3.14 Mononucleosis (Glandular Fever)

agk’s Library of Common Simple Emergencies

Presentation

The patient is usually of school age (nursery through night school) and complains of several days of fever, malaise, lassitude, myalgias, and anorexia, culminating in a severe sore throat. The physical examination is remarkable for generalized lymphadenopathy, including the anterior and posterior cervical chains and huge tonsils, perhaps meeting in the midline and covered with a dirty-looking exudate. There may also be palatal petechiae and swelling, splenomegaly, hepatomegaly, and a diffuse maculopapular rash.

What to do:

• Perform a complete physical examination, looking for signs of other ailments, and the rare complication of airway obstruction, encephalitis, hemolytic anemia, thrombocytopenic purpura, myocarditis, pericarditis, hepatitis, and rupture of the spleen.
• Send off blood tests: a differential white cell count (looking for atypical lymphocytes) and a heterophil or monospot test. Either of these tests, along with the generalized lymphadenopathy, confirms the diagnosis of mononucleosis, but atypical lymphocytes are less specific, being present in several viral infections.
• Culture the throat. Patients with mononucleosis harbor group A streptococcus and require penicillin with about the same frequency as anyone else with a sore throat.
• Warn the patient that the convalescence is longer than that of most viral illnesses (typically 2-4 weeks, occasionally more), and that he should seek attention in case of lightheadedness, abdominal or shoulder pain,or any other sign of the rare complications above.
• Despite controversy, prednisolone is widely employed for symptomatic relief of infectious mononucleosis, usually 40mg of Prednisone qd for five days. It is particularly helpful in young adults with severe pharyngeal pain, odynophagia or marked tonsillar enlargement with impending oropharyngeal obstruction.
• Arrange for medical followup.

What not to do:

• Do not routinely give penicillin for the pharyngitis, and certainly do not give ampicillin. In a patient with mononucleosis, ampicillin can produce an uncomfortable rash, which, incidentally, does not imply allergy to ampicillin.
• Do not unnecessarily frighten the patient about splenic rupture. If the spleen is clinically enlarged, he should avoid contact sports, but spontaneous ruptures are rare.

Discussion

All of the above probably apply to cytomegalovirus as well, although the severe tonsillitis and positive heterophil test are both less likely. Some who report having mono twice probably actually had CMV once and mono once.

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