Infectious mononucleosis (mono) caused by Epstein-Barr virus (EBV) or occasionally by cytomegalovirus (CMV) deserves special mention. Splenomegaly and spleen fragility are often associated with mono and are a concern for team physicians because of the risk of splenic rupture. The prolonged fatigue accompanying mono is also especially difficult for athletes trying to return to training as soon as possible.

Epstein-Barr virus is prevalent and shed in saliva, thus, mono's reputation as the "kissing disease." About 50% of the U.S. population seroconverts by age 5 years, with a mild viral syndrome or asymptomatically. If an individual reaches college age (18-22) without infection, seroconversion results in a 30% to 70% incidence of mono (Schooley, 1999). Symptoms include 1 week of significant flulike symptoms with anterior and often significant posterior cervical lymph-adenopathy and exudative pharyngitis. Splenomegaly occurs in 50% of cases during weeks 2 to 3 of illness and usually resolves by weeks 4 to 6. Splenomegaly is difficult to confirm on examination alone and should be suspected in all athletes with mono. Significant fatigue is often prevalent, and although most symptoms resolve by 4 weeks, fatigue can last 12 weeks or longer (Rea et al., 2001).

Once suspected, the diagnosis of mono should be confirmed because of the risk of splenic rupture and implications for withholding sports participation. The diagnosis can be confirmed by a positive EBV heterophile antibody (Monospot) with 90% sensitivity by 3 weeks. False-negative results are common in the first 2 weeks, with a positive test in only 40% of those infected during the first week of illness. Therefore, an initially negative Monospot test in a suspicious case should be repeated 1 week later. An EBV or CMV viral capsid antigen (VCA) immunoglobulin M (IgM) assay can also provide evidence of acute infection, with 90% sensitivity at the onset of symptoms (Cohen, 1998).

There is no clear evidence-based answer for when an athlete with mono can safely return to sports. The risk of splenic rupture associated with sporting activity occurs almost exclusively in the first 3 weeks of illness (Kinderknecht, 2002). Many authorities recommend restriction from noncontact sports for 3 weeks, until symptoms have largely resolved and the spleen is not palpable. Returning athletes to contact sports can be considered after 4 weeks of illness, when all symptoms have resolved and splenomegaly is absent (Auwaerter, 2004). The range for normal spleen size varies significantly, and splenic ultrasound is not necessary in most cases but can be considered before returning an athlete to contact sports. Larger-than-normal ranges for splenic size have been described for taller athletes (Spielmann et al., 2005).

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