Mononucleosis (glandular fever) presents with fever, malaise, sore throat, and lymphadenopathy. A physical exam shows tonsillar swelling, petechiae, hepatosplenomegaly, and rash. Blood tests show atypical lymphocytes and positive monospot or heterophil tests. Treatment includes rest, prednisone for severe symptoms, and antibiotics only if a strep test is positive. Complications like airway obstruction or spleen rupture are rare.

1. Mononucleosis (Glandular Fever)
Presentation
The patient is usually of school age (nursery through night school) and complains of
several days of fever, malaise, lassitude, myalgias, and anorexia, culminating in a
severe sore throat. The physical examination is remarkable for generalized
lymphadenopathy, including the anterior and posterior cervical chains and huge tonsils,
perhaps meeting in the midline and covered with a dirty-looking exudate. There may
also be palatal petechiae and swelling, splenomegaly, hepatomegaly, and a diffuse
maculopapular rash.
What to do:
• Perform a complete physical examination, looking for signs of other ailments,
and the rare complication of airway obstruction, encephalitis, hemolytic anemia,
thrombocytopenic purpura, myocarditis, pericarditis, hepatitis, and rupture of the
spleen.
• Send off blood tests: a differential white cell count (looking for atypical
lymphocytes) and a heterophil or monospot test. Either of these tests, along with
the generalized lymphadenopathy, confirms the diagnosis of mononucleosis, but
atypical lymphocytes are less specific, being present in several viral infections.
• Culture the throat. Patients with mononucleosis harbor group A streptococcus
and require penicillin with about the same frequency as anyone else with a sore
throat.
• Warn the patient that the convalescence is longer than that of most viral
illnesses (typically 2-4 weeks, occasionally more), and that he should seek
attention in case of lightheadedness, abdominal or shoulder pain,or any other
sign of the rare complications above.
• Despite controversy, prednisolone is widely employed for symptomatic relief of
infectious mononucleosis, usually 40mg of Prednisone qd for five days. It is
particularly helpful in young adults with severe pharyngeal pain, odynophagia or
marked tonsillar enlargement with impending oropharyngeal obstruction.
• Arrange for medical followup.
What not to do:
• Do not routinely give penicillin for the pharyngitis, and certainly do not give
ampicillin. In a patient with mononucleosis, ampicillin can produce an
uncomfortable rash, which, incidentally, does not imply allergy to ampicillin.
• Do not unnecessarily frighten the patient about splenic rupture. If the spleen is
clinically enlarged, he should avoid contact sports, but spontaneous ruptures are
rare.

2. Discussion
All of the above probably apply to cytomegalovirus as well, although the severe
tonsillitis and positive heterophil test are both less likely. Some who report having mono
twice probably actually had CMV once and mono once.