International Journal of Pediatric Otorhinolaryngology Extra
Volume 2, Issue 4 , Pages 211-214, December 2007

Acute sinusitis complicating infectious mononucleosis in an adolescent

Department of Pediatrics C, Schneider Children's Medical Center of Israel, Petach Tikva and Sackler Faculty of Medicine, Tel Aviv University, 14 Kaplan St., Petach Tikva 49202, Tel Aviv, Israel

Received 1 February 2007; received in revised form 30 May 2007; accepted 2 June 2007.

Article Outline

Summary 

We describe an adolescent boy who presented with acute sinusitis complicating Epstein-Barr virus-induced infectious mononucleosis. Supportive and antibiotic treatment led to a full recovery.

Keywords: Adolescent, Epstein-Barr virus, Infectious mononucleosis, Sinusitis

 

Epstein-Barr virus (EBV), a member of the herpesvirus family, is one of the most prevalent viruses infecting over 90% of humans and persisting for the lifetime of the person [1]. EBV induces a broad spectrum of illness in humans. In most cases, the clinical manifestations of infectious mononucleosis presents as a clinical triad of sore throat, fever, and lymphadenopathy. Splenomegaly, palatal petechiae, and hepatomegaly are present in more than 10% of the cases [2]. Additional hematological, splenic, neurological, hepatological, renal, cardiac, and pulmonary complications, in addition to malignancy and death have been extensively reported in literature [3]. Sinusitis, however, has rarely been associated with EVB-induced infectious mononucleosis [4], [5], [6].

We report a case of an adolescent with primary EBV-induced infectious mononucleosis complicated by sinusitis, and review previous published cases.

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1. Case report 

A 16-year-old white adolescent male was admitted to Schneider Children's Medical Center of Israel with a 1-month history of high-grade fever, sore throat, cervical lymphadenopathy, malaise, anorexia, 4-kg weight loss, generalized weakness, and night sweats. Two weeks prior to admission, a cough and purulent (greenish-mucoid) rhinorrhea developed, accompanied by temporal and occipital headaches, as well as retro-orbital headaches, worsening when the patient bent forward. At onset of the disease, amoxicillin per os was prescribed. Throat culture was not performed prior to commencement of antibiotics. In the absence of a clinical response, treatment was switched after 1 week to penicillin VK per os for another week. When headaches worsened, the patient was referred to our emergency department.

Past medical history was positive for epilepsy, treated and balanced with valproic acid per os, and glucose-6-phosphate (G6PD) deficiency. The patient was fully vaccinated. Upon admission, he had been taking only antipyretics (acetaminophen and ibuprofen) at the proper dosage and time intervals. He denied visiting exotic places or exposure to animals or sick people.

Physical examination showed a pale, ill but fully alert and responsive adolescent. Vital signs were temperature 38.5°C, heart rate 69beats/min, blood pressure 90/50mmHg. The mucous membranes were dry. Percussion of the frontal and maxillary sinuses induced no pain. Bilateral cervical lymphadenopathy was noted, the largest nodes measuring 1.5cm in diameter; axillary and inguinal lymph nodes were not enlarged. There was no tonsillar hypertrophy, although a small infiltrate was seen on the left tonsil. Mild postnasal drip was observed. The abdomen was not distended; bowel sounds were normal; abdomen soft on palpation and without tenderness; the liver and spleen were palpated 3cm below the costal margin. Neurological examination was noncontributory.

Laboratory studies undertaken at admission revealed a white blood cell count of 5400/mm3, with 55% neutrophils, 31% lymphocytes, and 10% monocytes. Hemoglobin measured 9.5g/dl, mean corpuscular volume 91.4fl, red blood cell distribution width index 12.2%, reticulocyte count 2.4%, and platelet count 170,000/mm3. Direct and indirect Coombs’ tests were negative. Hematological blood smear showed normal white blood cells and platelets, and no signs of hemolysis or polychromasia. Renal function tests, serum electrolyte levels, and serum liver enzyme levels were within normal range.

Coagulation tests revealed no abnormalities except for an elevated serum fibrinogen level of 530mg/dl (normal range, 200–400mg/dl). Haptoglobin was also mildly elevated at 210mg/dl (normal range, 30–200mg/dl). C-reactive protein level measured 5.2mg/dl (normal range, 0–0.5mg/dl).

Serology for EBV was positive for EBV viral capsid antigen (VCA) IgM, negative for VCA IgG, and negative for nuclear EBV Ag (EBNA). Monospot test was negative, as were serologic tests for cytomegalovirus and toxoplasma. Chest and sinuses radiographs revealed no abnormalities. Lateral cervical radiograph revealed fullness of the soft tissue in the left lower cervical region. Computed tomography (CT) of the head without and with contrast medium revealed a normal brain parenchyma, without abnormal enhancement after contrast medium injection. Opacification of the right maxillary sinus, bilateral ethmoidal sinuses, and bilateral sphenoidal sinuses was noted, with an air–fluid level in the right sphenoidal sinus.

EBV infectious mononucleosis was treated by supportive bed rest, intravenous fluids, and antipyretics. As sinusitis was clinically indicated, we initiated IV cefuroxime axetil. However, there was no improvement in the clinical course after 3 days and based on the radiological findings, we switched to IV ceftriaxone and clindamycin. This led to normalization of the body temperature and an almost total alleviation of the headaches. Sore throat, night sweats, cough, and rhinorrhea resolved, and the patient regained his appetite.

Serum hemoglobin level increased to 11.4g/dl and liver enzyme levels were normal. After a week of intravenous antibiotics, the patient was discharged and given cefuroxime axetil per os for an additional week. Repeated serology for EBV at discharge (6 weeks after onset of symptoms) was negative for VCA IgM and positive for VCA IgG. Repeated monospot test and blood cultures were negative.

