Dr Jerin.K.John,Dr C.Jayakumar,DrPraveena Bhaskaran ,DrNavya George
16 year old boy apparently normal presented with sore throat and dysphasia of 2 weeks duration associated with high grade intermittent fever for more than 2 weeks duration.Actually he came to our hospital hospital on his own when Bone marrow examination was suggested as part of work up .He was running fever ofTmax of 102 -103 on most of the days. Clinically child had several cervical lymph nodes of size 2 x 1 cms and bilateral epitroclear lymph nodes with no focus in drainage area.
He also had bilaterally enlarged grade 2 tonsils with grey white patch and Hepatomegaly of 5cm below the right coastal margin and soft spleen of4cm in the left hypochondrium .
Other system wise clinics exam were negative
Differentials
Streptococcal tonsillo pharyngitis
EBV infection
Diphtheria
Kawasaki disease Atypical
Agranulocytosis
Oral Candidiasis
Initial labs done showed increased inflammatory markers (CRP 11.9 mg/l)with increased counts T-11.600/cmm N-11,L-75)predominantly lymphocytes.
LFT AST 166IU/L,ALT 240 IU/L)
EBV IGM was strongly positive
Peripheral smear Showed atypical lymphocytes
Cultures of blood and urine,Widal were negative
Chest X-ray normal
Child was Managed with hepatoprotectives.
and symptomatic medications
No antibiotics was given
Diagnosis Infectious mononucleosis
He was clinically and lab wise normal on follow-up after 3weeks
Mononucleosis classically presents with fever, lymphadenopathy, and tonsillar pharyngitis. EBV is a type of herpesvirus spread contact, typically with salivary secretions. The duration of oral shedding is not entirely clear, but high levels of shedding can continue for a median of 6 months after illness onset. Transmission is generally person-to-person, but EBV is not considered a highly contagious disease. EBV infects the epithelial cells of the salivary glands and the oropharynx. Lymphocytes residing in the tonsils get exposed to the virus and then enter the bloodstream. Lymphoid hyperplasia is common and may be seen as generalized lymphadenopathy, tonsillitis, and hepatosplenomegaly. Treatment is generally supportive for mononucleosis. Antipyretics and anti-inflammatory medications help to treat fever, sore throat, and the general fatigue seen in this illness. Hydration, rest, and good nutritional intake should also be encouraged
Classically described as ‘Kissing disease ‘but over crowded night stay for prolonged time in closed space could also lead to the spread
IMN is notorious for its long term complication
Children should be advised it o avoid contact sports till at-least spleen recedes as there is chance for its rupture
Peripheral smear should be repeated after three weeks if there is atypical lymphocyte
reported
Ultra short course of prednisolone for one day may be beneficial if there is severe obstruction for breathing at night and to prevent catastrophe
Carry home message
Clinical findings and lab helped him to avoid Bone marrow
Caveat Bone marrow examination is a safe procedure and should be done as peripheral smear is only a tip of iceberg