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Previous Volume 353:1421-1422 September 29, 2005 Number 13 Next

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To the Editor: The Medical Mystery in the August 4 issue¹ involved a 40-year-old man who presented with a four-day history of pain in the left upper quadrant of the abdomen, accompanied by fatigue, fever, sweating, and sore throat. A computed tomographic scan was obtained; it revealed multiple splenic infarcts (Figure 1) due to acute infectious mononucleosis. Laboratory studies on admission showed an elevated white-cell count (13,800 per cubic millimeter) with 51 percent lymphocytes, 31 percent of which were atypical, as well as the following abnormal liver-function values: aspartate aminotransferase, 123 U per liter; alanine aminotransferase, 244 U per liter; alkaline phosphatase, 216 U per liter; and total bilirubin, 0.9 mg per deciliter (15.4 µmol per liter). Transthoracic echocardiography revealed no abnormalities, and blood cultures showed no growth. An initial monospot test was negative, as were serologic studies for cytomegalovirus and hepatitis A, B, and C viruses. At a follow-up visit with a primary care physician one week later, a repeated monospot test was positive, and a polymerase-chain-reaction analysis for Epstein–Barr virus DNA from the previous week was found to be positive.

View larger version (40K): [in this window] [in a new window]   Figure 1. Computed Tomographic Scan of the Abdomen. The arrow indicates an area of splenic infarction.

 
Persons with acute infectious mononucleosis, often called "the kissing disease" because of its spread among adolescents by salivary contact, typically present with the triad of exudative pharyngitis, lymphadenopathy, and splenomegaly; splenic rupture or splenic infarction is a possible complication. The monospot test detects heterophil antibodies that are present in 90 percent of patients with acute infectious mononucleosis, but the test may require up to three weeks to become positive.

Primary infection with the Epstein–Barr virus in older persons is often associated with liver-function abnormalities. The patient in the current case may have contracted the infection from a new sex partner within the past 10 months. His liver-function values normalized over the next few months, and he had a full recovery.

Karen M. Kim, M.D.
Tufts University School of Medicine
Boston, MA 02111

Richard I. Kopelman, M.D.
Tufts–New England Medical Center
Boston, MA 02111

Editor's note: We received 1030 responses to this Medical Mystery from 73 countries. Forty-six percent of the respondents, many of whom specifically noted the splenic infarct, correctly identified acute Epstein–Barr virus infection. Twenty-eight percent correctly identified a splenic infarct but suggested other underlying causes, such as endocarditis and Lemierre's syndrome (jugular-vein septic thrombophlebitis) with paradoxical emboli to the spleen by way of a patent foramen ovale. Thirteen percent suggested a splenic abscess from a variety of organisms, and the remaining 13 percent suggested other diagnoses, including lymphoma, gastric carcinoma, pancreatic carcinoma, hemoglobinopathies, and splenic aneurysm. Splenic enlargement, which is often missed on physical examination, is important to recognize as an acute complication of infectious mononucleosis because of its potential to rupture spontaneously or with relatively minor trauma, such as that occurring in contact sports.

References

1. Kim KM, Kopelman RI. Medical mystery -- abdominal pain. N Engl J Med 2005;353:508-508. [Free Full Text]

PDF PDA Full Text Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited E-mail When Letters Appear Related Article by Kim, K. M. PubMed Citation