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A 17-year-old male presents to his physician complaining of 9 days of fatigue, subjective fever, and sore throat.
The subacute presentation of fatigue, fever, exudative pharyngitis, and posterior cervical lymphadenopathy in an adolescent patient make mononculeosis the most likely diagnosis. The heterophile antibody test, colloquially known as the monospot test, is the correct next step.Caused by the Epstein-Barr virus (the majority of the time), mononucleosis is a common condition of adolescence and young adulthood. Return to contact sports following infectious mononucleosis: the role of serial ultrasonography.

His exam reveals a temperature is 102 F, mobile posterior cervical lymphadenopathy, and splenomegaly.
If treated with ampicillin (because of a misdiagnosis of streptococcal pharyngitis), a puritic maculopapular drug rash can appear. Aside from the heterophile antibody test, other laboratory results that supports the diagnosis are a lymphocytosis and >10% atypical lymphocytes (Illustration A). Of note, during the first week of illness, the heterophile antibody test has a sensitivity of only 75% (improves to 85% later in the illness).

Illustration A shows reactive lymphocytosis, with atypical lymphocytes (blue-purple cells with large irregular nuclei).

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