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The Case of Mono That Was Not

Dylewski, Joe MDCM

Infectious Diseases in Clinical Practice: September 2008 - Volume 16 - Issue 5 - p 276
doi: 10.1097/IPC.0b013e3181661402
Reflections of an ID Specialist

St Mary's Hospital, Quebec, Canada.

Address correspondence and reprint requests to Joe Dylewski, MDCM, St Mary's Hospital, 3830 Lacombe, Montreal, Quebec, Canada H3T 1M5. E-mail:

I have to admit that I was not happy when the bellboy went off. I was in the middle of my Thursday morning clinic and was preoccupied by my usual menagerie of patients. The numeric message told me that it was my sister calling from work at another hospital down the street from where I was. I immediately called her back and was relieved that there was not a family crisis to deal with. All she wanted was a favor from me. Would I be willing to see the 16-year-old daughter of her close friend who had been waiting in the other hospital's emergency department (ED) for more than 3 hours? I asked why she thought that my services as an infectious diseases specialist would be required; she told me that the girl had been diagnosed as having infectious mononucleosis by her family physician, and she had been complaining of severe muscle aches for the past 2 weeks. I could not see any relationship between the 2 conditions, but I had previously met the parents, so I agreed to see her that day. I was also aware that the father had been diagnosed with malignant melanoma and had been on chemotherapy. Even before seeing the patient, I wondered whether this may have played some role in her symptoms. She arrived with her mother, and I ushered them into my clinic room to do a history and physical examination. The girl had been in excellent health until a few weeks prior when she began to notice strange musculoskeletal pain over her back and neck and headaches. There was no history of fever or chills, sore throat, or lymphadenopathy. My cursory physical examination was unremarkable. She had brought a copy of the laboratory tests that her family physician had ordered 2 weeks before. The complete blood test count was entirely normal, but there had been a positive test result for the heterophile antibody; this had been the basis of her diagnosis of acute mononucleosis. She had not manifested any of the typical signs or symptoms to account for the test result, so I believed the result to be of no importance. I explained this to her and her mother and said that I thought all would be well with time. They thanked me and left. I called my sister to explain that I thought the symptoms were unrelated to the laboratory result but that, if the girl did not improve, I would run more tests. I forgot about the case until 4 days later when my sister called to tell me that the girl was miserable. There had been no improvement over the weekend, and everyone was getting nervous. I arranged to see her again that afternoon and repeated my history and examination, still believing that her symptoms could be psychosomatic. I decided though that I would do more investigations including routine blood work and I would order a bone scan. Just as I was completing the paperwork, the girl said that she also had noticed that she had had double vision! I did not like the sound of this symptom, so I got on the phone and was able to book an ophthalmology clinic appointment for later that afternoon. I did not believe that much would come of this; however, I did not wish to be negligent, and I did not trust myself to be able to do a proper eye examination. About 3 hours later, I was paged from the ophthalmology clinic and spoke to the physician who had seen her. "Your patient has papilledema" was his curt assessment. The words hit me hard. I had downplayed her symptoms, and now, she was found to have something terrible. How was I going to tell her mother that she may have a brain tumor? Was this family already experiencing enough? I picked up the phone and arranged for a neurology consult to be done later in the day and filled out a requisition for an emergency computed axial tomographic scan. I accompanied the patient and her mother down to the ED where the neurologist would see her later. Things did not seem right to me. I wondered could there be another reason for the papilledema? As we walked toward the ED, I asked some more questions. Had she been on any medications recently? She said that she had received a course of antibiotics for a presumed sinusitis after her headaches had started. Also, she had been treated for acne with some medication, but she had stopped the drug about a month ago. Something familiar was coming to mind. What had she taken? Her mother was able to tell me that the acne medication was isotretinoin (Accutane), and the antibiotic had been ciprofloxacin. A ray of hope shone down on me as I scrambled to the nearest medication reference book I could find. At the same time, I was calling our pharmacist to ask the obvious "What are the side effects of Accutane?" We both found the answer simultaneously: benign intracranial hypertension (pseudotumor cerebri). There was a grin on my face as I turned to face the patient and her mother. There was going to be a less ominous differential diagnosis. I was now confident that her condition was benign and due to the Accutane. I relayed this information to the neurologist who performed a lumbar puncture after the patient had undergone a computed axial tomographic scan of her brain that was read as normal. The high intracranial pressure was documented, and appropriate treatment was started. After a couple of months, she had returned to normal. Never in my career had I experienced so many different emotions in such a short time. This case serves as a reminder that not everything an ID consultant deals with is infectious.

© 2008 Lippincott Williams & Wilkins, Inc.