Rhabdomyolysis, Not So Fast My Friend! - Page #4
 

Working Diagnosis:
Infectious Mononucleosis

Treatment:
Supportive treatment and rest
Remove from sport for at least 3-4 weeks from the onset of symptoms to reduce risk of splenic rupture
No evidence of quicker recovery with routine use of corticosteroids or acyclovir (corticosteroids reserved only for complications)

Outcome:
The athlete developed fatigue a few days after presentation which resolved after the first week. No other symptoms developed. Weekly LFT’s were followed which normalized around 2 weeks after diagnosis. His urine grossly cleared to normal within 1 week of presentation. A repeat abdominal ultrasound 2 weeks after diagnosis revealed resolution of splenomegaly.


The athlete was allowed to start non-contact cardiovascular activities 3 weeks from his initial presentation. All symptoms had resolved and LFTs had normalized. Splenomegaly had resolved (between weeks 2 and 3).
He was then progressed to full contact around 3.5 weeks from symptom onset. No return of symptoms or new symptoms after return to play. Athlete did not miss any subsequent practices. He started every game of the season.

Author's Comments:
90% due to Epstein-Barr Virus. 10% due to CMV, HHV-6, HHV-7.
Symptoms-typically fever, pharyngitis, fatigue, LAD
In one study, 77% had the usual IM syndrome, 12% had atypical symptoms, and 11% were asymptomatic

Diagnosis- History + labwork
CBC-lymphocytosis >50%, >10% atypical lymphocytes, other tests-“Monospot,” EBV IgG, EBV IgM, EBNA
Majority will also have elevated transaminases

Special Considerations in the Athlete
Splenic Enlargement
Present in 50-60% of cases, developing within the 1st 2 weeks
Increased risk of rupture-commonly day 2-21, rare after week 4
May consider abdominal ultrasound with interval follow-up prior to RTP.
Fatigue
Resume training according to symptoms-start at a reduced intensity and progress as tolerated
Athletes may take 3-4 months before returning to pre-morbid performance level.

Editor's Comments:
1. Heterophile antibody testing has high specificity (84-100%) but can be falsely negative in 25% of patients in first week. Thus, depending on the situation and resources, a reasonable approach to diagnosis might be to start with heterophile antibody test and then get a complete blood count with a differential (either concurrently or if heterophile antibody test is negative). A lymphocyte count < 4,000 mm^3 has 99% negative predictive value while atypical lymphocytes >10% had 92.3% specificity.
Doing the specific EBV antibody tests are good confirmatory tests (97% sensitivity and 94% specificity) but take longer and are more expensive. Again, considering the timing/urgency and resources, these tests could be the secondary tests if heterophile antibody and the CBC with diff are not conclusive and suspicion is still high.

I would also advocate for doing a thorough lymph node exam, especially looking at axillary, epitrochlear and inguinal nodes (in addition to the commonly checked neck nodes).

The recent AFP article contained the statistics quoted above
Am Fam Physician. 2015 Mar 15;91(6):372-6

The utility of ultrasound is limited because size of normal spleen is so variable. In this case, getting the sono to look at other causes is reasonable if the blood tests had not come back yet to confirm mono.
Also, important to caution the infected athlete to avoid all valsalva maneuvers during the first 3-4 weeks.

For those that work with teams, it's always a good reminder that theses athletes do not need to be isolated as transmission rates are low. However, avoidance of sharing of utensils and good hand-washing is important as transmission occurs via oral secretions. Asymptomatic athletes previously infected can shed the virus.

References:
1. Balfour HH Jr, Odumade OA, Schmeling DO, Mullan BD, Ed JA, Knight JA, Vezina HE, Thomas W, Hogquist KA. “Behavioral, virologic, and immunologic factors associated with acquisition and severity of primary Epstein-Barr virus infection in university students.” J Infect Dis. 2013;207(1):80.
2. Ebell, M. H., “Epstein-Barr Virus Infectious Mononucleosis.” Am Fam Physician. 2004 Oct 1;70(7):1279-1287.
3. Hosey RG1, Kriss V, Uhl TL, DiFiori J, Hecht S, Wen DY. “Ultrasonographic evaluation of splenic enlargement in athletes with acute infectious mononucleosis.”Br J Sports Med. 2008 Dec;42(12):974-7. doi: 10.1136/bjsm.2008.050807. Epub 2008 Sep 18.
4. Maki DG, Reich RM. “Infectious mononucleosis in the athlete. Diagnosis, complications, and management.” Am J Sports Med. 1982 May-Jun;10(3):162-73.
5. Putukian, M, O’Connor, F, Stricker, P., McGrew, C., Hosey, R., Gordon, S., Kinderknecht, J, Kriss, V., Landry, G. “Mononucleosis and Athletic Participation: An Evidence Based Subject Review.” American Medical Society for Sports Medicine. Kansas, Overland Park, 25 Aug 2008. Retrieved from https://www.amssm.org/SearchResults.html
6. Taga, K, Taga, H., Tosato “Diagnosis of atypical cases of infectious mononucleosis.”Clin Infect Dis. 2001 Jul 1;33(1):83-8. Epub 2001 Jun

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