Monospot Research Articles

A Teenager With Sore Throat and Neck Pain

This 15-year-old White female was admitted with a 7-10 day history of high fever, joint pain, and increasing shortness of breath. Her illness began 10 days prior to admission (PTA) with fever to 105°F and severe throat pain associated with blisters in the posterior oropharynx and what was thought to be enlarged right anterior cervical lymph nodes causing neck pain. She was seen in the acute care clinic at Disney World, Orlando, Florida, where she and her father were vacationing. A strep screen and heterophile antibody test were negative. She was discharged with symptomatic treatment. Over the next 2 days she had continued fever, an increasingly painful cough, pleuritic chest pain with dyspnea, watery diarrhea, decreased appetite, and intermittent abdominal pain. Seven days PTA she experienced right hip, right shoulder, and left knee pain. When her dyspnea increased, she was seen in the emergency department where a chest x-ray revealed a nodular pneumonia pattern. On admission she was unable to walk because of her hip pain and had moderate respiratory distress. Her temperature was 101.9°F, pulse 142 beats per minute, respirations 64 breaths per minute, blood pressure 101/57 mm Hg, and pulse oximetry 85% on room air. Tonsils were enlarged but there was no exudate. There was a slight fullness palpable from the right submandibular area to the mid neck. Exam of the heart was normal. There were decreased breath sounds at both lung bases. There was diffuse, poorly characterized pain around the right shoulder and right hip without appreciable joint effusion or increased pain on internal rotation. The rest of the physical exam was unremarkable.

A Teenager With Sore Throat and Neck Pain

This 15-year-old White female was admitted with a 7-10 day history of high fever, joint pain, and increasing shortness of breath. Her illness began 10 days prior to admission (PTA) with fever to 105°F and severe throat pain associated with blisters in the posterior oropharynx and what was thought to be enlarged right anterior cervical lymph nodes causing neck pain. She was seen in the acute care clinic at Disney World, Orlando, Florida, where she and her father were vacationing. A strep screen and heterophile antibody test were negative. She was discharged with symptomatic treatment. Over the next 2 days she had continued fever, an increasingly painful cough, pleuritic chest pain with dyspnea, watery diarrhea, decreased appetite, and intermittent abdominal pain. Seven days PTA she experienced right hip, right shoulder, and left knee pain. When her dyspnea increased, she was seen in the emergency department where a chest x-ray revealed a nodular pneumonia pattern. On admission she was unable to walk because of her hip pain and had moderate respiratory distress. Her temperature was 101.9°F, pulse 142 beats per minute, respirations 64 breaths per minute, blood pressure 101/57 mm Hg, and pulse oximetry 85% on room air. Tonsils were enlarged but there was no exudate. There was a slight fullness palpable from the right submandibular area to the mid neck. Exam of the heart was normal. There were decreased breath sounds at both lung bases. There was diffuse, poorly characterized pain around the right shoulder and right hip without appreciable joint effusion or increased pain on internal rotation. The rest of the physical exam was unremarkable.

Epstein-Barr virus-associated infectious mononucleosis and risk of systemic lupus erythematosus

Elevated levels of serological markers of EBV infection in patients with SLE and observations that infectious mononucleosis (IM) may precede some cases of SLE suggest a possible role of EBV in the aetiology of SLE. We evaluated the relationship between EBV-associated IM and subsequent risk of SLE in a population-based cohort study. We followed cohorts of Danes tested serologically for IM using the Paul-Bunnell (PB) heterophile antibody test between 1939 and 1989, and patients hospitalized with IM between 1977 and 2007 for subsequent first hospitalizations with SLE in the period 1977-2008. Standardized incidence ratios (SIRs) with 95% CI served as measures of relative risk. Risk of SLE was not increased either in individuals with a positive PB test (SIR = 1.1; 95% CI 0.8, 1.6; n = 27) or in individuals hospitalized with IM (SIR = 1.3; 95% CI 0.7, 2.2; n = 12). However, SLE risk in PB-negative individuals was significantly increased (SIR = 2.6; 95% CI 2.1, 3.2; n = 82), a risk that was particularly high 1-4 years after the PB test (SIR = 6.6; 95% CI 3.3, 13.2) and remained significantly elevated for >25 years. EBV-associated IM does not seem to be a risk factor for SLE. The temporal pattern of increased SLE risk in individuals with a negative PB test suggests that some patients who go on to develop SLE may present with unspecific symptoms, for which they may be tested for IM, long in advance of their SLE diagnosis.

