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Pediatr Integral 2025; XXIX (2): 141.e1 – 141.e2
M. Gómez de Pablos Romero*, M. Sánchez Martín**
*Adjunto de Pediatría de la Clínica Universidad de Navarra (Pamplona), **Adjunto de Pediatría del Hospital Universitario La Paz (Madrid)
42. Infectious mononucleosis in the EDs
Doctor: Mónica Gómez de Pablos Romero. Adjunto de Pediatría de la Clínica Universidad de Navarra. Pamplona
Patient: María Sánchez Martín. Adjunto de Pediatría del Hospital Universitario La Paz. Madrid
Doctor: Good morning, I’m Dr. Hawkins. What brings you here today?
Patient: Good morning Dr. Hawkins. I’m Sarah. I came today because I woke up with this rash. At the beginning of the week I started with sore throat and fever, so three days ago I went to my GP, and I was prescribed amoxicillin for pharyngitis. I haven’t really noticed much improvement: the fever continues and I feel really tired.
Doctor: OK. Does anything else hurt, or do you have any other symptoms? Headache, tummy ache, vomiting…?
Patient: I have been having headaches with the fever and a feeling of general discomfort.
Doctor: Alright. Do you remember if your GP performed a strep test?
Patient: No, he did not, actually.
Doctor: Any important medical history I should know about?
Patient: No, I don’t think so. I have never been hospitalised or surgically intervened.
Doctor: Perfect, let’s take a look, Sarah.
PHYSICAL EXAMINATION
Temp: 37.3ºC. Pulse: 87 bpm. BP: 112/62 mmHg. SpO2: 98%. Fair general condition. Alert and oriented in all three spheres. Well-nourished and hydrated. Capillary refill time: 2 seconds. Generalized maculopapular rash, lesions disappear with pressure. No respiratory distress. Cardiac auscultation: regular, no heart murmur. Pulmonary auscultation: general good bilateral ventilation, no pathological breath sounds. HEENT: pharyngeal inflammation with tonsillar exudates; normal bilateral otoscopy. Bilateral cervical lymphadenopathies, approximately 1.5 cm. Abdomen: soft, nontender to palpation, mild hepatosplenomegaly (1-2cm).
Doctor: Sarah, you do have pharyngitis. If it has not responded to three days of antibiotic, the cause is probably viral, one of the most common at your age being infectious mononucleosis. This is also consistent with the symptoms you describe and the findings of the physical examination. I would like to do a blood test to confirm the diagnosis.
Patient: This is the first time that I hear about infectious mononucleosis. What does it imply?
Doctor: You have probably heard about it as “the kissing disease” because it primarily spreads through contact with saliva from an infected person; for example, you can get it through kissing, sharing eating utensils with, or drinking from the same glass as someone who is infected with the virus. Mono is most often caused by a virus called Epstein-Barr virus. Mono causes fever, sore throat, feeling tired, body aches and swollen neck glands. Very rarely, it can cause more serious problems. But let’s not get ahead of ourselves; right now I will draw blood to see if you actually have mono.
Patient: OK, thank you doctor.
SUMMARY OF LAB RESULTS: Normal haemoglobin and platelets. Elevated leukocytes and lymphocytes with atypical lymphocytes and normal neutrophil count. Elevated liver enzymes.
Paul Bunnell (heterophile antibody testing): positive.
Doctor: Sarah, you have tested positive for infectious mononucleosis. The bad news is there is no cure for mono, but the good news is that most people feel better on their own after a few weeks. Nevertheless, it would also be normal if takes several months to feel completely better. To feel better, you should get plenty of rest and drink lots of fluids to stay hydrated.
Patient: Alright. And what about the amoxicillin? Do I have to continue taking it?
Doctor: Unfortunately, since the cause is a virus, antibiotics don’t work on this disease. In fact, it is quite common for a rash to appear in patients infected with mono after starting treatment with amoxicillin. However, you can take ibuprofen for the fever, sore throat or if you have muscle aches. One of the findings in your physical examination was a mildly enlarged liver and spleen, with elevated liver enzymes on the lab test, so it is better to avoid acetaminophen.
Patient: Why is this?
Doctor: The virus can affect the cells in your liver, and also your white blood cell function, causing your spleen to get bigger. This is nothing too serious, and it will completely resolve itself over time. However, this does mean that you should avoid sports or other physical activities, such as contact sports or heavy lifting for at least 1 month and then slowly add activities over a few weeks to months until you get to your normal activity level. Complete bed rest is unnecessary though, and you can go back to school as soon as you feel better. You should also have a blood test repeated in a month to confirm that your liver enzymes return back to normal.
Patient: Is there anything else I should be careful about?
Doctor: Although it is rare, a significant spleen enlargement can result in its rupture, so if you begin with abdominal pain, you should come back to the ED.
KEY WORDS:
Infectious mononucleosis: mononucleosis infecciosa.
GP (General Practitioner): médico de Atención Primaria.
Prescribed (to prescribe): prescribir.
Feeling of general discomfort: malestar general.
Strep test: test rápido de estreptococo.
Surgically intervened: intervenido quirúrgicamente.
Maculopapular rash: exantema maculopapular.
Tonsillar exudates: exudados amigdalares.
Consistent with the symptoms: consistente con los síntomas.
To imply: implicar.
The kissing disease: la enfermedad del beso.
To spread: diseminar, transmitir.
Swollen neck glands: ganglios linfáticos inflamados.
Muscle aches: dolores musculares.
Elevated liver enzymes: enzimas hepáticas elevadas.
Avoid sports or any other physical activities: evitar deportes y actividad física.
Heavy lifting: levantar peso.
Rupture (of liver or spleen): rotura de hígado o bazo.
Vegetarian and other alternative diets 