Infectious mononucleosis: return to play

American Medical Society of Sports Medicine Position Statement: Mononucleosis and Athletic Participation

ABSTRACT

Infectious mononucleosis (IM) is a common illness in children and young adults caused primarily by the Epstein-Barr Virus (EBV). Transmission occurs primarily through sharing oral secretions, thus IM is known as the "kissing disease." Common clinical manifestations include fever, pharyngitis, posterior cervical lymphadenopathy, and splenomegaly. Atypical lymphocytosis and transaminase elevations are common, and the diagnosis of IM is confirmed with laboratory findings of a positive heterophile antibody ("Monospot"), polymerase chain reaction, or antibodies specific to EBV. Individuals with acute IM may be quite symptomatic and not feel well enough to participate in sports. Splenic enlargement is common, with rupture a relatively rare occurrence, typically occurring within a month of symptom onset, but this risk complicates sports participation, and is often the reason for restricting activity. The management of IM is primarily supportive, with no role for antivirals or corticosteroids. The variability of clinical presentation and the risk of splenic rupture in patients with IM present clinicians with challenging return to play/return to sport (RTS) decisions. This position statement updates the Evidence-Based Subject Review on Mononucleosis by the American Medical Society for Sports Medicine published in 2008 and reviews the epidemiology, clinical manifestations, laboratory assessment, and management including RTS for the athlete with IM. This statement also addresses complications, imaging, special considerations, diversity and equity considerations, and areas for future clinical research. Understanding the evidence regarding IM and sport is essential when communicating with athletes and their families and incorporating shared decision-making in the RTS decision.

A brief overview of the Epstein Barr virus and its association with Burkitt's lymphoma

Epstein Barr virus (EBV) is known as an oncovirus and associates with several human malignancies such as Burkitt's lymphoma, other non-Hodgkin lymphomas, nasopharyngeal carcinoma, Hodgkin's disease, gastric adenocarcinoma, etc. in Burkitt's lymphoma, and the key event is the translocation of MYC gene, that increase of cell survival and aberrant expression of MYC gene. The biology of EBV and its function in the development of Burkitt's lymphoma are discussed in this review

Association of Splenic Rupture and Infectious Mononucleosis: A Retrospective Analysis and Review of Return-to-Play Recommendations

BACKGROUND

Infectious mononucleosis is typically a self-limited disease commonly affecting young adults. Splenic rupture is a rare but serious complication affecting 0.1% to 0.5% of patients with mononucleosis. Current guidelines (based on published case reports) recommend complete activity restriction for 3 weeks after onset of mononucleosis symptoms to reduce rupture risk. We examined actual timing of mononucleosis-associated splenic injury using a large repository of unpublished patient data.

HYPOTHESIS

The risk of splenic injury after infectious mononucleosis will remain elevated longer than previously estimated.

STUDY DESIGN

Retrospective case series.

LEVEL OF EVIDENCE

Level 4.

METHODS

The Military Health System Management Analysis and Reporting Tool (M2) was used to conduct a retrospective chart review. Coding records of TRICARE beneficiaries aged 5 to 65 years between 2006 and 2016 were screened. Patients diagnosed with both splenic injury and mononucleosis-like symptoms were identified, and their medical records were reviewed for laboratory confirmation of infection and radiographically evident splenic injury.

RESULTS

A total of 826 records of splenic injury were found in M2. Of these, 42 cases met the study criteria. Mean time to splenic injury was 15.4 (±13.5) days. Only 73.8% (n = 31) of injuries occurred within 21 days, and 90.5% (n = 38) of splenic injuries occurred within 31 days of symptom onset.

CONCLUSION

A substantial number of splenic injuries occur between 21 and 31 days after symptom onset. While most splenic injuries were atraumatic, consideration should be given to extending return-to-play guidelines to 31 days after symptom onset to minimize risk. Risk of chronic pain after splenic injury may be higher than previously believed.

