264 September/October 2003

CLINICAL REPORTPHC

figures are consistent with her pastgrowth along the 25th percentiles forheight and weight. Vital signs were:pulse 90, respirations 18, temperature98.8, and blood pressure 90/52. Herphysical exam was completely normalwith the exception of a liver edge pal-pable at 5 centimeters below the rightcostal margin. J.M.’s abdomen was soft,non-tender with normal active bowelsounds.

an adequate range of protein, iron, cal-cium, and carbohydrates. There are noissues with elimination or sleep.

FAMILY/MEDICAL HISTORYJ.M.’s parents are both 38 years-old andare in good health. Family history isnon-contributory at this time.

OBJECTIVE FINDINGSAt her 2-year visit, J.M. weighed 24pounds and was 33.5 inches long. These

DESCRIPTION OF CHILD

J.M. is a 25-month-old child in for herscheduled 2-year well-child care visit.Her previous visit to the office was 3months ago when she was seen afterseveral days of rhinorrhea, a slightcough, and low-grade fever. At that visit,Jayne was diagnosed with a viral upperrespiratory infection (URI) and wastreated symptomatically. Her motherhas no medical questions or concerns.

PAST MEDICAL HISTORYJ.M. with the exception of an occasionalURI. She has never been hospitalized,has no known allergies to medicationsor foods, and is current with immu-nizations.

SOCIAL AND DEVELOPMENTALHISTORYJayne lives with her parents and 5-year-old brother in a single-family homewith a dog and cat. Jayne attends acommunity-based child care setting 4days a week. Jayne’s development isexcellent in all areas. Her diet includes

Patricia Ryan-Krause is Assistant Professor at the Yale University School of Nursing, New Haven, CT.

Reprint requests: Patricia Ryan-Krause, MS, RN, MSN, CPNP, Yale University School of Nursing, 100 ChurchSt. South, PO Box 9740, New Haven, CT 06536.

J Pediatr Health Care. (2003). 17, 264.

Copyright © 2003 by the National Association of Pediatric Nurse Practitioners.

doi:10.1067/mph.2003.72

CASE STUDIES

CASE STUDIES QUIZ1. Considering the history and hepatomegaly found on the exam, what are your

differentials?2. How would you evaluate this child?3. What is your diagnosis?4. What is the treatment and prognosis for this infection?

Answers are on page 273-274.

A Toddler With

Hepatomegaly

SECTION EDITORS

Carol Rudy, MPH, ARNP, CPNARockwood Cl in ic Pediatr icsSpokane, Washington

Joan Greene, MSN, RN, CPNPAnnapol i s Pediatr icsAnnapol i s , Maryland

Sal ly Walsh, MSN, RN, CPNPPediatr ic Associates of NorwoodBoston, Massachuset ts

Pat r ic ia Ryan-Krause, MS, RN, MSN, CPNP

tivated T-cells, found in the peripheralblood. All values on the metabolicpanel were completely within normallimits; LFTs showed a slight elevationof aspartate aminotransferase (AST, 46)with all other values normal. The he-patitis panel revealed no infection withHepatitis A, B, or C. Screenings for cytomegalovirus and toxoplasmosiswere also negative. J.M.’s Epstein-Barrtiters revealed significantly elevatedIgM, elevated IgG, and a positive EBVearly antigen.

J.M.’s abdominal ultrasound re-vealed minor enlargement of both thespleen and the liver. The ultrasound re-vealed no focal hepatic or splenic le-sions, nodules, cysts, or masses consis-tent with malignancy, obstruction, orother chronic disease.

3. What is your diagnosis?

J.M.’s diagnostic evaluation suggestsinfectious mononucleosis (IM). Thehigh percentage of atypical lympho-cytes (34%) and mildly elevated WBCs(14.2) are very common findings in allage patients with IM. Often there are atleast 10% atypical lymphocytes. Leuko-cytosis is often an important finding ina patient with a viral illness such as IM.The mild anemia is likely virus-induced. The abundance of Downeycells on the blood smear is also sup-portive of the diagnosis of IM. The EBVtiters indicate infection with this virusand the elevated AST also supports thediagnosis since 50% of patients with thevirus will have high hepatic transami-nases, which do not produce jaundice.

