Case No 1
The girl aged 16 years admitted to hospital for two-week progressing picture of sore throat, swallowing difficulties and formation of a membrane on the tonsil surface
Medical History
Present Illness: Two weeks before – great fatigue, sore throat, difficult swallowing, GP visit treated her with Zinnat (cefuroxime) 250 mg bid po with slight effect from beginning, after several days symptoms worsened, sore throat, swelling of the neck, swollen eyelids, now she practically cannot swallow, cannot drink. She comes from GP to be admitted to hospital.
FHx: Nothing of note
EHx: Denies infection exposure
WSHx: Student of high school
PM/SHx: No diseases, no surgery. Injury: suffered by left forearm contusion a week ago, sprained ligaments
Allergies: Pollen, NKDA
GHx: : Menarché from 12 years, 26-35-day cycle, dysmenorrhea, virgo
Medications: None
Abuse: She denies smoking, alcoholic drinks and illicit drugs.
Physical Examination
T 36,4 °C, m 55 kg v 164 cm P 78, TK 115/65. Height/weight proportionate, oriented, eupnoic, tired appearance, pronounced rhinolalia. Skin pale, well-perfused. No rashes or other lesions. Head: no tender percussion, CN grossly intact, bilateral eyelid swelling, pupils isocoric, eye movement free. Nares without any discharge. Oral cavity: Limited mouth opening, mucous membranes erythematous somewhat dry, symmetrically enlarged tonsils meet in the midline (“kissing tonsils”), with yellowish-white membranes cover entire surfice of tonsilar pillars, brown-white coated tongue. Neck: Lymph nodes bilaterally large 3 cm and tender, smaller ones along sternocleidomastoid muscles. Chest: breathing clean, no wheezes. Regular rate and rhythm, with normal S1 and S2. No murmurs. Soft, flat, non-tender. No hepatosplenomegaly; liver span approximately 10 cm. Normoactive bowel sounds. Forearm in a bandage with a splint. Radial pulse bilat. +, capillary refill normal. Legs are symmetric in appearance, no lower extremity pain or edema. Meningeal signs: intimate neck stiffness caused by swollen lymph nodes, others are negative.
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Fig. 1 Photograph of the oral cavity |
Laboratory Tests
Hematologic tests:
- Blood count: WBC 15.4 10^9/l (4.0-10.0),
RBC 4.57 10^12/l (3.80-5.20),
Hgb 138.0 g/l (120.0-160.0),
Hct 0.396 1/1 (0.350-0.470),
mean corpuscular volume (MCV) 86.7 fl (82.0-98.0),
mean corpuscular hemoglobin (MCH) 30.2 pg (28.0-34.0),
mean corpuscular hemoglobin concentration (MCHC) 0.348 kg/l (0.320-0.360),
PLT 221.0 10^9/l (150.0-400.0)
Differential (machine): neutrophils 0.43 (0.45-0.70), lymphocytes 0.42 (0.20-0.45), monocytes 0.14 (0.02-0.12), eosinophils 0.00 (0.00-0.05), basophils 0.01 1/1 (0.00-0.02).
Differential (microscopic): neutrophil segmented 0.34, neutrophil banded 0.13, lymphocyte 0.32, monocyte 0.10, plasmatic cell 0.01, lymphomonocyte 0.01, reactive lymphocyte 0.09.
Biochemical lab tests:
- Urine chem.: U-pH 5.5 (5.5-6.5) U-specific weight 1.027 kg/l (1.015-1.020) U-Glucose 0 arb.j. 0 U-Ketones 0 arb.j. 0 U-Protein 1 arb.j. 0 U-Bilirubin 0 arb.j. 0 U-Urobilinogen 0 arb.j. 0 U-Blood 1 arb.j. 0 U-Nitrit 0 arb.j. 0 U-Erythrocytes 16 /ul (<30) U-Leukocytes 24 /ul(<30) U-Squamous epithelia 198 /ul (<30) U-Mucus 4 arb.j.
- Biochemistry of plasma and serum: Glucose 5.1 mmol/l (3.3-5.6), Na+ 136 mmol/l (132-149), K+ 4,9 mmol/l (3.80-5.50), Cl- 98 mmol/l(97-108), Urea 6.1 mmol/l (3.20-7.40), Creatinine 69 umol/l (64-110), AST 1.67 ukat/l (<0.65), ALT 1.89 ukat/l (<0.80), ALP 1.96 ukat/l (0.50-2.00), GGT 0.23 ukat/l (<1.10), CRP 6.8 mg/l (0.0-8.0)
Microbiology laboratory tests:
- Throat swab culture: obtained, result not yet available
- Epstein-Barr virus serology: anti EBV EBNA-1 IgM ELISA positive EBV VCA-IgM positive IP, EBV VCA-IgG positive IP, EBV EBNA-IgG negative IP, a-EBV EA-IgG positive IP (cut-off = 1)
Diagnostic Conclusion
Make a diagnosis
Treatment
Propose and give reasons
Questions
- Tell three principal clinical symptoms of established diagnosis.
- Which are main laboratory findings in established diagnosis?
- What is the name of the basic serological reaction to detect heterophile antibodies?