Description
A 26-year-old man presented to the emergency department with a 6-day history of fever, sore throat and malaise. His medical history was remarkable for pulmonary tuberculosis, for which he had completed a course of treatment a year ago. Physical examination revealed bilateral upper eyelid oedema (figures 1 and 2), enlarged tonsils with a sheet-like white exudate, tender palpable posterior cervical lymph nodes and hepatosplenomegaly.
Figure 1.
The presence of upper eyelid oedema is readily visible bilaterally.
Figure 2.
The prominence of the upper eyelid oedema can be better appreciated in this lateral view.
Laboratory examination was remarkable for a lymphocytosis of 8.780 cells/mL with reactive lymphocytes and marginal thrombocytopenia with 128.000 cells/mL and increased lactate dehydrogenase (LDH) with 1127 IU/L.
The combination of the Hoagland sign, along with exudative tonsillitis and posterior cervical lymphadenopathy, was typical of infectious mononucleosis. The diagnosis was confirmed by the presence of Epstein-Barr virus (EBV) IgM 20.85 AU/mL (0.5 AU/mL).
The patient received supportive treatment and was discharged 3 days later. On follow-up examination 3 months later, the patient was feeling well and his symptoms had receded. Upper eyelid oedema had subsided completely.
Upper eyelid oedema as a manifestation of infectious mononucleosis was originally described by Colonel Robert J. Hoagland in 1952. He observed a supraocular or upper eyelid oedema in a series of patients with infectious mononucleosis, which he described as ‘a drooping of the swollen orbital portion of the upper eyelid on the palpebral portion, and sagging of the latter, which is also swollen, resulting in a narrower ocular aperture’. This sign was noted in 19 out 56 patients in this series.1 However, its incidence has been reported to be much lower in other case series.2–4
Regarding the presentation of the sign, upper eyelid oedema occurs before the onset of pharyngitis and cervical lymphadenopathy, but after the onset of fever. There is no associated proteinuria, eyelid inflammation or conjunctivitis and the eyelids are not tender.5 It usually lasts for only a few days. The pathophysiology of the sign is not known, but it is assumed that it is caused by lymphocytic infiltration.6
Learning points.
Infectious mononucleosis can sometimes cause upper eyelid oedema, the pathophysiology of which is unknown.
The presence of upper eyelid oedema in a patient with pharyngitis and malaise should raise suspicion for the diagnosis of infectious mononucleosis.
Footnotes
Contributors: SL was the resident physician responsible for the patient, evaluated the patient and drafted the manuscript. LK evaluated the patient, obtained informed consent from the patient and drafted the manuscript. GPar was the attending physician responsible for the patient, evaluated the patient and drafted the manuscript. GPan evaluated the patient and drafted and reviewed the manuscript.
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests: None declared.
Patient consent for publication: Obtained.
Provenance and peer review: Not commissioned; externally peer reviewed.
References
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