Diagnosis of infectious mononucleosis without fever ...

Infectious mononucleosis (IM) is a common pediatric disease, and more than 90% of cases have fever, with eyelid edema first diagnosed, but no fever, and finally diagnosed with IM cases, have you ever encountered?

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Cases reappear

Child: Female, 4 years old, "eyelid edema 4 days" admitted to hospital.

History: bilateral eyelid edema after a cold 4 days ago, with tears in both eyes without significant hyperemia. With open mouth breathing, occasional cough. No fever, no shortness of breath, no foamy urine, normal urine volume. He was diagnosed with "respiratory infection" at a local hospital and given "cold granules" orally for 4 days, and the eyelid edema of the children was not relieved.

He had poor physical fitness in the past and was hospitalized for "pneumonia" many times. There is a history of adenoidal hypertrophy and tonsillar hypertrophy.

Physical examination: body temperature 36.5 °C, pulse 117 beats/min, weight 15 Kg. Moderate edema of both eyelids, palpable enlarged lymph nodes in both sides of the neck, the largest about 3 * 1 cm, medium mass, range of motion may be. Pharyngeal hyperemia is pronounced, bilateral tonsils II-III°, no purulent discharge and white film. There are no abnormalities on cardiopulmonary examination. The abdomen is flat and soft, palpable at 2 cm below the hepatic ribs and 4 cm below the splenic ribs. There is no edema in both lower extremities.

Laboratory tests: Blood count: WBC 13.72 * 10^9/L, HGB 116 g/L, RBC 4.29 * 10^12/L, PLT 151 * 10^9/L, NEUT 15.8%, LYM 78.9%. CRP< 0.5 mg/L, ESR 7 mm/h, procalcitonin 0.142 ng/mL, ferritin 67 ng/mL. Lipids: triglycerides 2.56 mmol/L, total cholesterol 2 mmol/L. EBV-CA-IgA negative, EBV-EA-IgA negative, EBV-Rta protein IgG negative.

Routine urination, liver and kidney function, creatine kinase, creatine kinase isoenzyme, electrolytes, coagulation function, immunoglobulins, complement normal.

Abdominal ultrasound: regular liver morphology, right hepatic oblique diameter of 97 mm, subcostal length of about 12 mm, spleen morphology is full, parenchymal echo is uniform, spleen thickness is about 29 mm, length diameter is 102 mm, and length under the ribs is about 40 mm, indicating splenomegaly.

Diagnostic ideas

●Exclude common edema factors: the most common causes of edema are cardiogenic edema, renal edema, and hepatic edema. The child is a 4-year-old girl with eyelid oedema as the first symptom, and a history of respiratory tract infection in the early stages of illness, and renal edema should be considered first. However, there is no ascites, edema of both lower extremities, normal serum protein and blood lipids, negative urine protein, and insufficient basis for renal edema.

Children with hepatosplenomegaly but no history of heart disease and signs of congestive heart failure are not considered for cardiogenic edema. Liver function is normal, abdominal color ultrasound does not show signs of portal hypertension, and hepatic edema is not considered.

●Perfect examination to confirm IM: children with eyelid edema onset, white blood cell elevation is dominated by elevated lymphocytes, accounting for 78.9%, combined with angina, lymphadenopathy, and hepatosplenomegaly, infectious mononucleosis is considered. Improved hematological analysis of blood cells can be seen in abnormal lymphocytes 12%, EBV DNA test: 2.76 * 10^3 copies/mL, which can confirm the diagnosis of infectious mononucleosis [1].

After admission to the hospital, acyclovir anti-infection was given for 10 days, the child's eyelid edema disappeared, the liver, spleen, and lymph nodes were significantly smaller than when he was admitted to the hospital, and the peripheral blood cell morphology was reviewed: no abnormal lymphocytes were found; EBV DNA test < 500 copies/mL, and the child's condition improved and he was discharged from the hospital.

