At the Bedside

  • Classic syndrome: fever, pharyngitis, fatigue, posterior cervical LAD, tonsillar exudates, palatal petechiae, splenomegaly.
  • Key exam points:
  • Assess airway: muffled voice, drooling, stridor, severe tonsillar hypertrophy.
  • Palpate abdomen for splenomegaly/LUQ tenderness.
  • Look for rash, jaundice, hepatomegaly, or neurologic findings.
  • Differential:
  • GAS pharyngitis, acute HIV, CMV mono-like illness, toxoplasmosis, gonococcal pharyngitis, peritonsillar abscess, leukemia/lymphoma.
  • Testing:
  • Heterophile antibody/Monospot: specific but may be falsely negative early, especially first week or in young children.
  • CBC: atypical lymphocytosis, lymphocyte predominance.
  • LFTs: mild transaminitis common.
  • Rapid strep/throat culture if GAS possible.
  • Consider HIV Ag/Ab + HIV RNA if high-risk mono-like illness.
  • Management:
  • Supportive: oral/IV fluids, NSAIDs/acetaminophen, throat analgesia.
  • Avoid amoxicillin/ampicillin unless clear bacterial indication — high rate of morbilliform rash in EBV.
  • No routine antivirals.
  • Steroids only for complications: impending airway obstruction, severe tonsillar edema, severe hemolytic anemia, severe thrombocytopenia, CNS involvement.
  • Disposition:
  • Discharge if tolerating PO, no airway compromise, no severe cytopenias, reliable follow-up.
  • Admit for airway risk, dehydration unable to tolerate PO, severe hepatitis, significant thrombocytopenia/hemolysis, neurologic complications.
  • Activity counseling:
  • Avoid contact sports/heavy lifting for at least 3 weeks from symptom onset and until clinically well; longer if splenomegaly or persistent symptoms. Splenic rupture risk is highest in first 3–4 weeks.
A Classic Presentation
A 19-year-old college student presents with 6 days of fever, severe sore throat, fatigue, and swollen neck glands. Exam shows exudative tonsillitis, palatal petechiae, posterior cervical lymphadenopathy, and mild LUQ fullness. Rapid strep is negative, CBC shows lymphocytosis with atypical lymphocytes, and Monospot is positive. She receives NSAIDs, oral fluids, return precautions for abdominal pain/syncope, and counseling to avoid contact sports for at least 3 weeks.

Study Directive

  • Draw a quick mono differential: EBV, CMV, acute HIV, toxoplasmosis, GAS, lymphoma.
  • Memorize 3 ED complications: airway obstruction, splenic rupture, severe cytopenias.
  • Practice counseling script: “No contact sports/heavy lifting for at least 3 weeks and until fully recovered.”
  • Review interpretation limits of Monospot testing during the first week of illness.

Recent Literature