1. Case of Week Department of Gastroenterology 이윤정

2. Chief complaint Sore throat ( onset : 2weeks ago ) Present illness Present illness 특이병력 없는 26 세 남자환자로 약 내원 2 주전부터 시작된 fever, headache, sore throat 를 주소로 개인병원에서 항생제 치료함. 치료중 nausea, vomiting 있었고 이 때 시행한 간기능 검사에서 AST/ALT (320/650 U/L) 증가소견 보여서 further evaluation 위해서 외래 통해 입원함. 오 * 균 (M/26) Admission date 2005.07.06 Patient’s history

3. Medical history DM/HTN/TB/Hepatitis ( -/ - / - /- ) OP Hx. (- ) Local 에서 Augmentin 375mg, ibuprofen 200mg. Po.tid. Family history Unremarkable Personal history Alcohol(+) : socially, Smoking(-) 건강식품이나 한약 복용력 없음. Travel Hx. (-) Sexual Hx. (+) : Intermittent intercourse with girl friend Patient’s history

4. 1.General : fatigue(+), fever/chilling sense(-/-) 2.Skin : itching sense(-), easy bruisablitiy(-), rash(-) 3.H & N : headache(+), neck stiffness(-), sore throat(+) 4.Resp. : cough(-), sputum(-), dyspnea(-) 5.Cardiac : anginal chest pain(-), orthopnea(-), palpitations(-) Review of systems

5. 6.G-I : anorexia(+), nausea(+), vomiting(-), abdominal pain(-), diarrhea(-) 7.Urinary : dysuria(-), hematuria(-), incontinence(-) 8.M-S : myalgia(+), trauma(-) 9. Endo. : weight change(-), temperature tolerance(-) 10. Neurology : syncope(-), seizure(-), dizzness (-) Review of systems

6. Physical examination * V/S 130/90 mmHg-104 회 /min-22 회 /min-36.5 ℃ *Body weight 71 kg Height 174 cm 1.General appearance Alert consciousness Acutely ill-looking appearance 2.Skin No rash or pigmentation 3.Head & neck Normocephaly No neck vein engorgement Both mild cervical lymph node enlargement fixation (-), tenderness (+) 4. Eyes & ENT Isocoric pupil with PLR (++/++) Whitish sclera, pinkish conjunctiva PTH (+++/++), PI (+/+), whitish patch infiltration

7. 5. Chest Symmetric chest expansion Clear breathing sound without crackles or wheezing Regular heart beat without murmur 6. Abdomen Soft & flat abdomen Normoactive bowel sound, No palpable mass No abdominal tenderness or rebound tenderness No hepatosplenomegaly 7. Back & extremities No CVA tenderness or rebound tenderness No pretibial pitting edema 8. Neurologic signs Motor &sensory : intact Physical examination

8. 1. Acute tonsilitis & lymphadenitis d/t streptococcal infection d/t viral infection Blood culture, throat culture serology check(ASO Titer) CRP, ESR check Initial impression (1)

9. 2.Acute hepatitis d/t viral hepatitis d/t toxic hepatitis d/t autoimmune hepatitis d/t chronic hepatitis with acute exacerbation Initial impression (2) Viral marker check (HAV,HBV,HCV) Abdominal sonography Drug history check

10. 1.CBC/DC 6,560/mm 3 – 14.0g/dL – 40.8% - 167,000/mm 3 (Seg. 30%, lympho 58%, mono 5%, eosino 1% atypical lympho 6% ) aPTT : 37C33, PT : 13.6S94C13.3, INR : 1.04 2.Blood chemistry Total bil./Direct bil. 0.8/0.3 mg/dL Total cholesterol 131mg/dL Protein/Albumin 6.9/3.9 g/dL AST/ALT 318/613 IU/L ALP/rGT 245/156 U/L ( 39-117 / <50 U/L) LD/CK 1051/49 U/L ( 218-472/ 38-160U/L) BUN/Creatinine 11/0.9 mg/dL Na/K/Cl 139/4.2/105 mmol/L Ca/P/Uric acid 9.2/3.2/5.3 mg/dL ( 8.4-10.2/2.5-5.5/2.5-6.3) Initial lab data

11. 3.U/A : RBC 0~1/HPF, WBC 0-1/HPF, urobilinogen(-) 4.CRP : 0.4 mg/dL ( <0.5 ), ESR : 2mm/hr (<9) 5.Viral marker : HBsAg/Anti-HBs/Anti-HBc IgG (-/+/+) Anti-HCV (-), HCV RT-PCR (-) Anti-HAV IgM (-) 6. Throat culture (-), blood culture (-) Initial lab data

12. CHEST

13. Abdominal sono

14. Impression Fever, sore thoat Exudative phrygotonsilitis Splenomegaly Abnormal LFT Atypical lymphocytosis IgM-VCAIgG-VCAEA Heterophilic Ab ? Infectious mononucleosis

15. CINICAL COURSE Infection T/F Symptomatic Tx.

16. Fever curve

17. Infectious mononucleosis Heterophili Ab(-) EBNA(-) EBV VCA IgM (+) EBV VCA IgG(+). EBV Antibody

18. Heterophile Anti-VCA IGM Anti-VCA IGG Anti- EA-D Anti- EA-R Anti- EBNA Acute IM +++++-- Convalescence +/--+- + Past infection --+--+ Reactivation --++++ +/-

19. Final diagnosis Infectious mononucleosis due to EB virus

20. IM Clinical manifestations Textbook of Pediatric Infectious Diseases. 5th ed. Philadelphia: Saunders; 2004

21. Ann Intern Med 1982;96:505-8 IM diagnosis

22. Ann Intern Med 1982;96:505-8 EBV Antibody