Comparison of Three Automated Immunoassay Methods for the Determination of Epstein-Barr Virus-Specific Immunoglobulin M

In this study we compared the performances of three commercially available Epstein-Barr virus (EBV) immunoglobulin M (IgM) assays on highly automated immunoassay platforms: BioPlex 2200 (Bio-Rad Laboratories), Immulite 2000 (Siemens Healthcare Diagnostics), and Liaison (DiaSorin). As a confirmatory method, immunoblotting was performed. The specificity of the three EBV IgM assays was evaluated by testing 293 selected sera from patients with various infectious and noninfectious diseases. After the exclusion of 30 samples, the specificities were 96.2% for Liaison, 98.1% for Immulite, and 97.0% for BioPlex. For evaluation of the sensitivity, samples from 70 consecutive patients with a positive heterophile antibody test were examined, irrespective of clinical or biological findings. After the exclusion of six samples, the sensitivities were 89.1% for Liaison, 84.4% for Immulite, and 89.1% for BioPlex. Finally, in a prospective study performed with 500 samples obtained from consecutive patients and sent in by general practitioners, we also determined Epstein-Barr nuclear antigen IgG and viral capsid antigen IgG in a two-phase approach. Concordance of the EBV serologic status was 96.2% between Liaison and Immulite, 96.4% between Immulite and BioPlex, and 97.8% between BioPlex and Liaison. The three EBV IgM immunoassays that we evaluated have acceptable and comparable performances.

Meet the expert: microbiology case presentation severe EBV infection in a 22-year-old male

A 22-year-old male with a history of Type 1 diabetes was admitted to a local hospital in March of this year with generalised malaise and headache. He was noted to have a mild transaminitis, and variant lymphocytes in his blood film. A Monospot test performed at the time was negative. A lumbar puncture was also entirely normal, and he was diagnosed with an unspecified viral illness, and discharged. He re-presented to hospital in early August with a history of headache, fever, dyspnoea and abdominal pain. He was found to have diffuse lymphadenopathy, and massive hepatosplenomegaly. He had variant lymphocytes, thrombocytopenia and severe hepatitis. A mononucleosis screen was positive, and his Epstein-Barr virus (EBV) serology was consistent with primary infection. He had multi-organ failure requiring ventilatory support, vasopressors, continuous haemofiltration, and had marked cholestatic liver function tests. Initial plasma EBV DNA PCR demonstrated 710 000 copies/mL. Testing for cytomegalovirus (CMV) and human herpes virus-6 (HHV-6) was negative. After correction of his coagulopathy and thrombocytopenia, a lymph node biopsy was performed; this showed reactive changes consistent with infectious mononucleosis lymphadenitis, and some evidence of haemophagocytosis. After discussion, it was decided that there were no features of lymphoma on the biopsy. Initial genetic testing for X-linked immunodeficiency was negative. A working diagnosis of EBV-associated haemophagocytic syndrome was made, and he was commenced on cyclosporine, etoposide and hydro-cortisone. Over the next fortnight, his EBV levels reduced slightly, he was able to maintain his own ventilation, and his hepatic function improved, although he remained in anuric renal failure, and was still profoundly pancytopenic. He was discharged to the ward, but developed a severe nosocomial pneumonia with a marked deterioration in his hepatic function. His bilirubin level was elevated at over 400 μmol/L, and he developed intractable seizures secondary to encephalopathy. Six weeks into his hospital admission he died. A post-mortem revealed haemophagocytosis in multiple organs, with high EBV levels throughout the body. Further results of testing for additional primary immunodeficiency disorders are pending. This case raised several issues for us: • spectrum of EBV infections and review of previous cases of fulminant EBV infection at our institution; • histological similarities between EBV lymphadenitis and lymphoma; • pathophysiology and treatment of haemophagocytic syndrome; • association of haemophagocytic syndrome with certain infections.

