Posted tagged ‘sore throat’

Top ten things you didn’t know about mono. And kittens. (You won’t believe what happens next!)

January 15, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

So I noticed that blog posts cast as questions and answers, or “top ten lists”, seem to get a lot of hits. It also seems to help to include gratuitous references to high school, and pictures of kittens. And pleas to share with friends, and vague connections to charity. So let’s give it a try! If you love kittens and sunshine, be sure to share this with every human on the planet! For every share, some kind of charity will get loads of money. Probably.

Thanks to Kristi for the mono questions.


1. What’s mono?

“Mono” is short for “infectious mononucleosis”, a common viral infection of childhood. The “monocytosis” refers to what the blood smear looks like under a microscope– there are often a lot of white cells called “monocytes.”

Kids with mono have a wide range of illness. Some, especially younger children, are barely sick– maybe with a bit of sore throat and fever. Teenagers often fare worse, sometimes with a severe sore throat, swollen lymph nodes, fevers, and very low energy that can linger for weeks. And some people have active mono, spreading virus, with no symptoms at all.


2. What causes mono?

Classic mono is usually caused by a virus called “Epstein Barr” (often abbreviated EBV). A very similar illness can be caused by other viruses (CMV, or acute HIV), or other infections (toxoplasmosis.)


3. Is it true that you can only get it from kissing?

Well, maybe not only. During mono illness the saliva is loaded with mono virus, so sharing spit is the best way to give it to a friend or loved one. Mono can also spread by sharing utensils or cups, but the most efficient way to share saliva is kissing. Especially when standing upright in a high school hallway. So watch out!

Mono does not spread through casual or household contact.


4. How long is mono contagious?

It’s likely that people are most contagious when they feel the sickest with fever– but at least some people will continue to shed EBV in their saliva for many months, maybe even a year or two. And yes, they’re contagious that whole time. Did I mention kissing in the hallway wasn’t a great idea?


5. How long is the incubation period? I mean, how long does it take to get sick?

The incubation period varies. It’s probably in the range of 30-90 days. So when a teenager comes down with mono, it’s just about impossible to figure out who they caught it from.


6. What’s up with the spleen thing? I don’t even know what a spleen is!

IKR! I thought a spleen was a word Shakespeare used to confuse people:

“Saint George / Inspire us with the spleen of fiery dragons!”

“Haply my presence / May well abate the over-merry spleen”

But it turns out the spleen is an organ at the top left of your abdomen, usually tucked up under your ribs there. In about 40-50% of teenagers with mono, the spleen will get enlarged.

The problem, though, isn’t just that the spleen is large– it’s that rarely the spleen can rupture. And that’s really bad. A spleen rupture can occur even without mono, usually from trauma (like a car accident.) It’s thought that the enlarged spleen that can occur during mono might increase the risk of rupture, especially during tackle or rough sports (though that’s not entirely proven.) It’s also not clear if children with non-enlarged spleens are at risk for rupture during mono, or how long the risk lasts. Some people restrict everyone with mono from rough or tackle sports, regardless of spleen size; others use an ultrasound to measure spleen size (though that’s never been shown to help prevent rupture.) Should kids sit out for a fixed number of weeks, or until the spleen size returns to normal? There is no consensus on this issue. Spleen rupture itself is really quite rare, so it’s hard to do a study of the best way to prevent it.


7. Is it true that you can only get mono once?

Yes, or at least usually. Mono caused by EBV will only happen once in most people, even though the virus itself lurks in your body afterwards. Mono-like symptoms can rarely recur at times of immune compromise. The EBV virus can resurface to cause other health problems if the immune system is really knocked out (during chemotherapy, say, or with advanced HIV infection.)

It’s also possible that other infections trigger mono-like symptoms in some people after EBV infection.


8. Wait a minute. I’ve been tested for mono a bunch of times, and I’ve been told I had it more than once. What’s the deal?

It turns out that there are bunch of different tests for mono. Some show “past infections” that may have occurred years ago. Because you “test positive” for mono, that doesn’t mean you have acute mono right now. It might just mean you got over mono years and years ago. It depends on the test.


9. How is mono treated?

Rest, rest, rest. Fever reducing medicine can help if fevers are making you feel bad (though the fever itself won’t hurt you.) Extra fluids, pain medicine for the sore throat, and sleep.

Rarely, steroids are used. This can help especially if the swollen glands in the throat are making it hard to drink or talk or breathe.

