To the Editor:
Infectious mononucleosis (IM) denotes a clinical syndrome characterized by systemic somatic complaints with prominent fever, fatigue and malaise, lymphadenopathy, and sore throat. The principal cause of IM is primary infection with Epstein-Barr virus (EBV). Approximately 10% of cases are more appropriately termed IM-like illness and may result from primary infection with cytomegalovirus, Toxoplasma gondii, human immunodeficiency virus, adenovirus, viral hepatitis, and possibly rubella virus.1 Infectious mononucleosis caused by EBV usually resolves over a period of weeks or months without sequelae but may occasionally be complicated by a wide variety of neurological, hematologic, hepatic, respiratory, and psychological complications.1,2 The rarest but most deadly complication of IM is respiratory obstruction. These patients have massive tonsillar enlargement, pharyngeal edema, or both, sufficient to cause upper airway obstruction and death. It may be caused by swelling of the tonsils and adenoids; edema of the uvula, epiglottis, or arytenoids; or the formation of a pseudomembrane similar to that seen in diphtheria. Corticosteroids may have a role in hastening resolution of some complications, especially upper airway obstruction and possibly immune-mediated anemia and thrombocytopenia, but should be used judiciously.1,2
A 20-year-old man presented to our hospital complaining of 3-day fever, sore throat, dysphagia, fluxion, and severe cervical lymphadenopathy. He had no known allergies. On physical examination, his temperature was 37.5°C, blood pressure was 130/80 mm Hg, pulse was 90 beats/min, and respirations were 20 breaths/min. The patient's tonsils were markedly enlarged, with confluent exudates. The cervical lymph nodes were enlarged and tender. The white blood cell count was 13,100 cells/μL (lymphocytes, 43.5%; neutrophils, 42.5%), hemoglobin was 13 g/dL, hematocrit was 38.9%, and platelet count was 171,000/μL. The peripheral blood smear microscopy revealed 7% atypical lymphocytes. On admission, elevated serum levels of aspartate aminotransferase (120 U/L [reference range, 5-40 U/L]), alanine aminotransferase (267 U/L [reference range, 7-56 U/L]), and lactate dehydrogenase (1034 U/L [reference range, 313-618 U/L]) were observed. Monotest was negative. Clinical manifestation was compatible with IM syndrome. Specific antibodies for EBV, cytomegalovirus, Toxoplasma, and human immunodeficiency virus 1/2 were measured. Because of patient's tonsillar enlargement and severe cervical lymphadenopathy, intravenous methylprednisolone was initiated on the first hospital day. Intravenous hydration and clindamycin were also administered, because anaerobic microorganisms may be associated with this condition. 3,4.
On the second hospital day, despite corticosteroids administration, the tonsillar enlargement and cervical lymphadenopathy worsened, and obstructive dyspnea developed. The patient was intubated, because of near-complete airway obstruction. Five hours later, after patient's stabilization, he was transferred to another hospital's intensive care unit. One month later, he was discharged in good condition.
The next day, specific IgM EBV antibodies were positive (>160 U/mL). Diagnosis of EBV IM was established.5
Significant upper airway obstruction results from palatal and nasopharyngeal tonsil hypertrophy and inflammatory edema of surrounding soft tissues. Airway obstruction with progressive symptoms occurs in less than 5% of all patients and is one of the most common indications for hospitalization for IM. This complication mainly concerns younger children rather than adults, unlike our case.1,2,6,7
The benefit of corticosteroids for complications of IM has been advocated based on anecdotal experience but has not been critically evaluated. Corticosteroids are unnecessary in mild, uncomplicated cases and should not be routinely administered to all persons with IM. In addition, there are theoretical concerns about immunomodulation of a virus with transforming potential that has been causally linked to a variety of malignancies. Indications include incipient upper airway obstruction, autoimmune hemolytic anemia or neutropenia, thrombocytopenia with hemorrhage, meningoencephalitis, and other neurological complications. Intravenous or oral corticosteroids given for 1 to 3 days have been used with similar results of dramatic subjective improvement within 24 hours and objective improvement within 72 hours.1,6,7 Nevertheless, in our case, corticosteroids failed to prevent airway obstruction. Therefore, corticosteroid therapy may hasten resolution of complications in some but not all cases of IM.
Nikolaos Papadopoulos, MD*
Anastasios Liverezas, MD*
Nikolaos Antonakopoulos, MD*
Apostolos Karathanasis, MD†
Georgios Apostolopoulos, MD*
*Internal Medicine Department
411 General Army Hospital
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2. Boglioli LR, Taff ML. Sudden asphyxial death complicating infectious mononucleosis. Am J Forensic Med Pathol
3. Chretien JH, Esswein JG. How frequent is bacterial superinfection of the pharynx in infectious mononucleosis? Clin Pediatr
4. Hedstrom SA, Mardh PA, Ripa T. Treatment of anginose infectious mononucleosis with metronidazole. Scand J Infect Dis
5. Evans AS, Niederman JC, McCollum RW. Seroepid-emiologic studies of infectious mononucleosis with EB virus. N Engl J Med
6. Wolfe JA, Rowe LD. Upper airway obstruction in infectious mononucleosis. Ann Otol
7. Wohl DL, Isaacson JE. Airway obstruction in children with infectious mononucleosis. Ear Nose Throat J