Quiz 15

An 18 year old boy comes to the ER and you are the medical physician on call. He has a sore throat and he got Ampicillin from a walk in clinic in the area. He now has developed a maculopapular rash all over his body and also complains of difficulty in swallowing.(A question like this has been seen in at least 2 board exams)

Q1. Which one of the following statements about his condition is FALSE?

  1. A similar problem is seen in patients on allopurinol if they receive Ampicillin.
  2. CLL gives a similar problem
  3. Monospot test is the test of choice in making the diagnosis
  4. Acute HIV syndrome resembles the disease
  5. He should be considered allergic to Ampicillin

The answer is choice 5. (It is the false statement). This patient has been described so that the diagnosis of Infectious mononucleosis can be easily made. A maculopapular erythematous rash is seen in patients with infectious mononucleosis who receive Ampicillin/Amoxycillin. Ampicillin/Amoxycillin also produce a similar rash in patients who have either CLL(Chronic lymphocytic leukemia) or those who are on Allopurinol therapy. Monospot is the best test to look for Infectious mononucleosis (Paul-Bunnell test is not in use for this purpose in the US). Always beware of the Acute HIV syndrome in the exam and in real life - because you could easily miss it if you are not actively thinking about it. It can have the exact same presentation except that Ampicillin is not known to cause the rash in such patients. DO NOT GIVE AMPICILLIN/Amoxycillin JUST TO MAKE A DIAGNOSIS IN A "MONO" PATIENT.

Q2. You look into his throat and see that the tonsils are enlarged and both tonsils are meeting in the center and closing down on the oropharynx. What is the most appropriate next step?

  1. Tracheotomy (mini-trach)
  2. Call ENT on call for emergency tracheostomy
  3. Intubate nasally and protect the airway
  4. High dose IV steroids
  5. Intubate using a fiber-optic endoscope

The answer is choice 4. In mono, a situation like this responds very well to Steroids. There is no need to do any invasive procedure unless the situation is causing shortness of breath due to laryngeal obstruction (the earliest sign you will find is tachypnea). The patient should be closely observed for worsening.