A Case of Fatigue & Fever

1. A Case of Fatigue & Fever Submitted by: Dakota Warkentin, Geena Titus & JariVaarre 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 1Overview • 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 0.121 – 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 (4.4-11.3x109 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 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 http://www.uptodate.com/contents/infectious-mononucleosis-mono-in-adults-and-adolescents-beyond-the-basics • 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 http://emedicine.medscape.com/article/222040-overview#a0104