CLINICAL RELEVANCE

The risk for postmononucleosis splenic injuries remains elevated longer than current guidelines suggest. Restricting activity for 31 days after mononucleosis symptom onset may reduce the risk of splenic injury.

Exercise and the Athlete With Infectious Mononucleosis

OBJECTIVE

To determine appropriate management of the active individual with infectious mononucleosis (IM), including issues of diagnosis, the determination of splenomegaly, and other measures of disease status, the relationship of the disease to chronic fatigue syndrome (CFS), and the risks of exercise at various points in the disease process.

DATA SOURCES

An Ovid/MEDLINE search (January 1996-June 2015) was widely supplemented by "similar articles" found in Ovid/MEDLINE and PubMed, reference lists, and personal files.

MAIN RESULTS

Clinical diagnoses of IM are unreliable. Traditional laboratory indicators (lymphocytosis, abnormal lymphocytes, and a heterophile-positive slide test) can be supplemented by more sensitive and more specific but also more costly Epstein-Barr antigen determinations. Clinical estimates of splenomegaly are fallible. Laboratory determinations, commonly by 2D ultrasonography, must take account of methodology, the formulae used in calculations and the individual's body size. The SD of normal values matches the typical increase of size in IM, but repeat measurements can help to monitor regression of the disease. The main risks to the athlete are spontaneous splenic rupture (seen in 0.1%-0.5% of patients and signaled by acute abdominal pain) and progression to chronic fatigue, best avoided by 3 to 4 weeks of restricted activity followed by graded reconditioning. A full recovery of athletic performance is usual with 2 to 3 months of conservative management.

CONCLUSIONS

Infectious mononucleosis is a common issue for young athletes. But given accurate diagnosis and the avoidance of splenic rupture and progression to CFS through a few weeks of restricted activity, long-term risks to the health of athletes are few.

Approach to the Underperforming Athlete

Children and adolescents who participate in intense sports training may face physical and psychologic stresses. The pediatric health care provider can play an important role in monitoring an athlete's preparation by obtaining a proper sports history, assessing sleep hygiene, discussing nutrition and hydration guidelines, and evaluating physiologic causes of fatigue. Educating parents and athletes on the potential risks of high-intensity training, inadequate rest and sleep, and a poor diet may improve the athlete's performance and prevent symptoms of overtraining syndrome. Infectious mononucleosis must also be considered a cause of fatigue among adolescents. The signs and symptoms of overtraining and burnout are discussed in this article.

Epstein-Barr Virus-Associated Atraumatic Spleen Laceration Presenting with Neck and Shoulder Pain

BACKGROUND

Infectious mononucleosis, caused by the Epstein-Barr virus (EBV), is a common infection with worldwide distribution; more than 90% of people have been infected by adulthood. One of the most feared, albeit rare, complications, occurring in less than 0.5% of those infected, is splenic injury or rupture.

CASE REPORT

A febrile 15-year-old male presented to the emergency department with the chief compliant of headache, neck pain, and upper shoulder pain. He did not recall any specific traumatic injury. His abdomen was soft, nondistended, and was tender in the right and left lower quadrants. Right lower quadrant ultrasound demonstrated non-visualization of the appendix, moderate right lower quadrant free fluid, and positive McBurney's sign. CT of the abdomen and pelvis was ordered, which demonstrated moderate splenomegaly, with findings compatible with laceration through the anterior aspect of the spleen, with moderate hemoperitoneum. Monospot was negative and EBV panel demonstrated IGG negative, IGM positive, and, IGG negative. The patient was transferred to interventional radiology for a splenic angiogram and proximal splenic artery embolization. The angiogram demonstrated grade 3 laceration with moderate hemoperitoneum and no active extravasation or evidence of pseudoaneurysm. The patient was admitted and made a prompt recovery without any other sequelae.

CONCLUSIONS

The presentation of splenic injury or rupture can vary; the patient may complain of abdominal pain or left upper quadrant pain, may exhibit referred left shoulder pain when the LUQ is palpated (Kehr's Sign), or may exhibit hemodynamic instability. Given the spectrum of non-specific symptoms, diagnosing EBV-induced splenic laceration can be difficult.

