A 21-year-old woman comes to the office due to weakness and fever for 9 days. She has also developed headaches, myalgia, and a sore throat. The patient's symptoms have worsened since their onset, causing her to be unable to go to work. Despite remaining in bed for most of the day, she feels "exhausted." She has lost 2 kg (4.4 lb) over the past week. The patient has no significant medical history and takes no medications. She drinks alcohol occasionally and has smoked a pack of cigarettes a day for the past 7 years. She is sexually active and uses condoms "most of the time." Temperature is 38.3 C (100.9 F), blood pressure is 120/70 mm Hg, pulse is 82/min, and respirations are 16/min. Physical examination shows an awake but tired woman. There is no rhinorrhea or erythema of tympanic membranes; she has enlarged tonsils with white exudates. Large cervical and axillary lymph nodes are palpable bilaterally. S1 and S2 are normal without murmurs. Lungs are clear to auscultation bilaterally. The abdomen is soft and nontender with normal bowel sounds; the liver edge extends 2 cm below the right costal margin and there is palpable splenomegaly. There are no rashes or lesions. The appropriate workup is completed and the correct diagnosis is made. Which of the following is the most appropriate management?

Question

A 21-year-old woman comes to the office due to weakness and fever for 9 days.  She has also developed headaches, myalgia, and a sore throat.  The patient's symptoms have worsened since their onset, causing her to be unable to go to work.  Despite remaining in bed for most of the day, she feels "exhausted."  She has lost 2 kg (4.4 lb) over the past week.  The patient has no significant medical history and takes no medications.  She drinks alcohol occasionally and has smoked a pack of cigarettes a day for the past 7 years.  She is sexually active and uses condoms "most of the time."  Temperature is 38.3 C (100.9 F), blood pressure is 120/70 mm Hg, pulse is 82/min, and respirations are 16/min.  Physical examination shows an awake but tired woman.  There is no rhinorrhea or erythema of tympanic membranes; she has enlarged tonsils with white exudates.  Large cervical and axillary lymph nodes are palpable bilaterally.  S1 and S2 are normal without murmurs.  Lungs are clear to auscultation bilaterally.  The abdomen is soft and nontender with normal bowel sounds; the liver edge extends 2 cm below the right costal margin and there is palpable splenomegaly.  There are no rashes or lesions. The appropriate workup is completed and the correct diagnosis is made.  Which of the following is the most appropriate management?

Quizplus · Accepted Answer

Explanation: The primary means of treatment for infectious mononucleosis (IM) is supportive care (eg, rest, adequate hydration, nutrition, avoidance of strenuous activity). Acetaminophen or nonsteroidal anti-inflammatory drugs provide some symptomatic relief but do not shorten the duration of illness. (Choice A) Antiretroviral therapy (eg, reverse transcriptase inhibitors, protease inhibitors) is indicated for patients who have been diagnosed with or exposed to HIV infection. It is not indicated in the treatment of infections with Epstein-Barr virus (EBV), which is not a retrovirus. (Choice C) Oral acyclovir, an antiviral medication, may decrease viral shedding in EBV infection. However, with rare exceptions (eg, immunocompromised patients), its use does not shorten the duration of symptoms in an immunocompetent individual. In addition, most of the manifestations of IM (eg, fever, myalgia) are related to inflammation rather than viral replication. Therefore, acyclovir is not typically indicated in the treatment of IM. (Choice D) Oral penicillin is an appropriate antibiotic for patients with streptococcal pharyngitis; however, it is not indicated in the treatment of the viral pharyngitis that is characteristic of IM. Many patients with IM who erroneously receive beta-lactam antibiotics (eg, penicillin, amoxicillin) develop a generalized maculopapular rash (mechanism unclear). (Choice E) Oral prednisone, a corticosteroid, is not routinely indicated in the treatment of IM unless tonsillar enlargement is severe enough to warrant suspicion for impending airway obstruction or unless serious complications such as aplastic anemia occur. Educational objective: Epstein-Barr virus infectious mononucleosis is typically a self-limited illness treated with supportive care and nonsteroidal anti-inflammatory drugs. Symptoms generally resolve within weeks (other than fatigue, which persists for months). Antimicrobial therapy is not indicated.

A 21-Year-Old Woman Comes to the Office Due to Weakness