Infectious mononucleosis with Staphylococcus aureus pharyngitis co-infection

Epstein-Barr virus (EBV), a member of the herpesvirus family, is one of the most common human viruses affecting more than 90% of the world's population. The most common manifestation of primary infection is a self-limited clinical syndrome that most frequently affects adolescents and young adults. The incidence of clinical infectious mononucleosis is not well documented because reporting is not obligatory in most states. The available data have been derived from special surveys such as the community survey in Olmstead County, Minnesota, which includes the Mayo Clinic, where a rate of 200 per 100,000 patients had a positive heterophile test. 1 Once a diagnosis of mononucleosis is confirmed, treatment is supportive because there is no specific treatment for the disease. Mononucleosis is rarely fatal but some complications include central nervous system involvement, splenic rupture, upper airway obstruction, and bacterial super infections. The following clinical case is of a patient diagnosed with acute infectious mononucleosis with Staphylococcus aureus pharyngitis co-infection.

Erythema multiforme-like lesions in the course of infectious mononucleosis

The rash in infectious mononucleosis is usually diffusely macular. A 15-year-old boy presented to us with high grade fever, sore throat, malaise, body aches, and polyarthralgia. He developed annular, erythematous, and non-scaly eruptions on chest and right arm. Blanching erythema was noted on his trunk. He had bilateral tender cervical lymph nodes, severe pharyngeal congestion, petechiae on soft palate, uvular edema, infraorbital edema, and marginal tender hepatomegaly. Investigations revealed lymphocytosis and activated atypical lymphocytes in the peripheral smear, and positive monospot test. The boy subsequently recovered in one week with total disappearance of his rash. Epstein-Barr virus-related infectious mononucleosis was considered the most likely diagnosis for our patient. To our knowledge, this atypical case is the third reported case of annular lesions in infectious mononucleosis. Dermatologists and other clinicians should be alerted to this special presentation of primary EBV infection.

A 17-year-old Boy with Fever, Sore Throat, and Headache

<P>This 17-year-old boy was transferred for evaluation of fever, sore throat, and headache. He was well until 3 months prior to admission when he had developed fever and fatigue. Despite five courses of antibiotics, these symptoms continued intermittently for the next 2 months to the point that he was unable to play sports because of fatigue, having reportedly lost 25 pounds. Five days prior to admission, he started to have intermittent non-bilious emesis prompting another course of antibiotics. Three days prior to admission, he developed jaundice and right upper quadrant pain. On admission to an outside hospital, computed tomography (CT) of the abdomen revealed hepatosplenomegaly and mesenteric lymphadenopathy, and he was transferred. His past medical history was remarkable for meningococcemia at 11 years, from which he recovered without sequelae. The family history is unremarkable. There is no significant travel history. There are a dog and a cat at home.</P> <H4>Key Learning Points</H4> <OL> <LI>The major predisposing factor for recurrent invasive Neisseria infections is a deficiency of terminal complement.</LI> <LI>The heterophile antibody test is 90% sensitive for detecting EBV infection in adolescents; the sensitivity is much lower in children younger than 4 years old. The false-positive rate is very low.</LI> <LI> The diagnosis of hemophagocytic lymphohistiocytosis (HLH) is definite if a known genetic mutation is identified. A clinical diagnosis can be made if 5 of 8 criteria are found: 1) fever, 2) splenomegaly, 3) cytopenias affecting 2 of 3 cell lines, 4) hypertriglyceridemia or hypofibrinogenemia, 5) hemophagocytosis in a tissue without evidence of malignancy, 6) low natural killer cell activity, 7) serum ferritin greater than 500 ng/mL, and 8) soluble CD25 <u>></u>2400 U/mL.</LI> <LI>The diagnosis of X-linked lymphoproliferative disorder should be suspected in any boy with severe EBV-associated HLH.</LI> </OL> <H4>ABOUT THE AUTHOR</H4> <P>Dr. Listernick is Professor of Pediatrics at Feinberg School of Medicine, Northwestern University, and Director of the Diagnostic and Consultation Service, Division of General Academic Pediatrics, Children’s Memorial Hospital, Chicago, IL.</P>

