Description
A previously healthy 21-year-old man presented to the emergency department with odynophagia and cervical lymphadenopathies. Symptoms had started 10 days before with fever and asthenia. Physical examination revealed voluminous and tender cervical lymphadenopathies with an ulcerative and necrotic sore throat (figure 1, panel A) and inspiratory dyspnoea. Splenomegaly and jaundice were noticed. Laboratory findings included lymphocytosis (5.6 G/L) with 30% of activated lymphocytes and apoptotic cells (figure 1, panel B and C) and thrombocytopenia (77 G/L). Liver enzymes were elevated: aspartate aminotransferase 419 U/L (reference range 15–37), alanine aminotransferase 530 U/L (15–78); with cholestasis. Epstein Barr virus (EBV) serology was suggestive of primary infection with positive anti-VCA (viral capsid antigen) IgG, positive IgM and negative IgG anti-EBNA (Epstein-Barr nuclear antigen). The patient received acyclovir and corticosteroid to treat this severe infectious mononucleosis (IM). He rapidly recovered.
Figure 1.
Clinical aspect of the necrotic sore throat (panel A) in a patient presenting severe infectious mononucleosis with cytolysis, activated lymphocytes (panel B) and apoptotic cells (panel C) in circulating blood.
EBV causes usually subclinical infection during childhood, whereas infection of adolescents and adults results in IM, which is normally a benign illness.1 Mild liver enzymes elevation is common (80–90% of cases) and resolves spontaneously. Symptomatic hepatitis is uncommon (5% of cases). Fatal liver dysfunction can occur.1 Necrotic sore throat is an atypical presentation of IM. Differential diagnoses include Vincent's angina, primary syphilitic lesion, neoplasms and agranulocytosis.2 Activated lymphocytes and apoptosis are found in IM but also in HIV, cytomegalovirus infection or toxoplasmosis. Further evidence is needed concerning the therapeutic strategy for patients with severe IM, even if physicians may consider the use of antiviral medication in addition to steroid treatment.3
Learning points.
Necrotic sore throat can be a clinical presentation of severe infectious mononucleosis (IM).
Acyclovir and corticosteroids may be proposed as an option for patients with severe IM.
Footnotes
Contributors: CT wrote the case report; CT and TF performed the literature review; CT, TF, CC and FA significantly participated in improvement of the manuscript.
Competing interests: None.
Patient consent: Obtained.
Provenance and peer review: Not commissioned; externally peer reviewed.
References
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