Infectious
Mononucleosis
INTRODUCTION
Muhammad
Shukry is a 10-month Malay old presenting with intermittent fever, lethargy,
sore throat and abdominal discomfort of 9-day duration.
HISTORY
Shukry
first presents with intermittent fever 9 days ago. The highest temperature
reached is 38 -39 degrees celsius. He was seen by a GP on the third day.
Paracetamol but no antibiotics were given. Subsequently the fever did subside to
a low-grade temperature of 37.4 degree celsius. He has a sore throat that
worsened progressively over the same period. There is no cough, headache or
running nose. He is still feeding well and is playful and active. There is a
facial/peri-orbital swelling of one day duration together with abdominal
distension and discomfort. The mother noticed a decrease in frequency of passing
urine since 2 days ago. He is eating and drinking in normal amounts. There is no
change in bowel habits and the stools are hard and brown in color.
He
is a full-term baby by normal vaginal delivery. There were no complications
arising from the delivery. The mother was unable to recall his weight at birth,
but claimed he is healthy and fit. The
mother
breast-feed him for two months and then switched to formula milk. He is able to
stand up and walk a few steps and call "Papa" and "Mama".
His height, weight and OFC are within the 50th and 75th percentiles of his age.
There
is no travel or contact history. There is no family history of liver, kidney or
blood diseases. He has no history of frequent infections or morbidity. There is
no change in behavior, no diarrhoea,
vomiting, LOA or LOW, bone or joint pains.
PHYSICAL
EXAMINATION
On general inspection, Muhammad Shukry appeared normal and behaved appropriately
for his age. He
is alert, well and playing with his mother. He is not pale or jaundiced. The
cervical and occipital lymph nodes are enlarged with a diameter of 1cm. The
abdomen is distended, soft and non-tender. There are distended veins over the
epigastrium. The liver is enlarged 5cm below the right subcostal margin. Its
surface is smooth and has a sharp edge. The spleen is enlarged 3cm below the
left subcostal margin. No shifting dullness is elicited.
SUMMARY
Muhammad
Shukry is a normal well and active child presenting with a 9-day history of
fever, sore throat, cervical and occipital lymphadenopathy and
hepatosplenomegaly.
My
diagnoses are:
1)
Infectious Mononucleosis.
2)
Acute lymphocytic leukaemia.
3)
Thalassaemia.
4)
TORCH infections
I
would order the following investigations:
1)
Full blood count to detect anaemia, presence of underlying infection.
2)
Peripheral blood firm to study the RBC morphology.
3)
EBV serology to confirm diagnosis of infectious mononucleosis.
IF
EBV serology is negative, I'll then proceed with:
1)
Thalassemia screen.
2)
Liver function test.
3)
TORCH screen to detect other possible infections.
CASE
DISCUSSION
The
clinical picture presented by Muhammad Shukry resembles infectious mononucleosis
- high fever peaking at 39C of 1 to 2 weeek duration, sore throat,
lymphadenopathy and hepatosplenomegaly. ALL, thalassaemias and TORCH infections
are other possible differentials in
this age group, however they are less likely as the child appears to be well and
active and he does not have other signs supporting of these diagnoses, for
example, petechiae, pallor, bleeding, headache which are indicative of ALL and
thalassaemias. TORCH infections are
not
likely too as they will affect the child's development. Hepatitis is not likely
as the patient is not jaundiced and the stools are brown in color. Based on the
history and physical examination alone,
infectious
mononucleosis is the first on my differential list and that's why I will proceed
to do the EBV serology first before doing other tests.