Fra tonsillitt til koksitt

We present a 19-year-old woman with a throat infection, increased temperature, a positive mononucleosis monospot test and clinical signs of a lower respiratory tract infection. The diagnosis was thought to be mononucleosis complicated by bacterial pneumonia, but she was later found to have Fusobacterium necrophorum in blood cultures. She subsequently developed metastatic abscesses in her lungs and hip joint and was diagnosed with Lemierre's Syndrome. This case report highlights the importance of close links between clinicians and microbiologists in order to prevent morbidity and mortality in patients with an infectious disease.

An Unusual Sore Throat

<P>A previously healthy 15-year-old Hispanic boy presented to the emergency room with a history of fever and sore throat. Both symptoms began 4 days prior and progressed to include vomiting, difficulty swallowing, diarrhea, back pain, and generalized malaise. Initial vitals were temperature 100.2, heart rate 100/min, respiratory rate 20/min, blood pressure 90/73, and capillary refill time more than 2 sec. He appeared ill and dehydrated but oriented to time, place, and person. His physical exam was notable for erythema and prominence of left anterior tonsillar pillar with deviation of uvula to right side, positive trismus, and mild swelling and tenderness of the left lateral neck. Other systemic examination including respiratory, cardiovascular, abdominal, and neurological were unremarkable. Lab evaluation demonstrated WBC 23.8 with neutrophils of 95%, platelets 100, BUN 128, creatinine 2, CRP 36.33, and Ca 7.8. Urine analysis showed proteinuria and hematuria. Throat swab, blood, and urine were sent for culture. Rapid monospot test was negative. He received two IV fluid boluses. Clindamycin was started, and he was admitted to the PICU for further management.</P><H4>ABOUT THE AUTHORS</H4><P>Rajesh Dudani, MBBS, is Pediatrics Resident; and Norman Jacobs, MD, is Attending Physician, Pediatric Infectious Disease, John H. Stroger Hospital of Cook County, Chicago.</P><P>Address correspondence to: Rajesh Dudani, MBBS, 1926 W Harrison St, #1801, Chicago IL, 60612; fax 312- 864-9717; or e-mail <a href="mailto:dudanirajesh@gmail.com">dudanirajesh@gmail.com</a>.</P>

