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American Medical Society of Sports Medicine Position Statement: Mononucleosis and Athletic Participation
Margot Putukian1, Christopher A McGrew2, Holly J Benjamin3
1Major League Soccer, Princeton, New Jersey.
Abstract:
Infectious mononucleosis (IM) is a common illness in children and young adults caused primarily by the Epstein-Barr Virus (EBV). Transmission occurs primarily through sharing oral secretions, thus IM is known as the "kissing disease." Common clinical manifestations include fever, pharyngitis, posterior cervical lymphadenopathy, and splenomegaly. Atypical lymphocytosis and transaminase elevations are common, and the diagnosis of IM is confirmed with laboratory findings of a positive heterophile antibody ("Monospot"), polymerase chain reaction, or antibodies specific to EBV. Individuals with acute IM may be quite symptomatic and not feel well enough to participate in sports. Splenic enlargement is common, with rupture a relatively rare occurrence, typically occurring within a month of symptom onset, but this risk complicates sports participation, and is often the reason for restricting activity. The management of IM is primarily supportive, with no role for antivirals or corticosteroids. The variability of clinical presentation and the risk of splenic rupture in patients with IM present clinicians with challenging return to play/return to sport (RTS) decisions. This position statement updates the Evidence-Based Subject Review on Mononucleosis by the American Medical Society for Sports Medicine published in 2008 and reviews the epidemiology, clinical manifestations, laboratory assessment, and management including RTS for the athlete with IM. This statement also addresses complications, imaging, special considerations, diversity and equity considerations, and areas for future clinical research. Understanding the evidence regarding IM and sport is essential when communicating with athletes and their families and incorporating shared decision-making in the RTS decision.
Insights
Infectious mononucleosis (IM), caused by Epstein-Barr Virus (EBV), presents challenges for athletes due to potential spleen enlargement. This review offers updated guidance on managing IM and facilitating safe return to sports (RTS).
Area of Science:
- Sports Medicine
- Infectious Diseases
- Pediatrics
Background:
- Infectious mononucleosis (IM), commonly known as the "kissing disease," is a frequent illness in children and young adults, primarily caused by the Epstein-Barr Virus (EBV).
- Clinical signs include fever, pharyngitis, lymphadenopathy, and splenomegaly, with diagnosis confirmed by heterophile antibody tests or EBV-specific antibodies.
- Athletes with IM face challenges in returning to play (RTP) due to symptomatic illness and the risk of splenic rupture.
Purpose of the Study:
- To provide an updated evidence-based review on infectious mononucleosis (IM) for athletes.
- To guide clinicians on the management of IM, including return to sport (RTS) decisions.
- To address complications, imaging, special considerations, and future research in IM and athletic participation.
Main Methods:
- This position statement synthesizes current evidence on IM epidemiology, clinical presentation, diagnosis, and management.
- It specifically focuses on return to play (RTP) guidelines for athletes diagnosed with IM.
- The review incorporates updates since the 2008 American Medical Society for Sports Medicine review.
Main Results:
- Infectious mononucleosis (IM) management is primarily supportive, with no established role for antiviral or corticosteroid therapies.
- Splenic enlargement is a common complication, posing a risk of rupture, which is a critical factor in return to play (RTP) decisions.
- Variability in clinical presentation and RTS risks necessitate careful, individualized decision-making for athletes.
Conclusions:
- Updated guidelines are crucial for managing infectious mononucleosis (IM) in athletes, balancing recovery with safe return to sport (RTS).
- Shared decision-making between clinicians, athletes, and families is essential for navigating RTS protocols.
- Further research is needed to refine understanding and management of IM in athletic populations.
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