If it smells like a virus…

EBV

The vast majority of mind numbing pediatric acute clinic visits in December and January are for colds and fevers. This is probably the majority of pediatric ED visits as well, but seeing as we have only 2 months dedicated to pediatric exposure, I don’t think we should be doing winter rotations…the learning is limited. However, I did have an interesting case last week. A 14 year old girl was referred to our Emergency Department for possible Meningitis. The ED took one look at her and knew that this 3 week illness she was suffering from was certainly NOT meningitis, so they sent her, appropriately, to our clinic. THe parents were obviously terrified that their daughter had some horrible disease, due to her fever of three weeks.

“What could be wrong?” Mom worriedly asks me.

“I don’t have enough information yet,” Mrs. Jones.

“Our doctor said she needed IVs. What does that mean?” she pressed.

“I need to ask you a few more questions first, and then examine your daughter. After that, I can answer more of your questions.”

I proceeded to get the chief complaint: fever and fatigue, and the history…three weeks of fatigue, sore throat, fevers on and off, decreased appetite. And information provided by the PCPs referral “hepatosplenomegaly” which means her liver and spleen were enlargeed. On top of that, he send off a blood cell count and liver enzymes which were slightly high, her white cells were normal, as were her red blood cells. Her exam showed significant cervical lymphadenopathy (swollen lymph nodes in her neck). Any guesses yet what she has?

This visit was all about pattern recognition: Fever, fatigue, sore throat, swollen lymph nodes, enlarged liver and spleen. If it looks like “Mono”, smells like Mono, and feels like Mono, it’s probably Mononucleosis (“the kissing disease”) and certainly NOT meningitis.

I sent off electrolytes, renal tests and Epstein-barr virus antibodies (the virus that causes Mono), and gave her some IV fluids that she probably didn’t need…despite the parents telling me initially that she hadn’t eaten or drunk anything in days, she was asking for McDonalds and fighting with her brother. The fluids probaby gave her a little extra oomph though.

If you’re wondering why a 14 year old has Mono (most of us associated it with high school and college aged students that get it from kissing, or sharing cups, toothbrushes or other icky stuff) the fact is that most of us have already had teh epstien barr virus when we were kids. We probably had a sore throat with a negative strep throat test, and it went away in a few days, then we were protected from the Kissing Disease during high school and college. It’s the kids that managed to skate through childhood without contracting it who get hit so hard they frequently miss an entire semester of school because of it.

Anyway, the results of the Mono blood tests were positive, I reassured the parents and had them follow up with previously mentioned PCP. Who knows why he referred her, maybe he’s far enough out of his pediatric training that he didn’t remember the disease. Maybe he didn’t say “meningitis” but said “mononucleosis” and the parents heard the big nasty word. Maybe he simply referred her to the ED for IV fluids because he couldn’t do it in his office.

In any case, my “pattern recognition” skills made the parents think I was a genious. Sometimes we just get lucky.

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