What is the next step in managing a patient with persistent fatigue and mild abdominal pain one month after a diagnosis of infectious mononucleosis (mono), with a previously normal complete blood count (CBC) and positive mononucleosis test?

From the Guidelines

For a patient with persistent fatigue and mild abdominal pain one month after a diagnosis of infectious mononucleosis, I recommend further evaluation to rule out complications or alternative diagnoses, starting with liver function tests and an abdominal ultrasound to assess for hepatitis and splenomegaly, as these are common complications of mono that can cause abdominal pain and fatigue 1. The patient's symptoms of ongoing fatigue and mild abdominal pain warrant investigation to rule out potential complications of mononucleosis, such as hepatitis or splenic rupture.

• Liver function tests, including AST, ALT, bilirubin, and alkaline phosphatase, should be ordered to evaluate for hepatitis, a common complication of mono that can cause abdominal pain.
• An abdominal ultrasound should be performed to assess the liver and spleen, as splenomegaly can persist for weeks to months after mono infection.
• Consider testing for other viral infections that can cause similar symptoms, such as CMV, EBV titers (to confirm recent infection), and hepatitis panel.
• A comprehensive metabolic panel would help assess overall organ function.
• Persistent fatigue after mono is common and can last 3-6 months, but ongoing abdominal pain warrants investigation to rule out complications like splenic rupture or hepatitis.
• If liver function tests are abnormal, referral to a gastroenterologist may be appropriate.
• In the meantime, recommend supportive care with adequate rest, hydration, and avoidance of contact sports if splenomegaly is present, as suggested by the management of fatigue in adult survivors of cancer 1. The most recent and highest quality study on management of fatigue in adult survivors of cancer suggests that a comprehensive approach to managing fatigue is essential, including evaluation of contributing factors and implementation of supportive care measures 1.
• The study highlights the importance of assessing for underlying causes of fatigue, such as anemia, hypothyroidism, and adrenal insufficiency, and managing these conditions accordingly.
• Additionally, the study recommends referral to a physical therapist for assessment and treatment of deconditioned state, which can contribute to persistent fatigue 1.

From the Research

Next Steps in Managing Persistent Fatigue and Mild Abdominal Pain

• The patient's symptoms of persistent fatigue and mild abdominal pain one month after a diagnosis of infectious mononucleosis (mono) should be evaluated further 2.
• A thorough review of systems, physical examination, and laboratory tests may be necessary to determine the cause of the patient's symptoms 3, 2.
• The location of the abdominal pain can help guide further evaluation, and imaging studies such as ultrasonography or computed tomography may be recommended based on the location of the pain 2.
• Laboratory tests may not be useful in guiding evaluation or treatment for fatigue, as abnormal laboratory results do not necessarily indicate the cause of fatigue 4.
• A comprehensive assessment of the patient's fatigue should include evaluation of potential causes such as pain, emotional distress, sleep disturbance, anemia, and hypothyroidism 3, 5.
• Management of fatigue should be cause-specific, and treatment should be tailored to the underlying cause of the fatigue 3, 5.
• Nonpharmacologic interventions such as moderate exercise, restorative therapies, and nutritional and sleep interventions may be beneficial in managing fatigue 3, 5.
• Pharmacologic therapy such as antidepressants or erythropoietin may be considered if specific causes of fatigue are identified 3, 5.