3.14 Mononucleosis (Glandular Fever)
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agk's Library of Common Simple Emergencies


Presentation
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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:
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- Perform a complete physical examination, 
   looking for signs of other ailments, and the 
   rare complication of airway obstruction, 
   encephalitis, hemolytic anemia, thrombo- 
   cytopenic purpura, myocarditis, pericard- 
   itis, hepatitis, and rupture of the spleen.
- Send off blood tests: a differential white 
   cell count (looking for atypical lympho- 
   cytes) 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 mono- 
   nucleosis 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 infect- 
   ious mononucleosis, usually 40mg of 
   Prednisone qd for five days. It is partic- 
   ularly 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:
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- 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
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All of the above probably apply to cyto- 
megalovirus 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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