Fully resting at the worst part of the illness seems to help prevent mono from turning into weeks or months of malaise and low energy. However, you don’t want to rest and miss school too long– once you’re starting to feel better, try to make it back to school at least part days, and work up from there. Though rest is important, too much rest for too long leads to deconditioning and social isolation, which can make it hard to return to full activities. Teens with more-severe mono sometimes need an individualized treatment plan with a roadmap to get them recovered and back to school.


10. Did you pad this out to ten questions?


The many causes of sore throat: Diagnostic pearls

June 26, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Sallie wrote in about what to do when a common complaint is caused by an uncommon diagnosis. Her child was having a lot of sore throats, one after another, and saw a lot of doctors before the final diagnosis was reached. It’s a good question, and a golden opportunity to talk about keeping your mind open to new ideas, especially when things aren’t progressing as expected.

Pearl #1: Common diagnoses are common

Common things happen commonly—or, in other words, when someone is sick, it’s much more common for it to be a common illness than an uncommon illness. 90% of sick visits to pediatricians are for one of 5 diagnoses. Those rare things you read about on the internet? They don’t happen much. That’s why they’re called “rare.”

For people with a sore throat, the very common diagnosis is a viral infection that will get better. These infections begin with a sore throat, then turn into a stuffy nose and cough. There may be some fever and aches. We’ve all had this, multiple times. It’s an upper respiratory infection, and it’s the single most common driver of pediatric visits. And we still don’t have any effective treatment for it. Humbling.

One other common diagnosis that causes sore throat is a strep infection, or “strep throat.” (It’s never “strept throat.” I have no idea where that extra “t” comes from.) Strep is less common a viral sore throat, but it’s still fairly common. So many people with sore throat (especially when accompanied by fever and red tonsils and enlarged lymph nodes) get a strep test to see if it’s viral or strep.

Sore throats can be caused by other common infections, too: influenza, mononucleosis, or laryngitis. These usually cause other symptoms that make the diagnosis easy (or easy-ish), but sometimes they don’t… which leads us to the next pearl:

Pearl #2: It is much more common for common diseases to present uncommonly, than for uncommon diseases to present at all

Most people with influenza will have fevers and aches, in addition to sore throat; most people with croup or laryngitis will have hoarse voices or a barky cough; most people (at least teenagers) with mono will have fevers and tiredness in addition to their sore throat. But, again, not always. And these common conditions will sometimes fool you by not causing every expected symptom.

Or: let’s say a child has frequent sore throats—but they don’t seem to be viral or bacterial. That is, they’re not accompanied by fevers or runny noses or cough, and strep tests come back negative. What’s likely to be going on? It could be a genuinely weird, uncommon diagnosis—or, more likely, it could be a common thing that’s presenting in an odd manner. For instance, GERD (reflux) is common, and usually presents with heartburn or spitting up or an obvious sensation of food coming up into the mouth. But sometimes, it can cause sore throats.

Pearl #3: Even though they’re rare, if you keep looking you’ll find uncommon diagnoses Pearls #1 and #2 pretty much discount rare diagnoses, because they’re rare. But: every once in a while, those rare things do happen. But if doctors stop looking for them, they’ll never find them. Nearly everyone has a common diagnosis—except those rare people who don’t. And no one comes into the office with a stamp on their forehead that says “Think! I have something rare!”

Chronic or recurrent sore throats can rarely be caused by, among other things, a mass or tumor in the throat; or by nerve damage that prevents the vocal cords from operating normally; or by irritation from a toothpaste or mouthwash. Or from yelling frequently, especially if you’re not yelling correctly (yes, there’s a right way to yell that will cause less damage to your throat. Some people don’t do it right.)

One quite-rare example of a cause of chronic or recurrent unexplained throat pain is Eosinophilic Esophagitis (EE). This is an inflammatory condition that usually causes mostly esophageal symptoms (symptoms similar to heartburn, or to a feeling of food getting “stuck.”) Rarely, this uncommon condition can present in a very uncommon way: with sore throat. Which is actually, after a prolonged diagnostic journey, what Sallie’s son turned out to have.

The only way to diagnose EE is with a biopsy—you have to look down there, in the throat, with a scope, and get some tissue. Not everyone with sore throats needs that kind of evaluation. But we need to keep in mind that at least some kids with common complaints might just have something genuinely rare going on. If we don’t look, we’ll never see.

Hey! If you liked thinking about this—the way doctors think about making diagnoses, about looking for needles in haystacks and thinking critically about clues and medical mysteries, you might enjoy my lecture series at The Great Courses! It’s called “Medical School For Everyone”, and it’s a series of 24 medical case studies for laymen to try to figure out. I’ll give you the clues! Check it out through that link, and let me know what you think!

