A 4-year-old patient came to the clinic for consultation due to tiredness, the examination being normal; 5 days later, she had an urticarial rash on the lower limbs which disappeared on arrival at the clinic. Two days after the last visit, she developed a fever of 38.5oC, it appears that she has a cold and her tiredness has increased, and the macular rash persists, now affecting the lower and upper limbs and face, although we cannot visualise it at the time of the examination either.
Physical examination: periorbital and eyelid oedema, more accentuated in the morning for the last 3 days. Mouth breathing with nasal obstruction, conspicuous sub-maxillary and laterocervical lymphadenopathy, congestive tonsils and on abdominal palpation splenomegaly and hepatomegaly measuring 4 cm. Conspicuous inguinal adenopathies of 2 cm in diameter. Abotarated facies. No exanthema. Neurological normal. Axillary temperature of 38 oC. The rest of the examination and cardiopulmonary auscultation is normal with no signs of respiratory failure.
Laboratory results
- CBC: red blood cells 4,000,000, haemoglobin 10.9 g/dl, haematocrit 31.6%, MCV 78.4. Leukocytes: 21,200 (neutrophils 2%, segmented 31%, lymphocytes 50%, monocytes 5%, reactive lymphocytes 9%, lymphoplasmic cells 3%); platelets 203,400/ml.
- Transaminases: AST 245 and ALT 271 (mU/ml).
- Paul Bunell: negative.
- Urinalysis negative.
At the first visit a chest and abdominal X-ray was performed: alveolar condensation affecting LSD and corresponding to pneumonia; possible hilar adenopathies; abdomen with moderate splenomegaly.
Four days later, repeat examination: positive agglutination test (infectious mononucleosis). Hb 10.6; Htct 31.1; MCV 78.9; leukocytes 15,400 (segmented 27%, lymphocytes 60%, monocytes 5%, reactive lymphocytes 8%); platelets 246,800/ml. GOT/GPT 86/114 (mU/ml). Chest X-ray has improved with respect to the previous control (residual condensation in LSD and LMD).
Tests pending from the first visit: pharyngotonsillar exudate: normal flora in aerobic culture; detection of Epstein Barr: EBV Ac anti-anticapsid IgM 36.3 (positive greater than 11.5), EBV Ac IgG 51.2 (positive greater than 11.5).
Chest X-ray 10 days after the 1st visit: increased density in LSD of paramediastinal distribution associated with displacement of the minor fissure, suggesting segmental atelectasis probably residual to the infectious process.
Diagnosis: infectious mononucleosis with pneumonia2-6.