1. The Case of the Kissing Disease
Angela Yee: Researched Hx Questions, Physical Examination, Pathophysiology
Hemant Sharma: Researched Hx questions, Differential diagnosis with explanation, prognosis and patient education.
Maria Reyes Diaz: Researched Hx. questions, interpretation of lab results, most likely diagnosis with explanation, management, prognosis and patient education
Nipuni Ranepura: Researched Hx Questions, Lab investigations. Organized/Edited final slides
June 16, 2014
Presenter: Angela Yee

2. Hematology Case 1: Overview
•History
•Physical Examination
•Lab Investigations: results and interpretation
•Assessment: DDx and most likely Dx
•Management
•Prognosis and Patient education
Presenter: Angela Yee

3. History
20 year old female complains of worsening fatigue over the last week or so, with associated sore throat and headaches. She also reports occasional fever and chills. She normally runs 3 miles per day, which she has been unable to do since the onset of symptoms.
Presenter: Angela Yee

4. Additional Relevant History Questions
When did her symptoms begin and has she had similar symptoms previously?
Does she have generalized or localized pain/discomfort?
Are menstrual periods normal and regular?
Is she taking any medication?
Is she up to date with her immunizations?
Has she had a recent hospitalizations?
What is her past medical, family and social history?
Has she been in contact with anyone that is/has been sick?
Has she travelled outside the country in the past 6 mos?
Presenter: Nipuni Ranepura

5. Physical Exam
Erythema of the throat and tonsillar pillars. Cervical lymph nodes are swollen bilaterally, tender and mobile.
Presenter: Angela Yee

6. Laboratory Investigations
RBC 5.24 x 1012/L
Hgb 153 g/L
Hct 46.2 %
MCV 87.9 fL
MCHC 332 g/L
RDW 0.121
WBC 12.8 x 109/L
Neutrophils 24 %
Leukocytes 73%
Monocytes 0%
Eosinophils 3%
Basophils 0%
PLT 333 x 109/L
Heterophil antibody screen positive
Blood smear analysis
normocytic, normochromic red blood cells.
White blood cells are large with smudged chromatin pattern and reactive lymphocytes.
Platelet morphology is normal
Presenter: Maria Reyes Diaz

7. Interpretation of Lab Results(key findings)
Leukocytosis and Lymphocytosis: can indicate infection
Neutropenia: different etiologies
Monocytopenia: rare but can occur with autoimmune disorders or hairy cell leukemia
Positive Heterophile Test: Sensitive and specific test for detecting heterophile antibodies
Reactive Lymphocytes/ atypical lymphocytes
 common in some viral infections (i.e EBV and CMV)
Large WBC with smudged chromatin pattern: only significant when found in abundance
Presenter: Maria Reyes Diaz

8. Differential Diagnosis with brief explanation of rationale
Infectious mononucleosis
Rubella
Streptococcal Pharyngitis
Acute Herpetic Pharyngotonsillitis
Toxoplasmosis
HIV
Presenter: Hemant Sharma

9. Most Likely Diagnosis with brief explanation of rationale
The patient is a 20 yr old female presenting with common symptoms of Infectious Mononucleosis. She presents with malaise, headache, fever, chills, sore throat and lymphadenopathy. Lab results further support the diagnosis of Infectious Mononucleosis. Results were positive for leukocytosis, neutropenia, monocytopenia, and a positive heterophile test which is often a sign of mononucleosis. Worsening symptoms over the period of one week and the absence of other cold symptoms make these findings suspicious for Infectious Mononucleosis.
Presenter: Nipuni Ranepura

10. Pathophysiology  Transmitted through bodily secretions
 Virus infects B-lymphocytes
 B-lymphocytes target oropharynx, salivary glands, and the lymphoid
cells
 Activation of T-cells against the B-lymphocytes control infected
B-lymphocyte proliferation
 Infected B-lymphocytes enter bloodstream to spleen, liver, and
peripheral lymph nodes (clinical presentation)
 Initiation of acute infection and humoral immunity; EBV structural
proteins used to diagnose EBV
 Normal T-lymphocyte function
 Abnormal/ineffective T-lymphocyte function
Presenter: Angela Yee

11. Management  There is no treatment to completely eradicate the virus
 Acetaminophen or NSAIDs
Therapy is focused on management of symptoms
Corticosteroids: if complicated IM
Acyclovir: Antiviral, not very effective  not used
Antibiotics are NOT EFFECTIVE- amoxicillin & ampicillin are contraindicated
Rest
Mono causes extreme fatigue therefore adequate rest is important especially early in the infection process
 **Avoid strenuous physical activity for at least 3 weeks
Patients with IM are at risk for splenic rupture
Splenic rupture requires surgical intervention
Presenter: Maria Reyes Diaz

12. Prognosis & Patient Education
Mononucleosis is generally a self-limiting disease and infection
typically subsides within 2 to 4 weeks.
Most people recover without any permanent health
consequences. Complete recovery may take months
Complications are rare but life threatening, often due to splenic
rupture.
 Patient to refrain from strenuous physical activity for first 3 weeks
Patient should avoid exposing other people to their body
secretions because EBV remains viable in patients with EBV
infectious mononucleosis for months.
Although complete isolation is not required the patient is
instructed to still take precautions such as; Avoid sharing drinking
glasses or utensils and avoid kissing.
Presenter: Hemant Sharma

13. References
Aspectsin, C. & Saccomano, S.J. Clinician Reviews: Infectious mononucleosis. Quadrant Healthcom, Inc. 2013; 23.6: 42.
ALQEP: Hematology Morphology Critique [Internet]. [Updated 2004 May; Cited 2014 Jun 10]; Available from:
Auwaerter, Paul. Patient information: Infectious mononucleosis (mono) in adults and adolescents (Beyond the Basics). [uptodate]. updated July cited June Accessed from
Cunha, B.A. Infectious Mononucleosis: History [Internet]. [Updated 2014 Mar 30; cited 2014 Jun 10]; Available from:
Cunha, B.A. Infectious Mononucleosis: Pathophysiology [Internet]. [Updated 2014 Mar 30; cited 2014 Jun 10]; Available from:
Cunha, B.A. Infectious Mononucleosis: Physical [Internet]. [Updated 2014 Mar 30; cited 2014 Jun 10]; Available from:
Epstein-Barr virus and Infectious Mononucleosis. January 7, 2014; Available at:
Kaye, K.M. Infectious Mononucleosis [Internet]. [Updated 2013 July; cited 2014 Jun 10]; Available from:
Marshall A. Lichtman. Monocytosis and Monocytopenia

14. MediaLab incorporated. Smudge cells. Updated 2014. Cited June 2014
MediaLab incorporated. Smudge cells. Updated Cited June Accessed from
Merk Manual. Infectious Mononucleosis. Updated April Cited June Accessed from
Merck Manual. Lymphocytic Leukocytosis. Updated January Cited June Accessed from
Merck Manual. Monocyte Disorders. Updated January Cited June Accessed from
Merck Manual. Neutropenia. Updated January Cited June Accessed from
Patient information: Infectious mononucleosis (mono) in adults and adolescents (Beyond the Basics). Updated July Cited June Accessed from
Reddy, M. Smudge cells: clarifying the diagnosis [Internet]. [Updated 2007 Feb; Cited 2014 Jun 10]; Available from:
Salvaggio, MR. Herpes Simplex. January 25, 2012; Available at:
Vorvick, L.J. Mononucleosis [Internet]. [Updated 2012 May 15; cited 2014 Jun 10]; Available from: