What are the next steps for a 24-year-old patient with congestion, mild pharyngitis, ear fullness, and cervical lymphadenopathy, who is undergoing a mononucleosis (monospot) test and complete blood count (CBC)?

Management of a 24-Year-Old with Suspected Infectious Mononucleosis

For a 24-year-old patient with congestion, mild sore throat, ear fullness, and cervical lymphadenopathy, you should complete the monospot test and CBC, and additionally test for EBV-specific antibodies (VCA IgM, VCA IgG, and EBNA IgG) to confirm or rule out infectious mononucleosis.

Diagnostic Approach

Current Testing (Appropriate)

• Monospot test (heterophile antibody test)
  • Sensitivity of 87% and specificity of 91% 1
  • May be falsely negative during the first week of illness 1
• Complete blood count (CBC) with differential
  • Look for lymphocytosis (>40% lymphocytes) with atypical lymphocytes (>10%) 1

Additional Testing to Consider

1. EBV-specific serology if monospot is negative but clinical suspicion remains high:

   • VCA IgM, VCA IgG, and EBNA IgG 2
   • Interpretation:
     • Acute infection: VCA IgM (+), VCA IgG (+), EBNA IgG (-)
     • Past infection: VCA IgM (-), VCA IgG (+), EBNA IgG (+)
     • No previous infection: VCA IgM (-), VCA IgG (-), EBNA IgG (-) 2

2. Liver function tests

   • Elevated liver enzymes increase clinical suspicion for infectious mononucleosis, especially with a negative heterophile antibody test 1

3. Throat culture if Group A Streptococcal pharyngitis is suspected

   • Consider this if patient has persistent fevers, anterior cervical adenitis, and tonsillopharyngeal exudates 3
   • Note that EBV infection and strep throat can coexist

Management Plan

If Infectious Mononucleosis is Confirmed:

1. Supportive care

   • Rest and adequate hydration 2
   • Analgesic therapy (acetaminophen, NSAIDs) for pain and fever 3
   • Throat lozenges for symptomatic relief 3

2. Activity restrictions

   • Avoid contact sports or strenuous exercise for 8 weeks or while splenomegaly is present 2, 4
   • Monitor for splenomegaly (occurs in approximately 50% of cases) 4

3. Monitoring for complications

   • Be vigilant for upper airway obstruction, which can be a rare but life-threatening complication 5
   • Watch for signs of splenic rupture (occurs in 0.1-0.5% of cases) 4
   • Monitor for severe fatigue persisting beyond 3 months 4

If Group A Streptococcal Pharyngitis is Confirmed:

1. Antibiotic therapy
   • Only if testing confirms streptococcal infection 3
   • Benefits include shortening symptom duration by 1-2 days and preventing complications 3

If Both Tests are Negative:

1. Consider other viral causes
   • Most acute pharyngitis is viral in etiology 3
   • Common causes include adenovirus, parainfluenza virus, rhinovirus, and respiratory syncytial virus 3
   • Treatment remains supportive

Important Considerations

• Avoid unnecessary antibiotics if bacterial infection is not confirmed 3, 2
• Corticosteroids are not routinely recommended for uncomplicated infectious mononucleosis 1
• Monitor for persistent symptoms beyond 6 months, which may indicate chronic active EBV infection 2
• Patient education about the typical course of illness (most symptoms resolve within 2-4 weeks, though fatigue may persist longer) 4

Follow-up Recommendations

• Schedule follow-up in 1-2 weeks to assess symptom resolution
• Instruct patient to return sooner if experiencing:
  • Severe abdominal pain (concern for splenic rupture)
  • Difficulty breathing or swallowing (concern for airway obstruction)
  • Persistent high fever
  • Worsening symptoms after initial improvement

This approach provides comprehensive diagnostic and management strategies while avoiding unnecessary testing and treatments for this common condition in young adults.