Return to play after infectious mononucleosis

Context:

Infectious mononucleosis is a disease primarily of adolescence and early adulthood. The risk of splenic injury and chronic fatigue make return-to-play decisions a challenge for the clinician caring for athletes with infectious mononucleosis.

Evidence Acquisition:

Data were obtained from the PubMed and MEDLINE databases through December 2012 by searching for epidemiology, diagnosis, clinical manifestations, management, and the role of the spleen in infectious mononucleosis.

Study Design:

Clinical review.

Level of Evidence:

Level 4.

Results:

Infectious mononucleosis is commonly encountered in young athletes. Its disease pattern is variable and can affect multiple organ systems. Supportive care is the cornerstone, with little role for medications such as corticosteroids. Physical examination is unreliable for the spleen, and ultrasound imaging has limitations in its ability to guide return-to-play decisions. Exercise does not appear to place the young athlete at risk for chronic fatigue, but determining who is at risk for persistent symptoms is a challenge.

Conclusion:

Return-to-play decisions for the athlete with infectious mononucleosis need to be individualized because of the variable disease course and lack of evidence-based guidelines.

Recent advances in the understanding of infectious mononucleosis: are prospects improved for treatment or control?

Symptomatic primary Epstein-Barr virus infection is known more commonly as infectious mononucleosis, an illness known for afflicting adolescents and younger adults as a febrile illness accompanied by pharyngitis and lymphadenopathy. Historically believed to be generally benign, infectious mononucleosis has been linked more recently to increased risks of developing Hodgkin's lymphoma and multiple sclerosis. Advances in the understanding of host immune responses to Epstein-Barr virus have begun to elucidate the reasons why younger children typically experience subclinical infection whereas older individuals develop infectious mononucleosis. This review will highlight recent advances in the understanding of primary Epstein-Barr virus infection, and whether prospective treatments or vaccine strategies may affect native infection and its sequelae.

Spontaneous splenic rupture in infectious mononucleosis: case report and review of the literature

A 15-year-old previously healthy girl presented in full arrest after 1 week of flu-like symptoms, recent diagnosis of infectious mononucleosis, and 1 day of abdominal pain. There was no history of trauma. Focused assessment with sonography for trauma examination showed free fluid in the abdomen. The patient died despite aggressive resuscitative management and emergency laparotomy with splenectomy, which showed grade V splenic laceration. Infectious mononucleosis is a common viral illness of adolescence. Spontaneous splenic rupture is a rare but potentially fatal complication. Anticipatory guidance about the importance of seeking medical care if abdominal pain develops during infectious mononucleosis is crucial to early diagnosis and intervention in the case of rupture. We discuss the current literature surrounding the outpatient follow-up of splenomegaly associated with infectious mononucleosis, as well as current practice and treatment options when rupture occurs.

Return to work following sickness absence due to infectious mononucleosis

BACKGROUND

Epstein-Barr virus infectious mononucleosis among adults is notorious because of the prolonged incapacitating fatigue it causes.

AIMS

To investigate the duration of sickness absence and return to work following infectious mononucleosis.

METHODS

Episodes of sickness absence due to infectious mononucleosis were selected from an occupational health services register. The duration of sickness absence and return to work was assessed with Kaplan-Meier survival analysis.

RESULTS

Two thousand one hundred and thirty-seven episodes of absence due to infectious mononucleosis had a median duration of 91 days. Young employees (aged 15-24 years) had the highest return to work rates. Women had longer sickness absence than men. Employees working in small companies were absent longer than employees in large companies.

CONCLUSIONS

Occupational physicians should advise gradual return to work, starting 4 weeks after the onset of the illness, in order to prevent physical deconditioning and prolonged illness.

