An 18-year-old man comes to the emergency department due to 3 days of fever, myalgias, and profound fatigue. He was feeling fine prior to the onset of symptoms. The patient has a history of intermittent asthma for which he uses an inhaler as needed. He is a senior in high school and plays on the football team. Temperature is 38 C (100.4 F), blood pressure is 110/80 mm Hg, pulse is 88/min, and respirations are 16/min. BMI is 22.1 kg/m². On physical examination, the patient is found to have swollen lymph nodes in his neck and behind his ears. The tip of the spleen is palpable 1 cm below the left costal margin. Laboratory results are notable for the following: Which of the following is most likely to be elicited on further history?

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This patient has many of the classic features of Epstein-Barr virus (EBV)-induced mononucleosis, including fever, profound fatigue, lymphadenopathy, lymphocytosis (with atypical lymphocytes), and splenomegaly (palpable spleen tip). EBV is typically transmitted from an asymptomatic virus shedder to a susceptible individual through saliva transfer (eg, kissing). (Choice A) Anal sexual intercourse is more likely to transmit pathogens such as HIV, Neisseria gonorrhoeae, and Chlamydia trachomatis. (Choices C, D, and E) Urine can harbor pathogens such as cytomegalovirus, adenovirus, Escherichia coli, Staphylococcus saprophyticus, and Klebsiella pneumoniae; blood can harbor hepatitis B virus, hepatitis C virus, and HIV; and arthropods (eg, ticks) can harbor Rickettsia rickettsii and Borrelia burgdorferi, among others. (Choice F) Malaria and leishmaniasis, which can cause splenomegaly, are found in South Asia. However, malaria would classically be associated with anemia and thrombocytopenia. Visceral leishmaniasis (kala-azar) manifests as progressive splenic enlargement and weight loss over months. Educational objective: Typical clinical and laboratory features of Epstein-Barr virus (EBV) mononucleosis include fever, pharyngitis, lymphadenopathy, splenomegaly, and atypical lymphocytosis. EBV is generally transmitted from an asymptomatic virus shedder to a susceptible individual through saliva transfer (eg, kissing).

An 18-Year-Old Man Comes to the Emergency Department Due to 3