Working Diagnosis:
(1) COVID-19
(2) Reactivation of Epstein-Barr Virus consistent with infectious mononucleosis

Treatment:
Patient was withheld from activity for 3 weeks. Symptoms improved gradually over 2 weeks. Athlete underwent a clinical evaluation for cardiac pathology related to COVID-19 including ECG, hs-troponin, and echocardiogram which were all normal.

Outcome:
After clinical improvement and normal lab testing, she was started on a 5-day cardiac progression protocol and returned to full activity. The athlete experienced no adverse events related to her diagnosis.

Author's Comments:
This is a pertinent case that highlights the importance of maintaining a broad differential in the setting of the COVID-19 pandemic. In this patient, identification of an acute Epstein-Barr viral coinfection (EBV) with an active COVID-19 infection altered the return to play plan after diagnosis.
Though there is a scarcity of literature, reports suggest EBV may be reactivated in the setting of a COVID infection and should be a consideration for testing in contact athletes. This is especially difficult to discern due to the considerable overlap between symptom reports for both COVID-19 and infectious mononucleosis, including but not limited to fever, fatigue, pharyngitis, nausea, among others.
At the time of the case, the isolation period for COVID-19 infection was 10 days followed by a cardiac evaluation with ECG, hs-troponin, and echocardiogram recommended by the author's sports medicine department. The cardiac progression was then gradually increased over 5 days. Since then, CDC guidelines have shortened positive test isolations to as little as 5 days with theoretical return to sport on day 6. Additionally, guidelines from major sports medicine and athletics societies including AMSSM and NCAA suggest no additional cardiac testing which would expedite a return to sport. However, individuals with an EBV infection are recommended to withhold from athletic participation for 21-31 days to prevent splenic injury. While patients with infectious mononucleosis can be asymptomatic, reactivation of this illness with COVID-19 infection does put an athlete at risk for developing splenomegaly and rupture.

Editor's Comments:
Epstein-Barr virus (EBV) is a type of herpes virus that causes infectious mononucleosis (IM) which many refer to as "mono". It is believed that EBV is so widely disseminated within the human population that up to 95% of adults possess EBV antibodies. EBV is spread via oral secretions. It is important to note that not all individuals infected with EBV become symptomatic.
For those who do develop infectious mononucleosis, symptoms typically begin with malaise, headache, and fever. Sore throat, tonsillitis, posterior cervical lymphadenopathy, and severe fatigue often develop as well.
Splenomegaly can develop in approximately 50% of patients with IM. the risk of splenic rupture increases in those dealing with symptomatic IM. This risk is greatest within the first 14 days of infection and drops significantly after the third week. Due to this data it is advised that all athletes withhold from athletic participation for at least 21 days after symptom onset with IM, regardless of sport.

References:
Putukian, Margot, et al. "Mononucleosis and athletic participation: an evidence-based subject review." Clinical Journal of Sport Medicine 18.4 (2008): 309-315.

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