A 4-year-old Girl with Neurofibromatosis Type 1 and Hepatosplenomegaly

<P>This 4-year-old girl was first seen in the Neurofibromatosis Clinic at age 4 years for evaluation of neurofibromatosis type 1 (NF1). She had been diagnosed at 2 years on the basis of multiple café au lait spots and intertriginous freckling. A magnetic resonance imaging (MRI) scan performed at the time was said to have been normal. She had also been diagnosed at the time as having multiple juvenile xanthogranulomas (JXG) mainly on her abdomen. She had been getting complete blood counts every 4 to 6 months because of that diagnosis. Developmentally, she’s doing very well. She is in a preschool program receiving some speech therapy, but is otherwise keeping up with her peers. The family history is unremarkable for any member with NF1 or multiple café au lait spots.</P> <H4>Key Learning Points</H4> <OL> <LI>There are seven diagnostic criteria of which one needs two or more to establish the diagnosis of NF1. These include six or more café au lait spots greater than 0.5 cm in children or 1.5 cm in adults, axillary or inguinal freckling, two or more neurofibromas or one plexiform neurofibroma, an optic pathway tumor, a characteristic bony lesion (either dysplasia of the sphenoid bone or a long bone, most commonly the tibia), two or more iris Lisch nodules, and a positive family history.</LI> <LI>Juvenile xanthogranulomas (JXG), which are benign histiocytic disorders of the skin, are small yellowish papules. There is an association between JXG and the development of juvenile myelomonocytic leukemia (JMML).</LI> <LI>The sensitivity of the Monospot test increases with age; whereas it is only positive in 10% to 20% of young children who have proven Epstein-Barr virus (EBV) infections, the sensitivity is closer to 70% to 80% in adolescents who have infectious mononucleosis.</LI> <LI>Sarcoidosis tends to present in children under the age of 5 years with skin, eye, and joint disease, whereas older children tend to have disease affecting the lungs, lymph nodes, and eyes (uveitis).</LI> </OL> <H4>ABOUT THE AUTHOR</H4> <P>Dr. Listernick is professor of pediatrics at Feinberg School of Medicine, Northwestern University, and director of the Diagnostic and Consultation Service, Division of General Academic Pediatrics, Children’s Memorial Hospital, Chicago, IL.</P>

Relationship of Lymphocyte-Neutrophil Ratio to Heterophile Antibody Result

Abstract The heterophile antibody test (HAT) is commonly ordered at the same time as a complete blood cell (CBC) count in cases of suspected infectious mononucleosis. An absolute lymphocytosis with the presence of greater than 10% atypical lymphocytes is a good predictor of a positive HAT. We retrospectively studied patients who underwent HAT and had a simultaneous CBC count during an 8.5-year period. The ratio of the absolute number of lymphocytes to the absolute number of neutrophils (L/N) was determined to see if this measure could be useful in distinguishing those most likely of having a negative HAT. A total of 5104 patient samples were analyzed of which 501 (9.8%) were HAT positive. The L/N ratio was less than 0.5 in 2214 patients (43.4%), and in this group, only 46 (2.1%) were HAT positive. In the group whose L/N ratio was greater than or equal to 0.5, the HAT positivity rate rose to 15.7% (455/2888), for a relative increase of 60%. In the HAT-positive group, 153 (30%) did not demonstrate an absolute lymphocytosis. Restricting HAT to those having a CBC count with an L/N ratio greater than or equal to 0.5 will increase the HAT positivity rate and lead to a reduction of HAT performed.

Diagnostic performance of a new automated heterophile antibody test in adults and children

Epstein–Barr virus serologic profiles were obtained from 618 patients using an automated platform, including the new BioPlex heterophile assay. When compared with 2 IgM viral capsid antigen (VCA) assays and a predicate heterophile assay, the BioPlex heterophile assay was more likely to be associated with serologic patterns of acute infection.

Mononeuritis des N. oculomotorius bei infektiöser Mononukleose

A 19-year-old immune-competent patient developed right-sided headache and, subsequently, subacute diplopia. On clinical examination he had incomplete right oculomotor palsy. Cranial MRI showed pathologic contrast enhancement of the right oculomotor nerve at its exit point from the mesencephalon, and the CSF displayed slight pleocytosis. The following relevant differential diagnoses were not supported by additional examinations: neurosarcoidosis, Lyme neuroborreliosis, neurosyphilis, tuberculous meningitis, viral meningitis (HIV, VZV, CMV), CNS lymphoma, vasculitis associated with rheumatic disease, Tolosa-Hunt syndrome, and diabetic neuropathy. However, on the basis of blood lymphocytosis, positive heterophile antibody test (Paul-Bunnell test), the presence of IgM antibodies against Epstein-Barr virus capsid antigen, and elevated transaminases, infectious mononucleosis was diagnosed. Isolated neuritis of the oculomotor nerve is a rare parainfectious manifestation of infectious mononucleosis.

