A 15-year-old boy is brought to the clinic due to fatigue, malaise, fever, and sore throat for the past 6 days. The patient has been in bed most of this time, uninterested in reading or playing video games due to tiredness. He has no chronic medical conditions and takes no medications. The patient is sexually active and uses condoms inconsistently. He does not use tobacco, alcohol, or illicit drugs. Temperature is 38.3 C (101 F), blood pressure is 115/70 mm Hg, pulse is 90/min, and respirations are 18/min. Physical examination shows pharyngeal hyperemia with exudates along with cervical and axillary lymphadenopathy. Breath sounds are normal. There are no heart murmurs. The abdomen is soft and nontender. Mild hepatosplenomegaly is present. Joints have a normal range of motion. There is no skin rash. A rapid streptococcal antigen test is negative. Which of the following is the most appropriate management for this patient?

Question

A 15-year-old boy is brought to the clinic due to fatigue, malaise, fever, and sore throat for the past 6 days.  The patient has been in bed most of this time, uninterested in reading or playing video games due to tiredness.  He has no chronic medical conditions and takes no medications.  The patient is sexually active and uses condoms inconsistently.  He does not use tobacco, alcohol, or illicit drugs.  Temperature is 38.3 C (101 F), blood pressure is 115/70 mm Hg, pulse is 90/min, and respirations are 18/min.  Physical examination shows pharyngeal hyperemia with exudates along with cervical and axillary lymphadenopathy.  Breath sounds are normal.  There are no heart murmurs.  The abdomen is soft and nontender.  Mild hepatosplenomegaly is present.  Joints have a normal range of motion.  There is no skin rash.  A rapid streptococcal antigen test is negative.  Which of the following is the most appropriate management for this patient?

Quizplus · Accepted Answer

11ec25c8_d27f_565e_bc81_334f909d2739_MD0003_00 Infectious mononucleosis (IM) is typically caused by Epstein-Barr virus and presents with prolonged fever, pharyngitis, fatigue, and lymphadenopathy (commonly posterior cervical but can be generalized). Splenomegaly is seen in more than half of patients, and splenic rupture is a rare but potentially dangerous complication that is most common in male patients within 3 weeks of symptom onset. Manifestations of splenic rupture include abdominal pain and anemia. Due to the risk of splenic rupture, all patients should refrain from playing sports for a minimum of 3-4 weeks (4 weeks for contact sports) and until all symptoms (and splenomegaly) have resolved. This recommendation applies to patients with or without palpable splenomegaly on presentation because the spleen may not be palpable until it is 2-3 times its normal size. Ultrasonographic measurement of the spleen can confirm resolution of splenomegaly and authorize return to play in athletes participating in contact sports (eg, rugby, wrestling) or activities that increase intra-abdominal pressure (eg, weight lifting); however, it is not indicated at initial presentation. (Choice A) In most cases, IM is self-limiting and no treatment is necessary. Corticosteroids are considered for patients with complications of IM such as airway obstruction; however, this patient is breathing comfortably. (Choice B) Strenuous activities should be avoided, but the patient can conduct normal activities as tolerated; complete bed rest is not required. When the patient is afebrile and feeling well, he may return to class. (Choice C) Antibacterial therapy is appropriate for streptococcal pharyngitis (fever, pharyngitis, lymphadenopathy). However, this patient's negative rapid streptococcal antigen and splenomegaly make streptococcal pharyngitis unlikely. Empiric antibiotics (eg, amoxicillin) in a patient with IM can lead to a rash. (Choice D) In general, IM symptoms are due to host responses to viral infection rather than viral replication itself, so antiviral therapy is neither beneficial nor indicated, especially in an otherwise healthy adolescent. Educational objective: Infectious mononucleosis is characterized by prolonged fever, pharyngitis, fatigue, lymphadenopathy, and splenomegaly. Sports (especially contact sports) should be avoided for at least 3-4 weeks due to the risk for splenic rupture. References: Return to play after infectious mononucleosis. (http://www.ncbi.nlm.nih.gov/pubmed/24790693) Common questions about infectious mononucleosis. (http://www.ncbi.nlm.nih.gov/pubmed/25822555)

A 15-Year-Old Boy Is Brought to the Clinic Due to Fatigue