A 29‐year‐old male with a history marijuana and cocaine use presented with abdominal pain of three weeks duration. The pain was associated with nausea, emesis, dark urine, night sweats and fever. He denied recent travel or sick contacts. On admission he was mildly tachycardic and afebrile. On physical exam he had left upper quadrant abdominal tenderness and posterior cervical lymphadenopathy. A CT scan of the abdomen showed hepatosplenomegaly and focal hypodense regions in the spleen consistent with splenic infarcts. The patient was found to have mild transaminitis (AST: 147 U/L, ALT: 134 U/L) and a hemolytic anemia. His white blood cell count and lymphocyte count were initially normal, however they became slightly elevated. His Epstein‐Barr Virus (EBV) Immunoglobulin M (IgM) antibody, EBV early antigen, and Cytomegalovirus (CMV) IgM were found to be positive suggesting an acute mononucleosis with co‐infection by EBV and CMV complicated by splenic infarcts. Hepatitis panel and testing for HIV were negative. Blood and urine cultures were negative. The patient was seen by both infectious disease and gastroenterology, who felt he was co‐infected with EBV and CMV and that all of his symptoms and lab values could be attributed to infectious mononucleosis. The patient clinically improved with supportive care and was discharged with plans for outpatient follow‐up.
Infectious Mononucleosis is a syndrome typically seen in teenagers and young adults, which is characterized by fever, cervical lymphadenopathy, pharyngitis and fatigue. It is most often associated with EBV, however acute CMV infection can also cause the symptomatology of acute mononucleosis. Simultaneous infection with these two members of the herpes virus family has been documented, as has a reactivation of EBV during an acute infection of CMV, however it is rare in immunocompetent individuals in the age range of our patient. In addition to the dual cause of infectious mononucleosis, he also had the rare complication of splenic infarcts. EBV is documented as one of the potential causes of splenic infarcts, however few cases have been reported. The cause of splenic infarction in acute mononucleosis is poorly understood. In one pediatric case, the suggested cause of splenic infarction was proposed to be transient hypercoagulability due to decreased activity of protein C and protein S. In another case, anti‐phospholipid antibodies were transiently detected in the setting of CMV. The pathophysiology of splenic infarct in our patient was not determined and he was not tested for a hypercoagulable state.
Hospitalists commonly encounter patients with complaints of abdominal pain and nausea in the setting of a mild transaminitis. Although Infectious Mononucleosis is commonly an acute illness seen in the pediatric setting, this case stresses the importance that hospitalists keep the diagnosis of mononucleosis in their differential when evaluating an adult patient with this presentation. In addition, this case highlights the importance of testing for both acute EBV and CMV when infectious mononucleosis is suspected. It is unclear exactly what role the dual infection of EBV and CMV may have played in the development of splenic infarcts in this case, but this case shows the potential value of abdominal imaging in patients with suspected infectious mononucleosis who present with abdominal pain and that testing for transient hypercoagulability should be considered in patients who present with splenic infarction.
To cite this abstract:Navetta B, Feldhamer K. Double Mono: A Case of Coinfection with Ebv and Cmv. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 538. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/double-mono-a-case-of-coinfection-with-ebv-and-cmv/. Accessed January 29, 2020.