Lingua Villosa Nigra

A 24-year-old man presented with black discoloration and hairy appearance of his tongue, which he had had for 2 days, and a sore throat. He had been taking ciprofloxacin and doxycycline for the past week for an upper respiratory tract infection. He did not smoke or use oral tobacco products, and he was not taking any bismuth-containing compounds. Physical examination revealed white tonsillar exudates and a black discoloration of the tongue; no fever, adenopathy, or hepatosplenomegaly was noted. The results of a rapid streptococcal-antigen test and a monospot test were negative. A throat culture was positive for Candida albicans. . . .

Suppurative complications and upper airway obstruction in infectious mononucleosis

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-

Lemierre's syndrome in association with a cholesteatoma

A 17-year-old man presented with headache, sore throat and dizziness. He had been feverish and suffering from rigors. He had suffered from recurrent ear infections for 2 years and 2 weeks before admission he had received a course of amoxicillin for an ear infection. On examination he was flushed, pyrexial, tachycardic (130 bpm) and hypotensive (90/41 mmHg). The skin over the lateral border of his right sternocleidomastoid muscle was erythematous and tender. He had marked erythema of his throat and a macular blanching erythematous rash on his wrists, arms and knees. There was no neck stiffness or photophobia. Examination of the ears on admission did not detect any abnormality. Blood tests revealed neutrophilia, thrombocytopenia and a raised C-reactive protein level of 206.3 iu. Lumbar puncture was unremarkable. Monospot test was negative. He was treated with intravenous benzylpenicillin 1.2 g four times per day and cefotaxime 2 g three times per day. Four days after admission two blood cultures grew a non-haemolytic streptococcus, later identified as Enterococcus avium. Antibiotics were changed to amoxicillin, gentamicin and metronidazole. An ultrasound scan of the neck showed lymphadenopathy along the right anterior lymphatic chain and a patent right internal jugular vein. Transthoracic echocardiogram was unremarkable. The patient remained unwell. His pyrexia persisted, his haemoglobin dropped to 7.1 g/dl and his albumin to 23 g/litre. Computed tomography (CT) scan of the mastoids revealed fluid in the right middle ear, which continued into the mastoid antrum and was associated with sclerosis of the right mastoid air cells. A third blood culture grew gram-negative bacilli. Co-amoxiclav was started and the fever settled. Escherichia coli sensitive to amoxicillin was isolated. A CT scan of the thorax showed small bilateral pulmonary nodules, some of which contained small cavities, suggesting pulmonary abscesses (Figure 1). An ultrasound scan of his neck was repeated on day thirteen of his admission and revealed thrombosis of the right internal jugular vein. This was confirmed with magnetic resonance imaging, which also demonstrated extension of the clot into the sigmoid and transverse sinuses (Figure 2). The patient was anticoagulated for 6 months. In total, the patient received 2 weeks of intravenous amoxicillin, gentamicin and metronidazole and 6 weeks of co-amoxiclav and metronidazole. Review in ear, nose and throat outpatient clinic revealed a cholesteatoma that required excision. No other source of sepsis was identified despite extensive investigation.

Lymphocyte–White Blood Cell Count Ratio

To find a quickly available screening tool for the differentiation of patients with glandular fever from those with acute purulent tonsillitis. The null hypothesis was that there was no difference between the lymphocyte-white blood cell count (L/WCC) ratio between the 2 patient groups. Retrospective pilot study based on laboratory tests for lymphocyte counts, white blood cell counts, and the mononucleosis spot test. Ear, Nose, and Throat Department, St George's Hospital, London, England. One hundred twenty patients with glandular fever and 100 patients with bacterial tonsillitis. Results from the mononucleosis spot test in conjunction with the clinical picture and the L/WCC ratio were analyzed. Significant differences were evaluated using the Mann-Whitney test and Fisher exact test. The L/WCC ratio was significantly different in the 2 groups (P<.001). The mean L/WCC ratio in the glandular fever group was 0.54 and the mean L/WCC ratio in the bacterial tonsillitis group was 0.10. A ratio higher than 0.35 had a specificity of 100% and a sensitivity of 90% for the detection of glandular fever. We recommend that the L/WCC ratio should be used as an indicator to decide whether mononucleosis spot tests should be requested. A ratio higher than 0.35 had a high specificity in our study group.

