An infant with difficulty breathing (Page 2/2)

Prepared by...
Kanokorn Leepetcharut, M.D.
Virat Sirisanthana, M.D.
Department of Pediatrics, Chiang Mai University, Thailand
Differential diagnosis:
1.Infection
  > Virus ; Epstein-Barr virus (EBV) causing "Classical infectious mononucleosis"
  > Bacteria ; Streptococcal pharyngotonsillitis. ,Diphtheria
2. Malignancy
  > Lymphoma

"Con" for Streptococcal pharyngotonsillitis
  > Age of the patient. The common age of patient with Streptococcal pharyngotonsillitis is above 3 years.
"Con" for diphtheria with "Bull neck"
  > He already has had 3 doses of DTP vaccine.
"Con" for lymphoma
  > Onset of the symptoms are acute.


Investigations:
CBC: Hb 10.8 g/dL, Hct 33.1mg% Wbc 18,900cells/cu.mm (N 33 % Band 1% L 41%, atypical L 21% (Figure 2, 3), M 4 %), platelet count 221,000 /cu.mm.
U/A: Yellow, clear, pH 5.5, Sp.gr.1.027, Alb +1, Sug neg., WBC 0-1, RBC 0, Epith 0-1
Chemistry ; BUN 11, Cr 0.4, Na 139, K 4.4, Cl 105, CO2 20 (WNL)
Figure 2
Figure 3
What is the diagnosis?
Diagnosis: Infectious mononucleosis (IM)
Discussion: This patient has.....
> 1. Clinical presentations: fever, exudative pharyngitis, generalized lymphadenopathy and facial swelling
> 2. Hematologic feature: In the peripheral blood smear there are numerous atypical lymphocytes (21 %). some of them have "dented or scalloped" cytoplasm which is suggestive of "IM".
> With 1 +2, It is most likely that this patient has IM.
Treatment:
> Supportive and symptomatic : IV hydration
> Because of "potential airway obstruction", corticosteroid was given.
> Pending result of throat swab culture, penicillin was also started
Hospital course:
  All symptoms markedly improved in 2 days. Intravenous hydration and medications were discontinued. He was then discharged home and was seen "doing well" in the followed up clinic 2 weeks later.
Further Results of other investigations::
  Throat swab culture: normal flora
  EBV serology: The viral capsid antigen-IgM for EBV was positive

About Infectious mononucleosis:
> The clinical features of classic IM (or "mono") typically include at least three of the following: exudative pharyngitis, generalized lymphadenopathy, splenomegaly, malar facial swelling, and easy fatigability.
> The hematologic feature is the presence in the peripheral blood smear of at least 5% atypical lymphocytes
> The serologic feature is a slide test positive for IM antibodies (agglutinins for sheep or horse erythrocytes). Some call "heterophile antibody".
   

 

 Although most of classic IM is caused by Epstein-Barr virus, "EBV infection" and "infectious mononucleosis" should not be used as synonyms. EBV infection often does not result in classic IM, and mono-like illness can have causes other than EBV infection.

Primary EBV infection can now be demonstrated by antibody titers. The majority of children less than 10 years of age who have EBV infections are asymptomatic or have illnesses that do not resemble classic IM. However, if a young child does appear to have classic IM, specific EBV antibody tests, in addition to a test for heterophile antibody, should be done. In children age < 10 years, although they have EBV infection (confirmed by serology), they do not reliably produce "heterophile antibody".
   
Further reading:
1. Interesting case No. 62 "Infectious mononucleosis" page 2-4


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