Strep test horrors

September 5, 2009

The Pediatric Insider

© 2009 Roy Benaroch, MD

Sandy said, “Do you have a suggestion on how to handle a child who is hysterical at the thought of a strep test? Not just ‘I don’t want to’ but screaming and crying hysterically, running around the exam room to avoid the nurses.”

I’ve seen kids like this—scared out of their wits. I know a strep test isn’t the most pleasant thing in the world, but some children think they’re the most painful, horrible thing possible. Fighting and holding them down won’t help dispel their fears!

First, I hope that your pediatrician only wants to do a strep test if it’s really necessary. Most sore throats, even in the winter during strep season, are not caused by strep bacteria. Strep throat typically looks like this:

  • Sudden onset
  • Severe sore throat, with red and swollen tonsils
  • Swollen, tender lymph nodes in the neck
  • Usually fever
  • Sometimes abdominal pain, nausea, or vomiting
  • Sometimes headache
  • Seldom cough or runny nose

Most viral sore throats are more like this:

  • More gradual onset
  • Milder sore throat, without swollen nodes, or with small non-tender nodes
  • Often runny nose and cough
  • Fever, if present, will only be there for the first day or so

Based on the symptoms and physical exam, you and your doc can make a pretty good guess whether it’s likely to be strep. If it seems far more likely to be viral, it’s unnecessary to do the test. In fact, it’s more than unnecessary—it’s a very bad idea. A strep test isn’t perfect; if the “pre-test probability” of strep is very low, even a positive test will probably be incorrect.

What if based on the symptoms and physical exam the possibility of strep is very high? In that case, it may also be a good idea to skip the test—your doctor is probably going to prescribe antibiotics anyway, so why do the test? Strep tests are most important in that grey zone, when it’s kind of hard to know for sure whether an infection is likely to really be strep.

Taking it a step further, what would happen if you and the doctor decided to just skip the test, and make a guess? One of these four scenarios would occur:

  1. The child really has strep, and you’ve decided to give antibiotics. Well, that’s just peachy.
  2. The child really has strep, but you’ve decided against giving antibiotics. In this case, Junior will most likely get better anyway—but it will take a few extra days, and in the meantime he might be infecting other people. There’s also a small, but real chance that the infection can spread into an abscess, and a very small risk that untreated strep could result in heart damage from rheumatic fever (this is often given as the main reason to do the strep test, to avoid untreated strep. But in fact rheumatic fever for reasons unknown has become very rare in the developed world, even without antibiotics being used.)
  3. The child doesn’t have strep, but you put him on antibiotics anyway. We’d like to avoid doing this—unnecessary antibiotics contribute to bacterial resistance, and put your child at risk for allergies. Still, a single course of antibiotics is unlikely to make a huge difference in any significant way.
  4. The child doesn’t have strep, and you’ve decided to withhold antibiotics. Perfect.

Though it sounds like sacrilege to say it, this Pediatric Insider thinks: none of these four scenarios is likely to end in disaster.

So think carefully, and ask for your pediatrician’s input: for a child truly terrified of a strep test, is it really necessary to do it? Under ordinary circumstances, I think a strep test should always be done prior to antibiotics—there are risks of antibiotic overuse that are a real problem—but in an individual case where a child is going to be traumatized, there really is wiggle room for compassion and judgment.

OK, you’ve decided: you need to do the test. There are ways to (hopefully) minimize the discomfort and anxiety of the child. Some of these tricks I’ve tried:

  • Let the doctor do it instead of the nurse. I think some patients think I’m more gentle. I don’t know if that’s correct, but if makes Junior feel better, I’m game to try.
  • Let the child do it himself. Really. Tell Junior to hold the stick, and stick it down there, and swoosh it around. I’ll look with a flashlight to make sure you did it right, and I’ll keep my hands behind my back—promise. This really has worked for me, more than once.
  • If the child’s willing to work slowly with me, I’ll take the swab and just rest it on his tongue awhile. Let him get used to it. Keep talking, distracting, and inching it back. It sometimes might take a few false starts, but this can work.
  • Spray benzocaine solution back there to numb things up, wait 10 minutes, then do the test. Honestly, I’m not sure if maybe the benzocaine spray might interfere with the test—but at least the child feels he’s overcome some fear, and you can build from this positive experience in the future.

One thing I would not recommend is brute force. It might work—once—but it reinforces the worst lessons and scariest feelings, leaving the child vulnerable and completely out of control. It also makes future interactions a nightmare. Whether a strep test is done is never a critical issue. This isn’t someone who might be having a heart attack, or who needs an essential test to see if he has cancer. Keep things in perspective, and have some compassion. He probably feels pretty bad already, and doesn’t need some big galoot holding him down!