Erythrophagocytosis in Epstein‐Barr virus IgM‐mediated hemolytic anemia

A 16-year-old boy was admitted because of progressive jaundice and stupor after a diagnosis of infectious mononucleosis that was made 10 days earlier. The hemoglobin level was 49 g per L, total WBC count 34 x 10 9 per L, and PLT count 296 x 10 9 per L. A peripheral blood film showed a leukoerythroblastic picture, spherocytes, and marked erythrophagocytosis by neutrophils (see figure: peripheral blood film showing erythrophagocytosis by neutrophils [xlOOO]). The direct antiglobulin test was positive for the presence of C3d/C3b and negative for the presence of IgG. A panagglutinin reacting with the patient's own RBCs was found in serum. The agglutinin had a titer of 32 at 37°C, failed to react at 4°C, and disappeared after the serum was incubated with 5 mmol L DTT. The Donath-Landsteiner test failed to show biphasic hemolysins, although slight hemolysis was seen in the tubes containing patient's serum and incubated at 37°C. The heterophil antibody test for Epstein-Barr virus (EBV) was positive. Treatment was started with RBC transfusion, steroids, high-dose intravenous IgG, plasma exchange, and rituximab with a good clinical response. Erythrophagocytosis by neutrophils is most strongly associated with paroxysmal cold hemoglobinuria. This case illustrates the presence of very unusual erythrophagocytosis by segmented neutrophils in EBV associated warm IgM-mediated hemolytic anemia.

Infectious Mononucleosis Presenting with Severe Thrombocytopenia, Positive Anti-Platelets Antibodies, and Peripheral Blood Blasts.

Case Report: 18 year old male presents with 2 weeks history of sore throat, fever, and hemoptysis. Physical examination revealed exudative and hemorrhagic tonsillo-pharyngitis, posterior cervical lymphadenopathy, mild splenomegaly, and petechieal rash involving the extremeties and the trunk. On presentation, CBC showed Hgb of 15.5gm/dl, WBCs of 11.8 K/uL, Platelets count of 4 K/uL. Differential count showed lymphocytes of 56%, reactive lymphocytes 1%. Monospot test was positive. CT abdomen confirmed the physical finding of splenomegaly, and showed mild hepatomegaly. Treatment was initiated with pulse methylprednisone 1g/d, and IVIG 1g/kg/day. Both were given for 2 days. One unit of SDP was transfused on days 2, 4, 5. On day 4 platelets count was 6 K/uL. 2–3% blasts were detected on the peripheral smear on days 4 and 5. Bone marrow biopsy and aspiration were done on day 5. They revealed reactive marrow changes with no increase in blasts. Flow cytometry revealed reactive marrow lymphocyte subpopulations and no inrease in immature myeloid cells. Subsequently, EBV serology was reported; EBV capsid IgM and IgG were both positive at >4-fold higher than upper normal limit. In addition, Platelets antibodies were reported positive for IIB/IIIA, IB/IX, and IA/IIA. Platelets count on day 7 was 58 K/uL without platelets transfusion in the previous 24 hours.Conclusion: Literature review reveals rare cases of Infectious Mononucleosis presenting with severe thrombocytopenia. Most of these cases were treated successfully with steroids and /or IVIG, similarly to ITP. However, no previous association with peripheral blood blasts has been described. Moreover, only two previous reports have described the association between Infectious Mononucleosis and the presence of platelets antibodies but without details of the receptors involved.