Since IM largely affects teenagers and young adults, many of whom participate in sports and other physical activities, participation in these activities should likely be avoided. The question may arise as to when a patient with IM may return to sports or other physical activities. A case review of splenic rupture in athletes with IM showed that almost all patients had splenomegaly presenting between days 4 and 21 of illness onset and splenic rupture occurring between 4 and 7 weeks after illness onset.
There are no specific guidelines that state when a patient with IM may return to athletic participation, but the general recommendation is roughly 3 weeks after initial symptom onset for athletes to resume activity in noncontact sports and at least 4 weeks after symptom onset for strenuous contact sports or activities that can lead to increased abdominal pressure e. In the case of high contact or collision sports, a radiologic evaluation of the spleen might be warranted before return to activities.
It may take several months for athletes to regain a pre-illness level of fitness. Chronic Fatigue: Whereas resolution of acute symptoms of IM is typical in 1 to 2 weeks, fatigue may linger for months. A study by Katz et al examined the course and outcome of CFS in adolescents aged 12 to 18 years over a 2-year period following IM. This study showed that female gender was associated with a greater incidence of CFS.
Pharmacists can play a key role in the management and education of IM. The appearance of a morbilliform rash after penicillin administration for pharyngitis may signal that IM is the cause of the pharyngitis. Although prescription agents are not usually necessary for IM, counseling on selection of NSAIDs or acetaminophen for supportive care may be needed.
Providing answers to commonly asked questions about avoidance of sports and fatigue may also be needed. Infectious mononucleosis. Accessed February 1, Luzuriaga K, Sullivan J. N Engl J Med. Infectious mononucleosis in the athlete. Am J Sports Med. Infectious mononucleosis in adults and adolescents.
Haines JD. When to resume sports after infectious mononucleosis: how soon is safe? Postgrad Med. A prospective clinical study of Epstein-Barr virus and host interactions during acute infectious mononucleosis. J Infect Dis. Vetsika EK, Callan M. Infectious mononucleosis and Epstein-Barr virus. Expert Rev Mol Med. Current diagnosis and management of infectious mononucleosis. Curr Opin Hematol. Hoagland RJ. Prim Care. Spontaneous rupture of the spleen detected on CT as the initial manifestation of infectious mononucleosis.
Emerg Radiol. Peter J, Ray CG. Pediatr Rev. Effect of acyclovir on infectious mononucleosis: a double-blind, placebo-controlled study. Lack of effect of peroral acyclovir for the treatment of infectious mononucleosis. Torre D, Tambini R.
Acyclovir for treatment of infectious mononucleosis: a meta-analysis. Scand J Infect Dis. A virologic pilot study of valacyclovir in infectious mononucleosis. J Clin Virol. Corticosteroid therapy in Epstein-Barr virus infection effect on lymphocyte class, subset, and response to early antigen.
Arch Intern Med. Acyclovir and prednisolone treatment of acute infectious mononucleosis: a multicenter, double-blind, placebo-controlled study. Candy B, Hotopf M. Steroids for symptom control in infectious mononucleosis. Cochrane Database Syst Rev. Burroughs KE. Athletes resuming activity after infectious mononucleosis. Arch Fam Med. Spontaneous splenic rupture in infectious mononucleosis. Am J Roentgenol. Eichner ER. Phys Sportsmed.
Oski FA. Management of a football player with mononucleosis. Pediatr Infect Dis J. Determination of safe return to play for athletes recovering from infectious mononucleosis: a review of the literature. Clin J Sport Med. Noffsinger J. Physical activity considerations in children and adolescents with viral infections. Pediatr Ann. Post-infective and chronic fatigue syndromes precipitated by viral and non-viral pathogens: prospective cohort study. The chronic fatigue syndrome: a comprehensive approach to its definition and study.
Ann Intern Med. Chronic fatigue syndrome after infectious mononucleosis in adolescents. Featured Issue Featured Supplements. US Pharm. Diagnosis Patients with IM commonly complain of sore throat and fatigue. Pharmacologic Treatment Recommended therapy for management of IM has not changed much over the years.
Two hundred six patients met the criteria for a diagnosis of IM. The group with positive antibody tests represented The adolescent and young adult population aged represented Sex was fairly evenly split, with 99 male patients The history at presentation varied, but most commonly included sore throat Average duration of symptoms at presentation was 9.
The most common physical finding was cervical lymphadenopathy Laboratory evaluation found that patients The 6 patients 2. Twelve 9. Of the patients who had been seen on a separate occasion by their primary care physician PCP , 30 All but 4 of these patients The dosages and indications for use in these 4 patients were not available, and they were not included in further analysis of patients who received SCT. Specific steroids used, dosages, routes of administration, and duration of treatment differed dramatically among the population studied.
In general, patients who were not admitted received 1 intravenous dose of dexamethasone sodium phosphate, 0. Inpatients generally received dexamethasone, 0. However, similar consistency was not present with antibiotic use. While treatment would have been considered to have failed in all of these patients because of their subsequent ED presentation, fewer than half 28 of 63 [ The overall antibiotic use rate by the ED or hospital was Of the patients included in the study, Sixty-four of patients Indications for admission included severe and persistent symptoms, dehydration, hyperpyrexia, concern for airway obstruction, and other systemic complications.
