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Just another simple case of infectious mononucleosis?

Just another simple case of infectious mononucleosis?

Chen, Jay; Konstantinopoulos, Panagiotis A; Satyal, Sharad; Telonis, James; Blair, Donald C. The Lancet361. 9364 (Apr 5, 2003): 1182.

Abstract (summary)

The usual presentation of infectious mononucleosis is a triad of fever, pharyngitis, and adenopathy, although many other conditions are seen, including hepatitis, thrombocytopenia, and neutropenia.1 Diagnosis is usually made clinically in conjunction with a positive Monospot; EBV serology can be used to confirm the diagnosis. The presence of pleural effusions and ascites made the simple diagnosis of infectious mononucleosis questionable. Pleural effusion has rarely been reported in association with infectious mononucleosis, with fewer than twenty cases worldwide.2 Only seven cases of ascites complicating infectious mononucleosis have been reported, five of whom also had pleural effusions.3,4 Diagnosis in all reported cases was approached by aspirating the fluid. In this patient no invasive diagnostic procedure was done. It is possible that ascites and pleural effusions are more common complications of infectious mononucleosis than previously thought. Nevertheless, this report shows that ascites and pleural effusions can accompany infectious mononucleosis; and, given an otherwise typical clinical presentation, aggressive diagnostic intervention may not be warranted.

Full text

A previously healthy 19-year-old woman came to an emergency room in Connecticut on July 5, 2002, with a two-day history of fever to 39[middot]4[degrees]C, lymphadenopathy, myalgias, malaise, night sweats, fatigue, and intermittent rash on her thighs. White blood cell count was 4[middot]2x10^sup 9^/L (granulocytes, 19%; bands, 25%; lymphocytes, 42%; and monocytes, 13%) and platelet count was 141^times;10^sup 9^/L. Monospot test was negative. Doxycycline was begun empirically and she was discharged home. Because of persistent symptoms, she presented to the University Hospital, Syracuse, New York, on the seventh day of her illness. Monospot test was positive, and she was released home with a diagnosis of infectious mononucleosis. On the 11th day of illness she was admitted to hospital with new-onset tea-colored urine and continued fever to 39[middot]4[degrees]C. Tender bilateral cervical lymphadenopathy, a macular rash on both thighs, and minimal tonsillar enlargement without exudate were found. She had a mild leucocytosis (13[middot]0x10^sup 9^L) with 78% atypical lymphocytes; mild thrombocytopenia (138x10^sup 9^/l); slight anaemia (haemoglobin, 11[middot]6 g/dL) with normal red-blood-cell indices. There was elevation of hepatocellular and ductal enzymes (alanine aminotransferase, 211 U/L; aspartate aminotransferase,169 U/L; alkaline phosphatase, 567 U/L); elevated bilirubin; elevated lactic dehydrogenase (2053 U/L); and decreased haptoglobin (30 mg/dL). Hepatitis A, B, and C serologies, urine analysis, coagulation profile, electrocardiogram, and blood and urine cultures were negative. Computed tomography (CT) scan of the torso and abdomen showed small bilateral pleural effusions (figure , A), a small amount of ascites around the liver and Morrison's pouch (figure, B, C, D), and porta hepatis and portocaval lymphadenopathy (not shown). The ascites and bilateral pleural effusions were not tapped. Borrelia burgdorferi and Babesia microti serologies were negative. Ehrlichia PCR was negative.

Lymphocyte immunophenoryping (CD4, 14%; CD8, 82%; and CD4/CD8 ratio of 0.17. CD19 was 1% with no light-chain restriction) was consistent with acute Epstein-Barr Virus (EBV) infection, and did not support a diagnosis of a lymphoproliferative disorder. EBV antibody responses were consistent with acute infectious mononucleosis. The liver function abnormalities gradually increased and periorbital oedema developed. By the 37th day of her illness, she was clinically back to normal and her liver function tests had returned to normal.

The usual presentation of infectious mononucleosis is a triad of fever, pharyngitis, and adenopathy, although many other conditions are seen, including hepatitis, thrombocytopenia, and neutropenia.1 Diagnosis is usually made clinically in conjunction with a positive Monospot; EBV serology can be used to confirm the diagnosis. The presence of pleural effusions and ascites made the simple diagnosis of infectious mononucleosis questionable. Pleural effusion has rarely been reported in association with infectious mononucleosis, with fewer than twenty cases worldwide.2 Only seven cases of ascites complicating infectious mononucleosis have been reported, five of whom also had pleural effusions.3,4 Diagnosis in all reported cases was approached by aspirating the fluid. In this patient no invasive diagnostic procedure was done. It is possible that ascites and pleural effusions are more common complications of infectious mononucleosis than previously thought. Nevertheless, this report shows that ascites and pleural effusions can accompany infectious mononucleosis; and, given an otherwise typical clinical presentation, aggressive diagnostic intervention may not be warranted.

There were no conflicts of interest in this study, nor any funding sources.

Sidebar

Lancet 2003; 361: 1182

Department of Medicine, Division of ilnfectious Diseases, SUNY Upstate Medical University, 750 Adams Streey Syracuse, NY 13210, USA (J Chen BS, A Kanstantinopoulos MD, S Satyal MD, J Telonis MD, Prof D C Blair MD)

Correspondence to: Prof Donald C Blair (e-mail: blair@upstate.edu)

References

1 Cohen JI. Medical Progress: Epstein-Barr Virus Infection. New Eng J Med 2000; 343: 481-92.

2 Gathof BS, Kamilli I, Keller C, Zollner N. Pleural effusions in acute mononucleosis. Bildgebung. 1991; 58: 218-20.

3 Devereaux CE, Bemiller T, Brann O. Ascites and severe hepatitis complicating Epstein-Barr infection. Am J Gastroenterol 1999; 94: 236-40.

4 Colebunders R, Pen J, Mathijs R. Pleural effusion and ascites in infectious mononucleosis. Acta Clin Belg 1983; 38: 189-95