Correspondence

Medical Mystery: Abdominal Pain — The Answer

N Engl J Med 2005; 353:1421-1422September 29, 2005

Article

To the Editor:

The Medical Mystery in the August 4 issue1 involved a 40-year-old man who presented with a four-day history of pain in the left upper quadrant of the abdomen, accompanied by fatigue, fever, sweating, and sore throat. A computed tomographic scan was obtained; it revealed multiple splenic infarcts (Figure 1Figure 1Computed Tomographic Scan of the Abdomen.) due to acute infectious mononucleosis. Laboratory studies on admission showed an elevated white-cell count (13,800 per cubic millimeter) with 51 percent lymphocytes, 31 percent of which were atypical, as well as the following abnormal liver-function values: aspartate aminotransferase, 123 U per liter; alanine aminotransferase, 244 U per liter; alkaline phosphatase, 216 U per liter; and total bilirubin, 0.9 mg per deciliter (15.4 μmol per liter). Transthoracic echocardiography revealed no abnormalities, and blood cultures showed no growth. An initial monospot test was negative, as were serologic studies for cytomegalovirus and hepatitis A, B, and C viruses. At a follow-up visit with a primary care physician one week later, a repeated monospot test was positive, and a polymerase-chain-reaction analysis for Epstein–Barr virus DNA from the previous week was found to be positive.

Persons with acute infectious mononucleosis, often called “the kissing disease” because of its spread among adolescents by salivary contact, typically present with the triad of exudative pharyngitis, lymphadenopathy, and splenomegaly; splenic rupture or splenic infarction is a possible complication. The monospot test detects heterophil antibodies that are present in 90 percent of patients with acute infectious mononucleosis, but the test may require up to three weeks to become positive.

Primary infection with the Epstein–Barr virus in older persons is often associated with liver-function abnormalities. The patient in the current case may have contracted the infection from a new sex partner within the past 10 months. His liver-function values normalized over the next few months, and he had a full recovery.

Karen M. Kim, M.D.
Tufts University School of Medicine, Boston, MA 02111

Richard I. Kopelman, M.D.
Tufts–New England Medical Center, Boston, MA 02111

1 References

1. 1

   Kim KM, Kopelman RI. Medical mystery -- abdominal pain. N Engl J Med 2005;353:508-508
   Full Text | Web of Science | Medline

Citing Articles (2)

Citing Articles

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   Etienne M. Sokal, Karel Hoppenbrouwers, Corinne Vandermeulen, Michel Moutschen, Philippe Léonard, Andre Moreels, Michèle Haumont, Alex Bollen, Françoise Smets, Martine Denis. (2007) Recombinant gp350 Vaccine for Infectious Mononucleosis: A Phase 2, Randomized, Double‐Blind, Placebo‐Controlled Trial to Evaluate the Safety, Immunogenicity, and Efficacy of an Epstein‐Barr Virus Vaccine in Healthy Young Adults. The Journal of Infectious Diseases 196:12, 1749-1753
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   Michel Moutschen, Philippe Léonard, Etienne M. Sokal, Françoise Smets, Michèle Haumont, Pasqualina Mazzu, Alex Bollen, Francoise Denamur, Pascal Peeters, Gary Dubin, Martine Denis. (2007) Phase I/II studies to evaluate safety and immunogenicity of a recombinant gp350 Epstein–Barr virus vaccine in healthy adults. Vaccine 25:24, 4697-4705
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