Average hospital length of stay was 4. Otolaryngology consultation was obtained in 37 The reported disease complication rate was 5. Surgical intervention was required in 15 patients 7. For the remaining 81 patients Patient groups with and without SCT were compared for sex, age, disease severity, history of a previous visit, hospital admission rates, otolaryngology consultation, and complications of IM. No positive correlation between SCT and sex, age, or any other clinical characteristics used to diagnose IM eg, fever, duration of symptoms, tonsillar hypertrophy was identified.
However, analysis of SCT based on history of a previous visit revealed that patients seen by their PCP on an occasion before ED presentation were more likely to receive steroids than were those seen for the first time. Similarly, patients admitted to the hospital were nearly twice as likely to receive steroids as those managed as outpatients Table 1. These patients were most likely those with the most severe clinical symptoms. Patients seen by otolaryngologists were also more likely to receive SCT.
Indeed, As might be expected, analysis of the patients seen by otolaryngologists revealed increased rates of dehydration, dysphagia or odynophagia, tonsillar exudate, and tonsillar hypertrophy. However, the increased use of SCT by otolaryngologists was not supported by an increased rate of airway obstruction in these patients. Concern for possible airway compromise was mentioned in only 3 8. In an effort to compare clinical course and outcomes between SCT and non-SCT groups, rates of hospital admission, length of stay, and incidence of complications were compared, and no significant differences were identified Table 2.
As for the question of steroids and infectious complications, SCT use has been implicated previously in the development of infectious complications of IM, 6 - 8 although little evidence exists to support this claim. Examination of justifications given by practitioners in this study for the use of prophylactic antibiotic therapy suggests persistent concern in this regard. Indeed, the most commonly cited justification for antibiotic therapy when no clear indication existed was concern about possible bacterial superinfection with the use of SCT.
It is interesting, however, that 4 of the 8 infectious complications of IM 3 peritonsillar abscesses and 1 mediastinal abscess developed in the relatively small group of 17 patients who received SCT but no antibiotics from their PCP at initial presentation. Femur head necrosis, a rare but previously described complication of short-term SCT, was not found in any patient during or after the study.
Although IM is usually a self-limited illness, clinicians continue to search for ways to decrease the severity and duration of the symptoms. Corticosteroids have long been considered a potentially promising solution to this problem. Empirical reports of therapeutic benefit abound, and many studies have attempted to either corroborate or dispute these claims.
Early studies by Prout and Dalrymple, 1 Bender, 2 and Klein et al 3 randomly assigned large populations of college students with IM to receive SCT or placebo with or without antibiotics. These studies generally concluded that patients given SCT had decreased duration of fever and shorter duration of symptoms. Although more recent studies 15 have noted similar results, studies by Collins et al 4 and most recently by Tynell et al 5 found no improvement in duration of illness, sore throat, weight loss, or absence from school or work.
While controversy surrounds the issue of steroids and uncomplicated IM, clinicians universally agree that SCT is indicated in the case of airway obstruction secondary to IM. Several authors have described their success in averting emergency surgical procedures eg, tonsillectomy, tracheostomy with the use of SCT and intravenous fluids in patients with impending airway obstruction. The question of SCT use in IM is not just relevant because of the potential for improvement of symptoms.
Transient depression of non—EBV-specific cell-mediated immune functions early in the course of IM is well documented. Despite all of the suspicions about SCT, no differences in complication rates have been reported. Our similar complication rate between treated and nontreated groups agrees with previous findings. However, it must be remembered that, despite the apparent similarity in complication rates, dosages, duration of SCT, and the use of concurrent antibiotic therapy differed significantly among the treated population, making comparison more difficult.
Major references and review articles consistently recommend against the use of SCT in most patients with IM. Reasons for this discrepancy and the merits of this practice are probably difficult to describe. One explanation may be that patients demand results and clinicians prescribe in response to demand. The significant use of antibiotics in the setting of negative streptococcal cultures, as in this study, and the increased use of SCT when patients returned with persistent symptoms support this hypothesis.
This was highlighted in an editorial by Disney, 31 who empirically noted dramatic differences in symptom relief in his patients who were treated with corticosteroids. He asserted, as have many other clinicians, that he would continue to offer his patients what was, to him, an obviously beneficial treatment despite what the literature might say.
Finally, the apparent increased use of SCT by otolaryngologists may be partially accounted for by their heightened awareness of serious infectious and airway complications of any type of pharyngitis. This theory is supported in that most patients seen by otolaryngologists had significant tonsillar hypertrophy. The treatment of IM has been and will continue to be a subject of controversy and debate.
While recommendations and clinical studies dealing with IM are abundant, no recent studies have examined management practices and related outcomes. Our study corroborates previous assessments of typical symptoms, presentation, findings, and overall outcomes of IM. Factors associated with corticosteroid use include a history of more than 1 visit, inpatient admission, and otolaryngologic consultation. No apparent increases or decreases in the incidence of complications, rates of admission, or length of hospital stay were noted with treatment.
However, prospective randomized trials are necessary to definitively assert these findings. Nevertheless, published trials are just one factor contributing to the complex and sometimes difficult task of managing illness. The art of medicine will always be a balance between objective evidence and the experience and wisdom of the practitioner.
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