Return to Play After Infectious Mononucleosis

Abstract

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.

Infectious mononucleosis

“…w62 One study recommended that athletes wanting to return to contact sport at 3-4 weeks should have an ultrasound examination to ensure that the spleen had returned to normal size. w62 A systematic review published in 2014 advocated individualised recommendations for athletes, 18 and future work in this area may concentrate on splenic volume to allow a more accurate assessment of splenomegaly and risk.…”

Confusion and abdominal symptoms following a rugby tackle

“…Most splenic injuries in IM occur between 4 and 21 days after the onset of symptoms but have been reported as much as 8 weeks later 10. The majority are atraumatic, with only 14% of published cases reporting any preceding history of trauma; however, this figure may underestimate the role of minor traumas that may go unnoticed and therefore under-reported 8.…”

“…Sonographic assessment of splenomegaly (and consequently, of its resolution) can only be reliably made in patients for whom baseline measurements have been taken, due to the variability of normal splenic dimensions in the population, though this remains an ongoing area of research 20. Clinical assessment of splenomegaly is notoriously unreliable10 and no correlation has been found between the severity of IM and risk of splenic rupture 21. As such, there is yet no definitive method for establishing when it is safe for an athlete with IM to return to contact sports, hence the advice to avoid high-impact sport (as well as other high-risk activities like heavy lifting and vigorous activity) varies between 4–8 weeks after symptom onset for uncomplicated cases of IM 8 10.…”

Getting Back on the Field

“…The reviews of infectious mononucleosis 1 and febrile illness 2 are insightful and concise. These represent 2 areas where clinicians no longer have to guess at best treatment guidelines.…”