Progress and problems in understanding and managing primary Epstein-Barr virus infections

Epstein-Barr virus (EBV) is a gammaherpesvirus that infects a large fraction of the human population. Primary infection is often asymptomatic but results in lifelong infection, which is kept in check by the host immune system. In some cases, primary infection can result in infectious mononucleosis. Furthermore, when host-virus balance is not achieved, the virus can drive potentially lethal lymphoproliferation and lymphomagenesis. In this review, we describe the biology of EBV and the host immune response. We review the diagnosis of EBV infection and discuss the characteristics and pathogenesis of infectious mononucleosis. These topics are approached in the context of developing therapeutic and preventative strategies.

Normative spleen size in tall healthy athletes: implications for safe return to contact sports after infectious mononucleosis

OBJECTIVE

To establish normative parameters of the spleen by ultrasonography in tall athletes.

DESIGN

Prospective cohort observational study.

SETTING

University of Buffalo, Erie County Community College, University of Texas at Tyler, and Austin College.

PARTICIPANTS

Sixty-six athletes enrolled and finished the study. Height requirements were at least 6 feet 2 inches for men and at least 5 feet 7 inches in women.

INTERVENTIONS

Measurement of spleen size in tall athletes.

MAIN OUTCOME MEASURES

Ultrasound measurements of spleen size in tall athletes were compared with "normal-sized" controls from the literature. Mean, SD, and variance determined the sample distribution, and a one sample t test compared measurements in tall athletes with historical measurements in the average height population. Statistical significance was defined as P < 0.05.

RESULTS

Mean height was 192.26 cm (SD, ± 6.52) for men and 176.54 cm (SD, ± 5.19) for women. Mean splenic measurements for all subjects were 12.19 cm (SD, ± 1.45) for spleen length, 8.88 cm (SD, ± 0.96) for spleen width, and 5.55 cm (SD, ± 0.76) for spleen thickness. The study mean for spleen length was 12.192 cm (95% confidence interval, 11.835-12.549) and population mean was 8.94 cm (2 tailed t test, P < 0.01). In this population of tall athletes, normal spleen size was significantly larger than the normal spleen size of an average individual.

CONCLUSIONS

In the clinical arena, it can be difficult to know when the tall athletes with splenomegaly from infectious mononucleosis can safely return to contact sports. Previously, there has not been a sufficient "norm" for this population, but this study helps to establish baseline values.

Mononucleosis and athletic participation: an evidence-based subject review

Infectious mononucleosis (IM) is a common medical condition that afflicts thousands of young athletes each year. Despite the self-limited nature of this disorder, the variability of the clinical presentation and the rare risk of splenic rupture routinely present sports medicine clinicians with difficult return-to-play decisions. Currently there are no evidence-based guidelines regarding the management of the athlete with IM. This review discusses the available research data pertaining to the management of IM in young athletes and develops questions for future clinical research.

Determination of safe return to play for athletes recovering from infectious mononucleosis: a review of the literature

OBJECTIVE

Infectious mononucleosis is an acute self-limited disorder diagnosed by clinical and hematologic measures. This paper reviews the literature regarding the decision-making process for return to play in individuals at risk for complications due to infectious mononucleosis.

DATA SOURCES

Computerized literature search identified articles using the keywords infectious mononucleosis, athlete, injury, exercise, spleen rupture, and spleen radiography. Symptoms, physical examination, hematological markers, and radiographic evaluation were considered.

CONCLUSIONS

No strong evidence-based information supports use of a single parameter to predict the safe return to sports participation. Current consensus supports that athletes be afebrile, well hydrated, and asymptomatic with no palpable liver or spleen. Clinical judgment incorporating these criteria 1 month after diagnosis has been suggested as a safe predictor for gradual return to competition. These conditions for return to play do not guarantee that the spleen has returned to normal size and compliance, or that the risk of spleen rupture has returned to baseline. For those athletes participating in contact sports who wish to return to sports in an earlier time frame, or those with an equivocal examination, radiographic modalities may be used to help determine liver and spleen size. Further studies are required to support this practice.