Case Presentation: A 23-year-old male with no significant PMH or previous admission presents to the ED with one week of severe sore throat and difficulty swallowing. Patient reported raspy voice and no improvement with over-the-counter cough medications. Stated it was a sharp 7/10 pain which worsened with swallowing and head movement. Associated symptoms included chills, headache, nausea, and right face and neck pressure. On further questioning, the patient admitted to smoking cigarettes and marijuana, drinking beer daily, recent oral sex, and previous IV drug abuse. Patient remained afebrile and saturated 97-100% on room air. Physical exam was pertinent for right anterior cervical lymphadenopathy and right otitis externa with cerumen impaction. Initial treatment involved IV dexamethasone and ceftriaxone with humidified oxygen. Respiratory PCR nasopharyngeal swab was negative. Flexible laryngoscopy in ED showed acute epiglottis with severe laryngitis, and CT soft tissue neck was confirmatory for right greater than left edematous aryepiglottic folds identifying epiglottitis with narrowing of the supraglottic larynx and reactive cervical chain lymph nodes. Given identification of his high-risk behaviors, additional testing was pursued including HIV, Hepatitis C, and RPR which were negative. Furthermore, testing for infectious mono heterophile antibodies by latex agglutination was positive, and ultrasound of the abdomen showed mild splenomegaly.
Discussion: Infectious mononucleosis is a common condition in the young adult population characterized by sore throat, fever, fatigue, lymphadenopathy, and splenomegaly. However, epiglottitis is a rare yet life threatening complication that can cause acute distress and respiratory failure. We present an atypical case of infectious mononucleosis with laryngitis and epiglottitis. Epiglottitis is an inflammatory condition causing progressive swelling of the upper airway, which increases the risk of airway obstruction and respiratory compromise. It is important to consider infectious etiologies including: Haemophilus influenzae type B (HIB), Streptococcus pneumoniae, Group A Streptococcus, and Staphylococcus aureus, as well as noninfectious causes such as thermal injury, caustic ingestion, or foreign body ingestion (Guerra and Waseem, 2021). Clinical presentation can involve fever, chills, dysphagia, odynophagia to more concerning signs and symptoms of airway compromise including tripod positioning, muffled voice, drooling, tachypnea, and accessory muscle use. The typical presentation of infectious mononucleosis is characterized by fever, pharyngitis, adenopathy, fatigue, and splenomegaly (Rea et. al., 2001). In a hemodynamically stable and comfortable patient, a flexible fiberoptic laryngoscopy can be performed, though there is a low threshold for intubation. General management utilizes corticosteroids to reduce edema, starting empiric antibiotics, and involving ENT for appropriate monitoring (Guerra and Waseem, 2021).
Conclusions: This case demonstrates the importance of the patient history, the acute management of epiglottitis with frequent clinical assessments and monitoring to prevent an unstable airway, and consideration of alternative diagnoses such as EBV mononucleosis as a cause of epiglottitis when there is a high-risk patient.