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Matthew DeLaney, MD and Mike Weinstock, MD
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Patients with mononucleosis may present with non-specific symptoms that may be treated with antibiotics. Traditional teachings have maintained that ~100% of patients with mono who take antibiotics will develop a rash. In reality a minority of these patients will develop this complication. When present the rash is thought to be a hypersensitivity reaction rather than an actual allergy to the medication. While bothersome to the patients this rash is essentially harmless and can be managed with symptomatic treatment.

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sarah s. -

Question: If strep pharyngitis and mononucleosis present the same. If we do a rapid strep and it's negative should we always follow-up with a Monospot?

Mike W., MD -

I would advise against that as almost all of these (over 90%) will b viral pharyngitis. Symptoms and signs of mono (post cerv LAN, prolonged Sx, fatigue, splenomegaly, etc) should prompt a test for mono but rec against doing this routinely. Thx for the comment/question Sarah!

Jacob D., MD -

It was mentioned on this segment that the CDC does not recommend throat culture if the rapid strep is negative. I just looked on the CDC website, and it says: "A positive RADT can be used as confirmation of group A strep pharyngitis in children. However, a negative RADT in a child with symptoms of pharyngitis should be followed up by a throat culture. Clinicians should have a mechanism in place to contact the family and initiate antibiotics if the back-up throat culture is positive".
Can you send the link where it says a culture is not indicated after a negative RADT? I know I just heard that somewhere based on the high sensitivity of the RADT.

Just an aside, I have been suffering from the most painful sore throat ever, to the point where all I can take down is warm liquids. I was working in the office yesterday and asked one of my nurses for some ibuprofen. She asked if I was ok and I told her my throat was hurting. One of my colleague's over heard me, forced me into an exam room and demanded I get a rapid strep and culture at the same time. Based on my symptoms, my Centor=3 (lack of cough, swollen tonsil, and tender ant cervical lymph nodes). I had no intention of testing for strep. My rapid strep came back negative, so my colleague insisted on sending the culture against my wishes. They said if I had strep, I should go home, but if not, it was ok to be at work.

Mike W., MD -

The CDC rec was for adults not kids as they still rec culture w kids. Sorry for your sore throat and hope it is better now... of course by the time your culture returns, you will probably be better!

Suzanne B. -

How long should you wait before doing a mono spot test? 1-2 weeks?

Mike W., MD -

Thx for the question - here is DeLaney's comments on the monospot test, false negative 25% in the first week of illness:

The heterophile antibody test, also known as the monospot, is the most reliable test in the diagnosis of mononucleosis. The monospot test as a 25% false negative rate during the first week of illness and its accuracy only increases the longer the patient has been symptomatic. It is also inaccurate in patients under the age of 12 with only a 25-50% sensitivity in this younger cohort. For patients in the first week of illness or in patients younger than age 12, serology is the preferred method of diagnosis. Specifically, a positive IgM of the viral capsid antigen, (VCA) indicates an acute infection with EBV. If serology or monospot testing is not available, send a CBC and liver function tests which will show a leukocytosis with atypical lymphocytes seen on peripheral blood smear as well as an elevated LDH, AST and ALT.

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Hacking Up A Lung Full episode audio for MD edition 176:04 min - 83 MB - M4AHippo Urgent Care RAP - April 2018 Written Summary 365 KB - PDF