A 33 year-old female without significant medical history was admitted as a transfer from an outside hospital for daily fevers and generalized weakness for the preceding two weeks associated with neck pain. Had undergone an extensive infectious disease workup prior to arrival with Computed Tomography (CT) of head, chest, abdomen, and pelvis, blood cultures, lumbar puncture, HIV, spirochete, and Monospot screening without any obvious sources of infection.
On examination she was febrile to 39°C, tachycardic, normotensive, without tachypnea or obvious distress. Her lungs were clear to auscultation, had a regular rhythm without murmurs, was without abdominal pain or distension, and had no swelling in any of her extremities. Her laboratory results showed pancytopenia with a white blood cell count of 2 with lymphocytic predominance, no evidence of liver dysfunction, and a procalcitonin <0.10.
During her stay she developed acute abdominal pain, CT of her abdomen with contrast was repeated and showed intermittent hepatic hypodensity in the left hepatic lobe measuring 13 mm, and splenomegaly with hypodensity suggestive of infarct. Additionally nonspecific hilar and mediastinal lymphadenopathy had developed on CT chest. Transesophageal echocardiogram was performed and was without abnormalities. Given degree of suspicion Monospot test was repeated, returned positive, and Cytmoegalovirus (CMV) was confirmed with quantitative polymerase chain reaction (PCR).
Discussion:
Fever in the presence of splenic infarcts can be seen in hematological disorders of hypercoaguability, sickle cell disease, or autoimmune vasculitis, as well as both viral and bacterial infectious conditions. Splanchnic vein thrombosis and splenic infarction were the most prevalent thromboses associated with acute CMV infection with splanchnic vein thrombosis being the one most prevalent among immune-competent patients. Procalcitonin is a peptide precursor of calcitonin that rises in response to a pro-inflammatory process of bacterial origin and is actively suppressed in viral inflammations, which can be a useful adjunct in the clinical decision making process.
Conclusions:
A high degree of suspicion for CMV is required when young adults present with classic symptoms, including lymphadenopathy and splenomegaly, despite negative screen. Procalcitonin, a biomarker gaining use to determine etiology and degree of infection is a useful adjunct to the clinical decision making process. Hospitalists need to recognize the possibility that screening tests are not 100% sensitive.