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Snapshot
  • A 15-year-old woman presents to urgent care with a few days of fever and sore throat. She had recently gone to an outdoor music festival and shared multiple drinks and cigarettes with friends, who had similar symptoms. She denies having a cough. She also had not taken anything for it. On physical exam, she has palatal petechiae and cervical lymphadenopathy. A peripheral blood smear showed atypical lymphocytes and a Monospot test confirmed the diagnosis. She is counseled to avoid any contact sports.  
Introduction
  • Classification
    • Epstein-Barr virus (EBV) or human herpesvirus-4 (HHV-4)
      • an enveloped, linear double-stranded DNA virus
      • transmitted via respiratory secretions
        • “kissing disease”
      • causes mononucleosis
  • Epidemiology
    • incidence
      • common
    • demographics
      • common in teens and young adults
    • risk factors
      • Asian descent
        • EBV causes nasopharyngeal carcinoma
      • living in endemic areas
        • EBV causes Burkitt lymphoma
      • transplant recipient
      • poor sanitation
      • kissing
      • daycare centers
  • Pathogenesis
    • binds to B-cells via CD21, acting as a B-cell mitogen
    • can establish lifelong persistent infection in B-cells
    • T-cell-mediated immunity controls the latent infection
      • immunocompromised patients are at risk of reactivation
  • Associated conditions
    • lymphomas
      • e.g., Burkitt lymphoma and central nervous system lymphoma
    • nasopharyngeal carcinoma
    • lymphoproliferative disease
    • gastric carcinoma
    • oral hairy leukoplakia in HIV patients
  • Prognosis
    • most cases resolve
Presentation
  • Symptoms
    • fatigue
    • pharyngitis
    • maculopapular rash
      • if patients with mononucleosis were treated with amoxicillin
  • Physical exam
    • fever
    • posterior cervical lymphadenopathy
    • hepatosplenomegaly
    • palatal petechiae
    • tonsillar exudate
Studies
  • Labs
    • ↑ atypical lymphocytes on peripheral blood smear
      • enlarged nuclei
    • + Monospot test 
      • heterophile IgM antibodies detected by agglutination of sheep red blood cells
  • Making the diagnosis
    • can be made clinically with classic presentation 
    • laboratory studies when uncertain
Differential
  • Cytomegalovirus
    • distinguishing factors
      • can present with mononucleosis-like syndrome but can also present with more myalgias, arthralgias, and cough
      • does not typically present with sore throat and lymphadenopathy
Treatment
  • Management approach  
    • management is centered around supportive care and avoidance of contact sports, as patients are at risk of splenic rupture
  • Conservative
    • supportive care
      • indication
        • all patients
      • modalities
        • hydration
        • pain management
Complications
  • Splenic rupture  
  • Malignancy
  • Hemolytic anemia
    • treat with rituximab
  • Guillain-Barre syndrome

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(M2.PD.15.4678) A 16-year-old male presents to his pediatrician with complaints of malaise, fatigue, sore throat, and fever over the last several days. His vital signs are as follows: T 39.1 C, HR 82, BP 122/76, RR 14, and SpO2 99%. Physical examination is significant for splenomegaly, tonsillar exudate, and posterior auricular lymphadenopathy. The tonsils are not notably enlarged. Laboratory work-up shows an elevated lymphocyte count, atypical lymphocytes on a peripheral blood smear, and a positive heterophile antibody screen. Which of the following is the best management of this patient's condition?

QID: 107256
1

Bed rest and activity limitation

75%

(55/73)

2

Acyclovir

7%

(5/73)

3

Ganciclovir

10%

(7/73)

4

Amoxicillin

4%

(3/73)

5

Prednisone

3%

(2/73)

M 7 E

Select Answer to see Preferred Response

(M2.PD.14.13) A 17-year-old young man presents to his physician complaining of 2 days of fatigue, subjective fever, and a sore throat. His symptoms have been persistent during this time frame. He is sexually active but states that he uses condoms. He smokes marijuana daily and drinks alcohol on the weekends. His temperature is 100°F (37.8°C), blood pressure is 117/84 mmHg, pulse is 110/min, respirations are 16/min, and oxygen saturation is 98% on room air. Physical exam is notable for posterior cervical lymphadenopathy, splenomegaly, and the finding in Figure A. An initial rapid streptococcus antigen test is negative. What is the most appropriate management of this patient?

QID: 104460
FIGURES:
1

Amoxicillin-clavulanate

2%

(1/66)

2

Heterophile antibody test

80%

(53/66)

3

Peripheral blood smear

0%

(0/66)

4

Supportive therapy

14%

(9/66)

5

Throat culture

3%

(2/66)

M 6 E

Select Answer to see Preferred Response

Evidence (2)
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EXPERT COMMENTS (8)
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