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2. Discussion 

We describe a rare case of sinusitis complicating EBV-induced mononucleosis in an adolescent. Our patient had typical symptoms and signs of infectious mononucleosis, with positive serology for acute EBV infection. However, complaints of severe headaches, which worsened when bending forward, combined with purulent rhinorrhea and cough of 2 weeks duration, suggested secondary sinusitis. Diagnosis was confirmed by CT scan.

Acute viral sinusitis is one of the common causes of respiratory tract infections, usually resolving spontaneously, without treatment. It is estimated that in the pediatric population, 5–13% of these viral infections may be complicated by secondary bacterial sinusitis [7]. Gwaltney et al. studied 31 healthy adult volunteers (mean age 24 years) with self-diagnosed common cold. All had undergone CT scans. Most had occlusion of the ethmoid infundibulum and/or abnormalities of one or both maxillary–sinus cavities; many had abnormalities of the ethmoid sinuses; some had abnormalities of the frontal sinuses and sphenoid sinuses. After 2 weeks, CT scans were repeated in 14 subjects, none of had taken antibiotics. Most of these subjects had abnormalities of the infundibula. Sinuses had cleared or markedly improved. Rhinovirus was detected in nasal secretions from 24 (27%) of 90 subjects. The authors concluded that the common cold is associated with frequent and variable anatomical involvement of the upper airways, including occlusion and abnormalities in the sinus cavities [8].

Surprisingly, our review of the medical literature yielded only a few case reports of sinusitis associated with EBV-induced infectious mononucleosis in previously healthy people. Sumaya and Neerhout [4] described an 8-year-old girl with infectious mononucleosis complicated by sinusitis and periorbital infections. Givner et al. [5] described an adolescent boy with EBV-induced infectious mononucleosis followed by development of sinusitis, orbital cellulitis, and polymicrobial bacteremia. Corynebacterium haemolyticum was recovered from four blood cultures, as well as from pus obtained from the left maxillary antrum. Johnsen et al. [6], in a study of 467 patients aged 7–32 years with infectious mononucleosis, found otolaryngologic complications in 23 (5%), including 4 patients with maxillary sinusitis. Other complications included upper airway obstruction, peritonsillar abscess, otitis media, epistaxis, spontaneous mucosal bleeding in the oral cavity, and petechia in the oral cavity.

Acute sinusitis may be regarded as a bacterial superinfection caused by impaired mucocilliary clearance and edema, similar to findings in the middle ear [9]. Lymphoid hyperplasia and distortion of the normal architecture in the nasopharyngeal area with subsequent obstruction of the normal sinus drainage may also play a pathogenetic role.

It is unclear why acute sinusitis is not a more common complication of EBV infectious mononucleosis. Influenza virus, for example, like rhinoviruses, causes an upper airway infection associated with high rates of sinusitis [10]. The airway infection is characterized by lysis of the respiratory epithelium, with loss of ciliary function, decreased mucus production, and desquamation of the epithelial layer. All these changes are conducive to direct secondary bacterial invasion via the epithelium [11], thereby predisposing patients to secondary infections, such as otitis media, pneumonia, and sinusitis [10]. By contrast, EBV initially infects the lymphatic tissue of the oropharynx, including the tonsils and adenoidal residua, but not the sinuses [12]. In addition, EBV does not cause immune suppression, which may partly explain the low rate of secondary bacteriologic infections.

The diagnosis of infectious mononucleosis is usually straightforward. As most patients are not treated with antibiotics, the chances of masking the diagnosis of acute sinusitis are minimized.

Infection of humans with EBV results in both humoral and cellular immunity to the virus. The cellular immune response is more important in controlling EBV infection. Natural killer cells and CD4+ and CD8+ cytotoxic T cells control proliferating EBV-induced B cells during primary infection [13]. Therefore, sinusitis may appear in patients with immunological disorders, such as X-linked agammaglobulinemia, common variable immunodeficiency, selective IgA deficiency, and IgG subclass deficiency [14].

In our patient, however, this was the first episode of acute sinusitis and there was no history of recurrent infections, such as pneumonia, otitis media, urinary tract infection, and gastroenteritis. Therefore, his immunologic function was not assessed.

Sinusitis is sometimes associated with allergic disorders, such as allergic rhinitis and asthma [15]. However, our patient had no personal or family history of atopic disease. Functional endoscopic sinus surgery is generally considered a safe and effective technique for treating pediatric rhinosinusitis, with less than a 1% incidence of major complications.

Lieser et al. [16] conducted a retrospective review of patients treated for sinusitis between 1992 and 1993. A four-staged prognostic system was developed and used to compare results of medical and surgical treatments. Stage IV included patients with moderate to severe daytime cough. Stage III patients suffered from headaches, used daily medications other than antibiotics, had two or more chronic rhinosinusitis comorbidities (i.e., asthma, allergy, or immunodeficiency), but no daytime cough. Stage II patients experienced a nighttime cough or halitosis, but no stage III or IV symptoms. Those with no predictive factors for chronic rhinosinusitis were classified as stage I. Stages II and III, achieved improved ratings for FESS versus medical therapy in 79% versus 54% and 68% versus 42%, respectively. This study implies that children meeting stage II or III criteria may be good candidates for FESS. A subset of pediatric chronic rhinosinusitis patients who were more likely to benefit from FESS after failing to respond to maximal medical management was identified.

In conclusion, although sinusitis is a rare complication of EBV infectious mononucleosis, this case should alert clinicians to the possibility.

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PII: S1871-4048(07)00049-4

doi:10.1016/j.pedex.2007.06.001

International Journal of Pediatric Otorhinolaryngology Extra
Volume 2, Issue 4 , Pages 211-214, December 2007

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