A More Comprehensive Approach to Identifying Patients with Mononucleosis

A new systematic review provides advice for earlier, more accurate diagnosis of patients with infectious mononucleosis to help expedite proper treatment.

Symptoms are of limited value for the diagnosis of mononucleosis; sore throat and fatigue are sensitive but nonspecific. When mono patients present with enlarged tonsils and swollen glands, many physicians assume the issue is strep throat and prescribe antibiotics, completely useless against viral mono. "By overusing antibiotics, we increase resistance of bacteria," said study leader Mark H. Ebell, MD, MS, professor, College of Public Health, University of Georgia (Athens, GA, USA), "We waste money. We sometimes cause very serious adverse effects like allergic reactions or Clostridium difficile infection."

In addition to preventing the prescription of useless antibiotics, Prof. Ebell also wanted this study to inform the prognosis and recommendations given to patients after diagnosis. "I like to help doctors make the best use of their clinical skills, of the questions they ask, of the exam maneuvers they do, so they know what to focus on when they're seeing a patient," he said, "Also, we tend to focus a lot on diagnosis and treatment in medicine, but I think that the importance of making a good prognosis is underappreciated. Patients often ask: When am I going to feel better, doc?" For example, patients shouldn't expect to get out and play contact sports soon, as the virus enlarges the spleen (splenomegaly) and puts it at risk of rupturing.

In the 1990s, when Prof. Ebell first published on mono, "what I was struck by then was how limited the research was,” he said, "So I wanted to revisit that area and see if the research had improved over the past 20 years." Prof. Ebell and colleagues set out to systematically review studies involving the clinical diagnosis of mono. Their goal was to determine how clinicians can best use the presence of signs & symptoms and lab tests for white blood cell (WBC) counts.

Their review relied on articles from PubMed and EMBASE dating from 2015 back to 1966 and 1947, respectively. These articles were narrowed to 11 studies that allowed the researchers to look at effectiveness of physical exams and WBC count analysis in detecting mono in individual patients.

They found that the best predictors of mono were swollen posterior cervical or axillary lymph nodes, fatigue, and enlarged spleen, as well as % of a patient's WBCs that are lymphocytes or atypical lymphocytes. Having over 50% lymphocytes or 10% atypical lymphocytes greatly increased the likelihood of mono.

Prof. Ebell noted that the "literature is still pretty bad" when it comes to analyzing mono, but he plans to work in collaboration with UGA's University Health Center to: examine the accuracy of the Monospot test (a screening test for presence of viral antibodies in blood); evaluate the signs & symptoms of patients; and analyze individual patients’ prognoses over the course of illness.

The report, by Ebell MH et al, was published April 12, 2016, in the Journal of the American Medical Association (JAMA).

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