Pediatric Infectious Disease Case (True Life Awesomeness)
16 year old male presents to ED with new-onset severe jaundice, transient rash, fatigue, nausea, vomiting and decreased appetite. Patient’s girlfriend had mono 2 months ago, but monospot test at primary care physician was negative 2 days prior to presentation. No lymphadenopathy or sore throat. Physical exam reveals hepatomegaly and temperature 102 F. Labs showed anemia, thrombocytopenia, leukocytosis, elevated bilirubin & liver transaminases. Patient was admitted to ID floor for further evaluation.
On exam on floor, patient was extremely jaundiced with scleral icterus and marked yellowing of oral mucosa. Initially, no rash was seen. On exam 3 hours later, the following was seen on patient’s abdomen:
(NOTE: DE-IDENTIFIED PHOTO & CASE!)
Patient described the rash as itchy.
Further testing revealed acute EBV infection (mononucleosis), direct coombs consistent with hemolytic anemia and low reticulocyte count consistent with bone marrow suppression.
The virus had caused cold-agglutinin mediated hemolytic anemia. The RBC rupture caused release of bilirubin. The virus had also triggered rapid-onset hepatitis, so his liver was not able to clear the bili, leading to jaundice & LFT abnormalities. FURTHERMORE, the virus caused bone marrow suppression, so his body was not able to compensate for the loss of RBCs.
So remember the following:
- Mononucleosis can present in atypical ways. This patient had no lymphadenopathy, splenomegaly or sore throat. Always have high suspicion based on history
- Mono can have serious sequelae such as hepatitis, hemolytic anemia, bone marrow suppression, splenic rupture and others!
- Monospot testing is specific, but not sensitive! (if positive, believe it. if negative but still suspicious, test further)
I LOVE INFECTIOUS DISEASE
