An Unusual Presentation of Glandular Fever

Area of Science:

• Virology
• Immunology
• Hematology

Background:

• Epstein-Barr virus (EBV) is a common herpesvirus, with over 90% of adults over 40 showing serological evidence of past infection.
• Primary EBV infection in youth is often asymptomatic, but young adults frequently develop infectious mononucleosis (IM), characterized by pharyngitis, lymphadenopathy, and fever.
• Severe IM complications like hepatitis and HLH can occur, with Caucasian males and smokers at higher risk.

Observation:

• A 21-year-old male presented with prolonged fever, cough, and pharyngitis, along with pancytopenia and elevated ferritin.
• Initial tests, including Monospot and EBV serology, were negative, but abdominal ultrasound revealed splenomegaly.
• Repeat Monospot and EBV serology became positive days later, coinciding with new hepatitis.

Findings:

• Histopathology of a lymph node biopsy showed Sternberg-reed cells, indicative of resolving IM.
• The case demonstrated a significant time lag in the positivity of serological tests for EBV.
• The patient exhibited pancytopenia, low vitamin B12/folate, and a highly elevated serum ferritin level.

Implications:

• This case underscores the importance of maintaining a high clinical suspicion for IM, even with atypical presentations.
• Physicians must be aware of the varied clinical manifestations of IM and the potential delay in diagnostic test results.
• Understanding the diagnostic challenges and temporal aspects of EBV serology is critical for timely and accurate diagnosis of infectious mononucleosis.