Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Infectious Mononucleosis
An acute, self-limited viral infection characterized by fever, malaise, sore throat, generalized lymphadenopathy, splenomegaly, and increased numbers of atypical lymphocytes and monocytes in the blood.
I. Etiology: Epstein-Barr virus (EBV), a herpesvirus. Infectious mono is an initial or primary EBV infection. EBV produces other clinical disorders as well.
II. Incubation period: 4 to 6 weeks
III. Communicability
A. Low to moderate contagion
B. Transmitted by close contact, especially by oropharyngeal secretions
C. Because it is spread by the oral–pharyngeal route, kissing may well be the chief mode of spread in adolescents and young adults.
D. Viral shedding through saliva occurs in 90% of patients in the first week of illness and continues for up to 18 months.
E. The period of communicability is not known because 10% to 20% of healthy, seropositive individuals shed virus intermittently.
IV. Incidence
A. Can occur at any age but is most commonly diagnosed in adolescents and young adults (15 to 22 years of age)
B. Incidence in males and females is equal.
C. Peak incidence in females is 16 years and in males is 18 years.
D. Occurs endemically in group settings, such as boarding schools and colleges
V. Immunity: One attack is felt to confer immunity, although after the initial EBV infection, the virus regularly produces infection of the
B lymphocytes for life.
VI. Subjective data: Gradual onset of
A. Malaise
B. Fever
C. Headache
D. Sore throat
E. Swollen glands
F. Abdominal pain
G. Anorexia, nausea, vomiting
H. Excessive fatigue
I. Jaundice (rare)
VII. Objective data
A. Early in disease (first few days)
1. Tonsils, enlarged and erythematous; small areas of patchy gray exudate
2. Pharynx inflamed
3. Petechiae at junction of hard and soft palate. Seen at the middle to end of first week of illness.
4. Bilateral cervical adenopathy—anterior and posterior chains
5. Fever: 101F to 103F
6. Periorbital edema
B. After 3 to 5 days of presenting complaints, the following may be found in addition to the above:
1. Tonsillar exudate becomes more extensive with large patches.
2. Pharyngeal edema
3. Tender anterior and posterior cervical adenopathy
4. Axillary and inguinal adenopathy
5. Erythematous maculopapular rash
6. Jaundice
7. Splenomegaly in approximately 75% of patients
8. Hepatomegaly in approximately 50% of patients
C. Laboratory tests
1. White blood cells (WBC) generally 12,000 to 18,000/mm3
2. Lymphocytes over 50%, with numerous atypical lymphocytes and monocytes
3. Monospot test: Positive after 7 to 10 days of illness
4. Heterophil antibody test: Titer of 1:112 significant, 1:160 diagnostic (may be negative for first 7 to 10 days of illness and in young children). Heterophil titers are highest during first 4 weeks; antiEBVs reach peak titers within 2 to 4 weeks and persist probably throughout life.
5. Throat culture to rule out streptococcal pharyngitis (seen concurrently in about 20% of children with infectious mononucleosis)
VIII. Assessment
A. Diagnosis is made by the history, clinical findings, and positive laboratory results.
B. Differential diagnosis
1. Streptococcal pharyngitis: Positive throat culture; may occur concurrently
2. Blood dyscrasias, especially leukemia: Pancytopenia and blast cells present
3. Measles: Preceded by a 3to 4-day prodrome of cough, coryza, and conjunctivitis; pathognomonic Koplik’s spots present; negative immunization history
IX. Plan
1. Viral exanthems: Clinical course differs; extensive lymphadenopathy is very rare.
2. Viral hepatitis: Clinical picture similar, but fewer atypical lymphocytes and lacks positive heterophil; liver function tests are abnormal.
A. Symptomatic
1. Rest according to degree of illness until afebrile
2. Liquids
3. Acetaminophen or ibuprofen (if streptococcal infection has been ruled out) for elevated temperature or discomfort
4. Warm saline gargles
5. No contact sports
B. Treat concurrent streptococcal pharyngitis with penicillin or erythromycin (see protocol, p. 388). Do not use amoxicillin. It causes an allergic-type rash in approximately 80% of patients treated.
C. Corticosteroids do not generally affect the course of the disease. However, they are indicated if upper respiratory obstruction by enlarged, infected tonsils is impending or pharyngitis is so severe that child is not taking liquids.
1. Prednisone dosage:
a. Adolescent: 20 mg tid for 5 days
b. Child: 1 to 2 mg/kg tid for 5 days.
D. Note: Acyclovir has not been proven to modify the clinical course of uncomplicated infectious mono, although it has good in vitro activity against EBV.
E. Splenic ultrasound prior to return to sports, especially in athletes participating in football, hockey, soccer, lacrosse
X. Education
A. Infection is self-limited.
B. Treatment is symptomatic.
C. Isolation is unnecessary.
D. Throat may be very sore.
E. Gargle: 1 tsp of salt in a glass of warm water, as often as necessary
F. Encourage fluids
1. Avoid orange juice or carbonated beverages if sore throat is a problem.
2. Use cool, bland liquids.
G. Rest.
1. Encourage bed rest when febrile.
2. Encourage frequent rest periods.
H. Patient may feel an overwhelming fatigue, which may persist for as long as 6 weeks.
I. Strenuous activity and contact sports should be avoided while splenomegaly persists.
J. Avoid alcoholic beverages because of the possibility of liver involvement.
K. Encourage a well-balanced diet as soon as anorexia subsides.
L. Acute phase lasts 1 to 2 weeks; fatigue generally resolves in 2 to 4 weeks.
M. Complete recovery may take 3 to 6 weeks.
N. Call office if rash or jaundice appears.
O. Patient should not donate blood.
XI. Follow-up
A. Diagnosis may not be confirmed on the first visit, even with a high index of suspicion; therefore, patient may need to be seen in 24 to 48 hours for confirmation of the diagnosis or reevaluation.
B. Monospot or heterophil antibody test becomes positive 1 week after onset of illness.
C. Recheck weekly until patient is completely recovered and splenomegaly no longer persists.
D. More frequent telephone contacts may be necessary during acute phase, particularly if throat is so sore that drinking is a problem.
XII. Complications
A. Splenic rupture
B. Neurologic
1. Guillain-Barré syndrome
2. Aseptic meningitis
C. Peritonsillar abscess
D. Airway occlusion
XIII. Consultation/referral
A. Marked toxicity, splenomegaly, or respiratory compromise (may require prednisone)
B. Markedly enlarged tonsils and difficulty swallowing (may require prednisone)
C. Jaundice