Infectious mononucleosis

Infectious mononucleosis (IM) is an acute proliferative infectious disease of the monocyte-macrophage system resulting from EBV infection, typically manifested as a "triad" of fever, angina, and cervical lymphadenopathy, which may be accompanied by hepatosplenomegaly and peripheral blood characterized by increased lymphocytes and dysplasmophils.

The peak age of onset of IM is 4 to 6 years, which is benign self-limiting disease, with a good prognosis in most cases and a few serious complications such as hemophagocytic syndrome [2].

Table 1 Diagnostic basis for infectious mononucleosis[3]

Diagnostic doubt analysis

●Causes of eyelid edema: Im IM diagnosis is not difficult when the child has a "triple sign" and typical symptoms of hepatosplenomegaly. However, for the early stages of the disease, some young children are atypical or have serious complications. In this case, the child began with eyelid edema, and there was no fever during the course of the disease, and the clinical manifestations were atypical. The literature reports that 15 to 25 percent of IM cases may have eyelid edema, possibly related to obstructed blood return due to cervical lymphadenopathy and compression of the cervical veins [4].

IM with eyelid edema as the first symptom is easily misdiagnosed as kidney disease, and it is necessary to carefully examine the body during differential diagnosis, improve liver and kidney function, urine protein testing, complement, anti-"O" testing, and be vigilant against the possibility of infectious mononucleosis.

●No cause of fever: 90 to 100% of children with IM have fever of varying degrees, with variable heat patterns, fever lasting about 1 week, and fever lasting 2 weeks or more in severe cases. Young children may have no fever or only low-grade fever [1]. However, the clinical presentation of IM may vary with host immune response and tissue-organ reactive lymphocyte infiltration [5].

In this case, the child was young, had repeated pneumonia in the past and was admitted to the hospital, and had a weak constitution. The absence of fever during the course of the child's illness and a negative EBV antibody test are presumed to be related to the inability of the body to produce an adequate immune response to Epstein-Barr virus in the early stages of the disease.

Treatment tips: IM has no specific treatment, and is mainly symptomatic and supportive. In the acute phase, bed rest should be taken, and attention should be paid to preventing spleen rupture and avoid squeezing or impacting the spleen. Acyclovir antiviral therapy is optional, but antiviral therapy does not improve symptoms or shorten the course of illness [6].

Co-infections can be treated with antibiotics, but ampicillin and amoxicillin should be avoided to avoid causing hypersensitivity reactions that worsen the condition.

Curated: Sunny days

Title image source: Stand Cool Helo

bibliography:

Li Youyi, Xu Jinghang, Shi Yiyi, et al. Retrospective analysis of EBV antibody titers and DNA load of EPD and clinical features in patients with infectious mononucleosis[J] . Chinese Journal of Infectious Diseases,2018,36 (10): 616-621.

Hu Yamei, Jiang Zaifang, Shen Kunling, Shen Ying. Practical Pediatrics of Zhu Futang[M]. 8th ed. Beijing: People's Medical Publishing House, 2015:916.

Infectious Disease Group, Science Branch of Chinese Medical Association. Expert consensus on principles for the diagnosis and treatment of diseases related to EPS infection in children. Chin J Pediatrics,2021.59(11):905-911.

Wang Xia, Zhan Shuwen. Eyelid edema caused by infectious mononucleosis in children: 25 cases of diagnosis and treatment[J]. Journal of Yangtze University(Self-Science Edition).2014,11(14):14-15.

Chen Hongying, Liu Chunyan, Zou Yan, et al. Clinical characteristics of 218 cases of pediatric infectious mononucleosis[J]. Chinese Journal of Pediatric Hematology and Oncology.2013,18(2):81-83.

[6] De Paor M, O'Brien K, Fahey T, Smith SM. Antiviral agents for infectious mononucleosis (glandular fever)[J]. Cochrane Database Syst Rev. 2016,12(12):CD011487.