure to organisms that cause congenital infections, such as cytomegalovirus (CMV). However, Epstein-Barr virus is a much more common cause of IM than CMV, and patients with CMV-associated IM typically do not have pharyngitis or lymphadenopathy. Other viruses that can cause fetal complications (eg, parvovirus, HIV) are not consistent with this patient's symptoms. (Choice C) Patients with IM are not at increased risk of sequelae while conducting nonstrenuous activities of daily living (eg, attending school), so this patient may attend classes as soon as he is afebrile and feeling well. (Choice D) Antibiotic therapy is appropriate in a case of streptococcal pharyngitis. However, this diagnosis is less likely in this patient as posterior cervical adenopathy and extreme fatigue are uncommon in streptococcal pharyngitis, and in the absence of treatment the patient with streptococcal pharyngitis would likely have significantly worsened by day 10 of fever. (Choice E) High-dose aspirin therapy is a treatment for Kawasaki disease (fever, lymphadenopathy, rash, conjunctivitis, mucous membrane changes, edema of the extremities). This patient does not meet the criteria for this diagnosis. In addition, the patient has symptoms, such as exudative pharyngitis, that are not present in Kawasaki disease, and he is outside the typical age range (age 1-4). Educational objective: Infectious mononucleosis is a viral syndrome most commonly caused by Epstein-Barr virus and commonly presents with fever, fatigue, lymphadenopathy, exudative pharyngitis, and hepatosplenomegaly. Splenic rupture is a rare but dangerous sequela. Splenomegaly is often present even when not detected on physical examination; therefore, the most important recommendation is for all patients to avoid contact sports to prevent this sequela.

A 16-Year-Old Boy Comes to the Office Due to Fever