Case Presentation: 32-year-old previously healthy man presented with a week of fatigue and five days of low-grade fevers. He reported mild left abdominal pain worsened with inspiration. He denied a sore throat and other upper respiratory symptoms. He recently travelled to northern Wisconsin where he obtained multiple mosquito bites. He had been in contact with individuals with upper respiratory symptoms. His mother had a history of autoimmune hemolytic anemia. He presented with a temperature of 100.9 degrees Fahrenheit and heart rate of 108. He was overweight and non-toxic appearing. Oropharynx was clear and he had no palpable lymphadenopathy or organomegaly. He had no murmurs and abdomen was soft and nontender. WBC was 6.7 K/UL with lymphocytic predominance. Hemoglobin was 11.9 g/dL, and platelet count was normal. AST was 103 U/L, ALT 158 U/L, prothrombin time 15.4 seconds, and INR 1.4. Bilirubin was normal. Computerized tomography scan of the abdomen had multiple splenic infarcts and portacaval lymphadenopathy. Transthoracic and transesophageal echocardiograms showed no vegetations, and he had no other evidence of thromboembolic disease. He continued to be intermittently febrile despite being on intravenous vancomycin and ceftriaxone. He was also empirically placed on doxycycline for a possible tick-borne illness. Peripheral blood smear showed reactive lymphocytes consistent with an acute viral infection. He was ultimately found to be EBV VCA IgM positive and IgG negative. EBV nuclear antigen IgG was negative. EBV quantitative PCR was 8700 IU/ml. Antibodies to rickettsia, anaplasma, ehrlichia, and lyme resulted negative. AST and ALT peaked to 164 U/L and 306 U/L respectively, then trended downward. He was feeling well, pleuritic abdominal pain improved, and close outpatient follow up was arranged.
Discussion: When hospitalists encounter abdominal pain and splenic infarctions, etiologies of hematologic and thromboembolic disorders initially come to mind. Especially in young healthy individuals, the differential must also include infectious causes, specifically Epstein Barr Virus (EBV). The exact pathophysiology of infarction by EBV is unclear but has been documented as a rare complication of the virus. Management of splenic infarction is often conservative, but patients must be monitored closely given the possibility of life-threatening complications such as splenic rupture and hemorrhage.
Conclusions: Epstein Barr Virus is a familiar virus which often presents as infectious mononucleosis – typical symptoms include sore throat, fever, and enlarged lymph nodes. Rarely, splenic infarctions can be seen. This case highlights a presentation of EBV uncommon to the well-known infectious mononucleosis illness.