Interactive Quiz: Sore Throat and Fever
Welcome to Infectious Diseases Consultant's latest interactive diagnostic quiz. Over the next few pages, we'll present a case and ask you to make the diagnosis and treat the patient. Along the way, we'll provide details about the case, and at the end, we'll share the patient's outcome.
Ready to get started? >>
First, let’s meet the patient…
A 6-year-and-10-month-old girl presented with a sore throat and fever of 3 days’ duration. She denied cough, rhinorrhea, dyspnea, diarrhea, and genitourinary tract symptoms. She had no history of recent travel.
At physical examination, her temperature was 39.8°C, her pulse was 70 beats/min, and her respiratory rate was 16 breaths/min. Examination revealed pharyngeal erythema with a minimal exudate, tonsillar hypertrophy, and enlarged cervical lymph nodes.
Are you correct? >>
Answer: Perform a rapid strep test
Results of a rapid strep test were positive, and amoxicillin oral suspension, 400 mg/5 mL, twice daily for 10 days was prescribed.
Three days later, she presented again with persistent fever, swelling of the upper eyelids, pharyngeal erythema, enlarged cervical lymph nodes, and hepatosplenomegaly but no rash.
Results of a complete blood cell count showed a white blood cell (WBC) count of 4500/µL (reference range, 4.4-10.8 ´ 103 µL) and a platelet count of 114 ´ 103/µL (reference range, 130-400 ´ 103 µL). The differential count showed 21% neutrophils and 54% lymphocytes. The total bilirubin level was 0.9 mg/dL (reference range, 0.2-1.2 mg/dL), the alkaline phosphatase level was 304 U/L (reference range, 38-126 U/L), the aspartate aminotransferase (AST) level was 997 U/L (reference range, 10-45 U/L), and the alanine aminotransferase (ALT) level was 539 U/L (reference range, 5-40 U/L). Urine dipstick test results were normal.
Are you correct? >>
Answer: Mononucleosis spot test
Results of a mononucleosis spot test were positive for Epstein-Barr virus (EBV). Urine dipstick test results were normal.
Are you correct? >>
Answer: Infectious mononucleosis (IM)
IM was diagnosed and was treated symptomatically.
One week later, the patient still had a fever with abdominal pain and occasional vomiting. Physical examination findings at that time were remarkable for enlarged cervical lymph nodes and hepatosplenomegaly.
Follow-up laboratory tests disclosed the following values: WBC count, 6600/µL; platelet count, 291 ´ 103/µL; AST, 245 U/L; ALT, 240 U/L; EBV viral capsid antigen (VCA) IgM antibodies, >160 U/mL (reference range, 36-43.99 U/mL); and EBV VCA IgG antibodies, 67.1 U/mL (reference range, 18-21.90 U/mL).
Are you correct? >>
Answer: Acyclovir
With continued supportive measures, the patient recovered in the following few weeks. At initial presentation, our patient received a diagnosis of a streptococcal infection and was treated with amoxicillin. However, she had a concomitant EBV infection. Despite amoxicillin use, a morbilliform rash did not occur. Approximately 30% of patients with EBV IM have group A streptococcal carriage of the oropharynx. However, swelling of the upper eyelids is uncommon in patients with IM.
EBV-specific antibody can be used in patients who lack heterophile antibodies. VCA IgM and IgG antibodies are elevated in 90% of cases.
Therapy for IM consists of supportive measures. Corticosteroids are indicated for established airway obstruction, autoimmune hemolytic anemia, severe thrombocytopenia, and hemophagocytic lymphohistiocytosis. Acyclovir has no significant role in the treatment of IM.
Authors and citation >>
Authors:
Manish Kumar, MBBS
Extern, Peconic Bay Medical Center-Northwell Health, Riverhead, New York
Kamal K. Singh, MD
Chief of Pediatrics, Peconic Bay Medical Center-Northwell Health, Riverhead, New York; Clinical Assistant Professor of Pediatrics, New York Institute of Technology College of Osteopathic Medicine, Old Westbury, New York
Sandeep A. Gandhi, MD, FACP, FIDSA
Infectious Disease Consultant, Peconic Bay Medical Center-Northwell Health, Riverhead, New York; Clinical Associate Professor of Medicine, New York Institute of Technology College of Osteopathic Medicine, Old Westbury, New York
To read the full case report, see:
Kumar M, Singh KK, Gandhi SA. Epstein-Barr virus [published online December 13, 2017]. Consultant360. https://www.consultant360.com/articles/epstein-barr-virus-infection.