Suppurative complications and upper airway obstruction in infectious mononucleosis

Abstract

A 17-year-old female patient presented to the emergency department reporting having fever, sore throat, and pain with swallowing for several days. The result of her rapid strep screen was negative. She had an elevated white blood cell count, mildly elevated AST and ALT levels, and a positive result from a heterophile antibody test (BBLTM MonoslideTM). She was diagnosed with infectious mononucleosis. Given her inability to tolerate oral fluids, she was admitted to the hospital for intravenous hydration. After 3 days of receiving methylprednisolone intravenously, she had worsening throat pain, progressive neck swelling, difficulty handling her secretions, and new respiratory symptoms. During the examination, she was sitting upright in bed in moderate respiratory distress. She had kissing, exudative tonsils with palatal and uvular edema. Examination of her neck showed significantly enlarged anterior and posterior cervical lymph nodes without fluctuance. Her lung exam revealed subcostal retractions with transmitted upper airway sounds but good aeration. The edge of her liver and spleen tip were palpable. Because of the rapid progression of symptoms while on medical therapy, computed tomography (CT) of the neck was performed. Sagittal reconstructions showed adenoidal hypertrophy compromising her nasopharynx, and massive tonsillar enlargement causing nearly complete obstruction of her oropharyngeal airway (Fig. 1), with airway narrowing to less than 2.5 mm in axial images. Bilateral low-density lesions within the paratonsillar regions were suggestive of abscesses and retropharyngeal soft-tissue swelling was consistent with phlegmon (Fig. 2). The patient was taken to the operating room for an emergent tonsillectomy. Bilateral peritonsillar abscesses were drained, pus was sent for culture, and her tonsils were excised. Cultures from the abscesses grew Streptococcus milleri. The patient was discharged home 2 days later to complete a 2-week course of oral clindamycin. Most patients with infectious mononucleosis (IM) have a benign, self-limited course. However, a wide range of severe complications have been described including airway obstruction, splenic rupture, meningoencephalitis, Guillain-Barre syndrome, peritonsillar abscess, and hemolytic anemia. Upper-airway obstruction results from lymphoid hyperplasia throughout Waldeyer’s ring, with associated soft-tissue edema. As many as 25% of patients hospitalized for IM will have some degree of airway obstruction. Peritonsillar abscesses (PTAs) occur in approximately 1% of hospitalized patients with IM and may further obstruct the airway. Most commonly, peritonsil-