1. A Case of Fatigue & Fever
Submitted by:
Dakota Warkentin, Geena Titus & Jari Vaarre
June 16, 2014
Compilations:
Patient History- Dakota, Geena & Jari
Interpretation of results- Dakota
Differential Diagnosis with Rationale- Dakota, Geena & Jari
Pathophysiology- Dakota
Management- Geena
Prognosis & Patient Education- Dakota, Geena & Jari
References- Dakota
Editing and Arrangements: Dakota & Geena
Vocal recordings: Dakota & Geena

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

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.

4. Additional Relevant History Questions
Describe “worsening” fatigue- OPQRST
OPQRST of headache and sore throat
What, if anything, has helped with relief of symptoms?
Have you/do you have a cough and phlegm? (Dry or Wet/ colour)
Any nausea, vomiting or abdominal pain? Any joint/muscle pain?
Any unusual bowel movements such as constipation or diarrhea?
When was your last period? Was it light, normal or heavy?
Pain, unusual smell, colour or discharge on urination?
Are you sexually active? If yes, any new partners?
Recent travel outside of country? When, where and how long? Any insect bites or infections?
Recent hospitalizations? Visiting to health care facility?
Past medical Hx., Medications (incl. OTC and herbal)? Smoking, alcohol and street drug use?

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

6. Laboratory Investigations
RBC 5.24 x 1012/L
Hgb 153 g/L
Hct 46.2 %
MCV 87.9 fL- femtoliter
MCHC 332 g/L
RDW – Red cell distribution width
WBC 12.8 x 109/L
Neutrophils 24 %
Lymphocytes 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

7. Interpretation of Lab Results(key findings)
WBC count high 12.8x109 cell/L ( x109 cell/L)
Neutrophil low 24% (45-73%)
Lymphocyte high 73% (20-40%)
Monocytes low 0% (2-8%)
Positive Heterophil Antibody Test- detects heterophil antibodies, diagnose recent mononucleosis infection
Reactive Lymphocytes- antigen stimulation

8. Differential Diagnosis with brief explanation of rationale
Epstein-Barr Virus (EBV) - infectious mononucleosis; symptoms of fever, sore throat, lymphadenopathy; physical examination and lab work correspond with EBV; Positive heterophil antibody test.
Bacterial Pharyngitis - fatigue, sore throat, fever, headache, chills, swollen/tender anterior cervical nodes.
Strep throat – associated with sore throat, fatigue, and fever with no associated cold symptoms (cough); no tonsillar exudate noted on examination, no throat swab results for S. pyogenes.
Sinusitis – associated with fever and congestion that could cause a headache; history lacks presence of purulent phlegm, physical exam did not demonstrate tenderness on palpation over sinuses
Anemia- fatigue commonly associated with anemic condition; RBC counts were normal

9. Most Likely Diagnosis with brief explanation of rationale
EBV (infectious mononucleosis) given:
Sx consistent with EBV
physical exam findings of lymphadenopathy
positive heterophil antibody results
leukocytosis- greater than 10 x 109cell/L
enlarged WBC’s

10. Pathophysiology
Infectious mononucleosis caused by Epstein-Barr Virus (EBV)
Transmission: via body secretions, usually oropharyngeal;
can also infect cervix or transmit through blood transfusion
EBV infects B lymphocytes in oropharyngeal epithelium
Circulating B cells spread infection throughout reticuloendothelial system (RES) e.g. liver, spleen, peripheral lymph nodes
Infection B lymphocytes cause humoral and cellular response
T-lymphocyte response essential for infection control -Natural Killer and CD8+ cytotoxic T cells control proliferation
Immune response: cytokine release causes fever
Proliferating EBV infected B cells: in RES - cause lymphocytosis; in lymphatic tissue of oropharynx - causes pharyngitis

11. Management Rest and fluids are indicated during the acute stages.
Can treat for fever, sore throat and malaise with acetaminophen or NSAIDs.
Antibiotics, particularly ampicillin/amoxicillin, results in rash - DO NOT administer.
Increased risk of splenic rupture - therefore avoid contact sports and heavily physical activities.
Administer corticosteroids if there is acute airway obstruction and refer to ENT immediately.

12. Prognosis/Patient Education
Review that EBV is acquired via kissing, sharing utensils or drinking glasses - AVOID salivary contact to prevent spread of virus.
Inform patient to avoid heavy physical activities due to risk of spleen rupture
Patients should know signs and symptoms to be aware of and how to treat or address issues eg. fatigue, shortness of breath, fever.
Ensure patient understands fatigue may take a long time to resolve
Follow up with physician before resuming ANY physical activity.
Prognosis:
Patients may take up to two months to return to normal energy levels.
Some patients may develop chronic fatigue.

13. References
Auwaerter, PG. [Internet] UpToDate: Patient Information, Infectious mononucleosis in adults and adolescents. C2013 [cited June 12, 2014]. Available from
Klostranec, JM. Kohlin, DL. The Toronto Notes 28th ed. Toronto, ON. Toronto Notes for Medical Students Inc. 2012
Lee, M. Basic Skills in Interpreting Laboratory Data. 4th ed. Bethesda, MD. American Society of Health-System Pharmacist Inc. 2009
4. Medscape [Internet] Infectious mononucleosis; c2014 [cited June 12, 2014]. Available from