Low quality research, infectious mononucleosis, and clinical experience.


People and doctors think twice

For a test that’s ten times the price

When for a positive test

The treatment is rest

And the quick, easy lab seems so nice. 

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In 2010, I danced back from the brink of burnout and traveled for a year doing temporary medical assignments from Barrow, Alaska to New Zealand’s South Island.  I’m now working at a Community Health Center part-time, which has come to mean 54 hours a week.

Eight viruses belong to the human herpesvirus family.  Herpes 1 brings cold sores or fever blisters; herpes 2 gives the recurrent STD blisters.  Herpes 3 is the Varicella-Zoster virus and gives rise to chickenpox and shingles.  The Epstein-Barr virus belongs to the same family, and causes infectious mononucleosis, or mono.

My personal experience with mono came in January of 1969, with a sore throat, nausea, loss of appetite and headache.  I dragged myself to the Department of University Health, got a blood test and went to sleep for the next week and dragged myself back.  The doctor declared I did not have mono.

I didn’t get better, and 8 weeks later dragged myself to a different doctor in the same building who announced the diagnosis of mono.  No, I replied, the other doctor told me the test came up negative.  Well, he said, look at the lab slip.

Sure enough, someone had written the word POSITIVE on the yellow 3×5 lab slip.

They used the Beef Heterophile Agglutination test back then; the updated version carries the trade name MonoSpot.

Twenty percent of the population cannot make the chemical that causes the reaction; we now have sophisticated confirmatory tests that can distinguish between mono acute, chronic, recent past, distant past, and not mono.  But it costs ten times more than the Monospot.

Chronic mono happens but not very often; those patients who get it have other problems with their immune systems.

I had to explain those things to a patient Wednesday who kept having problems with recurrent severe sore throats (and who gave me permission to include a good deal more information than I have) for years.

The standard treatment for mono boils down to six weeks of bed rest.  More common non-standard treatment includes steroids.

No one would use the word brilliant to refer to the research done last century on the use of Tagamet (cimetidine) in mono.  The patients in each arm numbered in the few dozen.  The publication did not mention the dose.

Within 5 years of reading the article I had personally treated more mono patients with cimetidine than had been in the original study.  After 10 years, I could tell my patients my clinical experience: 25% of mono patients bounce back dramatically under Tagamet in less than 24 hours, 50% bounce back but less dramatically in less than a week, and 25% do not respond.

The patient considered the costs of the lab tests and the cost of the generic cimetidine, and decided for treatment.

I’ll know the outcome next week.


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