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Clinical Case Analysis: 5-Year-Old Boy with Fever, Tonsillar Exudate, Lymphadenopathy, Rash, and Hepatosplenomegaly

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1. PRELIMINARY DIAGNOSIS

Justification:

"Rash can occur in up to 20% of patients and is more common in patients treated with antibiotics, most commonly ampicillin or amoxicillin as well as with other penicillins." — Red Book 2021, Report of the Committee on Infectious Diseases, p. 547

"Patients suspected to have infectious mononucleosis should not receive ampicillin or amoxicillin, which may cause nonallergic morbilliform rashes." — Red Book 2021, p. 552

• Hb 130 g/L — normal for age
• Erythrocytes 4.8 × 10¹²/L — normal
• Leukocytes 18 × 10⁹/L — leukocytosis
• Neutrophils 28% — relatively low (lymphocytosis dominant)
• Eosinophils 1% — normal
• Lymphocytes 40% — elevated
• Monocytes 9% — mildly elevated
• Atypical mononuclear cells 20% — diagnostic hallmark
• ESR 20 mm/h — mildly elevated

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2. DIFFERENTIAL DIAGNOSIS

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3. EXAMINATION PLAN

Laboratory

Imaging

Monitoring

• Serial liver enzymes weekly
• Repeat CBC at 1–2 weeks
• Throat culture result

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4. TREATMENT PLAN

General Measures

• Hospitalization — already done; justified given hepatosplenomegaly, rash, severity
• Bed rest — especially while hepatosplenomegaly present
• Adequate hydration and nutrition
• Analgesics/antipyretics: Paracetamol (acetaminophen) 10–15 mg/kg/dose q4–6h for fever and throat pain
  • Avoid aspirin (risk of Reye syndrome)
• Stop ampicillin immediately — the rash is a drug-related, non-allergic morbilliform reaction in the context of EBV; it does not indicate penicillin allergy

Antiviral Therapy

• No approved antiviral treatment for EBV-IM
• Acyclovir/valacyclovir: have in vitro activity but produce no clinical benefit in immunocompetent patients — not recommended routinely
• "Although acyclovir and valacyclovir have in vitro antiviral activity against EBV and reduce viral replication, they produce no clinical benefit in infectious mononucleosis." — Red Book 2021, p. 552

Corticosteroids

• Not routinely indicated
• Use only if:
  • Marked tonsillar inflammation with impending airway obstruction
  • Massive splenomegaly
  • Myocarditis
  • Hemolytic anemia
  • Hemophagocytic lymphohistiocytosis (HLH)
• Dose if indicated: Prednisone 1 mg/kg/day orally (max 60 mg/day) for 5–7 days, with tapering

Throat Management

• If concurrent streptococcal pharyngitis confirmed: use azithromycin or cephalosporins (avoid all penicillins/ampicillin/amoxicillin)

Activity Restriction

• Avoid all strenuous activity and contact sports for at least 21 days after symptom onset — risk of splenic rupture
• After 21 days with no symptoms and no overt splenomegaly: limited non-contact aerobic activity permitted
• Return to contact sports: after 4–7 weeks if asymptomatic with no splenomegaly

Dietary

• Age-appropriate, light diet; hepatoprotective (avoid fatty foods); adequate caloric intake

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5. PREVENTION AND ANTI-EPIDEMIC MEASURES

In the Hospital

• Standard precautions are recommended (per Red Book 2021)
• No airborne or droplet isolation required beyond standard hygiene
• No special ward isolation necessary

Transmission

• EBV is transmitted primarily via saliva ("kissing disease")
• Also transmissible via shared utensils, cups, food/drink
• Virus may be shed in saliva for months after recovery

Control Measures for Contacts

• Avoid salivary exchange — do not share food, drinks, or utensils with individuals who recently had IM
• No specific prophylaxis or post-exposure treatment available for contacts
• No isolation of the patient from family members is required, but close contact precautions should be advised

No Vaccine Available

• There is currently no licensed EBV vaccine

Notification

• Infectious mononucleosis is generally not a notifiable disease in most jurisdictions; however local public health guidelines should be followed

For the Child at Discharge

• Educate parents: avoid kissing, shared utensils for at least 4–6 weeks
• School restriction: not required (EBV widely circulating, most adults already immune), but child should remain home until fever resolves and appetite/energy return
• Follow-up in 2–4 weeks with repeat CBC and liver function tests
• Return precautions: seek emergency care if severe abdominal pain (splenic rupture), difficulty breathing (airway obstruction), or jaundice

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