Infectious Mononucleosis Complicated with Bilateral Peritonsillar Abscess and Splenic Infarction

A Rare Manifestation of Infectious Mononucleosis Tonsillitis

The purpose of this case report is to describe a rare case of infectious mononucleosis (IM) hemorrhagic tonsillitis. Our patient presented with acute tonsillitis complicated by spontaneous tonsillar hemorrhage. This is a single case report with a literature review. A 19-year-old male presented to the emergency department with a 10-day history of worsening sore throat, recurrent fevers, malaise, and dysphagia to solids and liquids, as well as a three-day history of epistaxis and hemoptysis. He tested positive for Epstein-Barr virus and rhinovirus. On exam, a "hot potato" voice was noted along with bilateral tonsillar edema, erythema, and hypertrophy. Both tonsils with dry blood coating and no exudates were visualized. Computed tomography (CT) imaging of the neck demonstrated subcutaneous emphysema isolated to the tonsils. Treatment consisted of intravenous antibiotics and steroids, followed by an oral antibiotic, with subsequent full resolution of symptoms. This case illustrates a rare, severe manifestation of IM tonsillitis that radiographically can mimic other more severe soft-tissue neck infections on imaging, such as cervical necrotizing fasciitis. In patients presenting with hematemesis, hemoptysis, and/or epistaxis, along with tonsillar edema, erythema, and hypertrophy, a diagnosis of spontaneous hemorrhagic tonsillitis should be considered. The radiographic findings of soft-tissue emphysema in the deep spaces of the head and neck region may be seen in the setting of IM, mimicking other soft-tissue infections of the deep neck spaces.

Clinical, Hematological, Biochemical and Radiological Characteristics for Patients With Splenic Infarction: Case Series With Literature Review

Background

Splenic infarction is a frequently missed diagnosis in acute clinical conditions and is often under-diagnosed due to the lack of high-quality evidence on pathophysiology of splenic infarction. Due to the scarcity of such evidence, no consensus guidelines regarding the diagnostic approach and management of patients with splenic infarction exist. Most of published articles on splenic infarction are case reports and there was no systematic review on splenic infarction.

Methods

We conducted a retrospective analysis of all radiologically confirmed cases of splenic infarction patients with any history of admission at National Center for Global Health and Medicine Kohnodai Hospital, from 2014 to 2020. Further, to understand the pathophysiology that causes splenic infarction, we searched the literatures on splenic infarction.

Results

We found 18 patients with splenic infarction. The average age was 78 years, and about half of patients had abdominal pain; however, the other half did not have abdominal pain. One-third of patients with splenic infarction died. Leukocytosis with neutrophilia, a decrease of lymphocytes, anemia, hypoalbuminemia, and liver dysfunction were observed. Fibrinogen was decreased and D-dimer was remarkably elevated. Lactate dehydrogenase (LDH) and C-reactive protein (CRP) were remarkably increased. Six patients (33.3%) had cancer, four patients (22.2%) had atrial fibrillation, and four patients (22.2%) had infection. We found 466 case reports on splenic infarction published from 1975 to 2021. Recently, the number of case reports on splenic infarction due to infection, especially, coronavirus disease 2019 (COVID-19), has been remarkably increasing. Furthermore, we found that leukocytosis, a decrease of lymphocytes, elongated activated partial thromboplastin time, decrease of fibrinogen, liver dysfunction, elevation of LDH and blood urea nitrogen can be the prognosis predicting factors for patients with splenic infarction.

Conclusion

Our study elucidated clinical, hematological, biochemical and radiological characteristics for patients with splenic infarction. We newly found significant differences in blood cell counts, coagulation markers, transaminases, LDH and blood urea nitrogen between patients who died and those who survived, suggesting that these parameters can be the prognosis predicting factors for splenic infarction. Further, our systematic review on case reports about splenic infarction showed the etiology of splenic infarction and the trend of the causative diseases.