Mononucleosis is an illness caused

early antigens appear early in the infec-tion, may persist for several weeks, andmay reappear with stress from other ill-ness (Peter & Ray, 1998).

J.M.’s CBC revealed white blood cellsin the upper range of normal (14.2), amildly depressed hemoglobin (10.5)

and hematocrit (30.5), a high percent-age of atypical lymphocytes (34%), anda low percentage of segmented neu-trophils (10%). Platelets were normal.The smear revealed an abundance ofDowney cells, which are circulating ac-

1.What are your differentials?

A variety of conditions may presentwith hepatomegaly. These include in-fections, tumors, metabolic, vascular, orobstructive disorders (Treem, 2000).Since J.M. is a healthy child with nor-mal growth, no complaints, and nosymptoms, her evaluation should focuson conditions that may present withisolated physical findings rather thanconditions that include serious, signifi-cant symptoms.

2. How would you evaluate this child?

In evaluating an apparently well childwith a single abnormal physical find-ing, it is important to choose laboratoryevaluations that provide as much infor-mation as possible and focus specifi-cally on the abnormal finding. The fol-lowing evaluations were ordered:Complete blood count (CBC) with dif-ferential and smear, complete meta-bolic panel, liver function tests (LFTs),toxoplasmosis, cytomegalovirus, Ep-stein-Barr Virus (EBV), hepatitis panel,and an abdominal ultrasound. Al-though there are two possible evalua-tions for Epstein-Barr infection, themonospot was not ordered for J.M. be-cause its sensitivity is only 20% inyoung children. This test is frequentlyused to assess EBV infection in olderchildren (>5 years-old). It is easy to per-form and has a sensitivity of 85% inolder children and a specificity of 97%(Peter & Ray, 1998). In some patients themonospot may be negative initially andthen become positive after 2-3 weeks ofillness. A more accurate test, particu-larly in a child of J.M.’s age, is viral spe-cific serology. In this evaluation, IgMantibodies to the Epstein-Barr virus willbe elevated early in the course of the in-fection and will persist for weeks tomonths. IgG antibodies will show agradual rise, then fall and persistthroughout a lifetime. Antibodies to the

273September/October 2003

Reprint requests: Patricia Ryan-Krause, MS, RN, MSN, CPNP, Yale University School of Nursing, 100 ChurchSt. South, PO Box 9740, New Haven, CT 06536.

J Pediatr Health Care. (2003). 17, 273-274.

Copyright © 2003 by the National Association of Pediatric Nurse Practitioners.

doi:10.1067/mph.2003.72

QUESTIONS &ANSWERS

(Data on page 264.)

CLINICAL REPORTPHC

Pat r ic ia Ryan-Krause, MS, RN, MSN, CPNP

In evaluating an

apparently well child with

a single abnormal physical

finding, it is important to

choose laboratory

evaluations that provide as

much information

as possible and focus

specifically on the

abnormal finding.

PHCCASE STUDIES

274 Volume 17 Number 5 JOURNAL OF PEDIATRIC HEALTH CARE

by the Epstein-Barr virus. It is commonworld-wide but presents differentlyacross cultures and socioeconomic set-tings. In many developing countries orin poor areas of developed countries,many children are infected between theages of 3 and 6 years with mild or sub-clinical infection (Peter & Ray, 1998). Inmore economically stable areas, the in-fection is often symptomatic and occursbetween the second and fourth decadeof life. The most common mode oftransmission is through saliva. It is notespecially easy to transmit IM througheven close household contact. Trans-mission occurs through intimate con-tact, hence the nickname, “Kissing Dis-ease”. It is not spread via aerosolcontamination or fomites (Peter & Ray,1998). The incubation period is between30 and 50 days in older children andadolescents but may be shorter inyoung children (Jenson, 2000).

In older patients, the common pre-sentation often includes fatigue, mal-aise, lymphadenopathy, fever, and sorethroat. On physical exam, the pharyngi-tis often resembles Group A Beta He-molytic Streptococcal disease (GABHS)with petechiae on the soft palate and en-larged exudative tonsils. Five percent ofpatients with IM will also have docu-mented GABHS pharyngitis (Jenson,2000). Conversely, if a patient with doc-umented GABHS pharyngitis does notimprove after 48 hours of antibiotics, IMshould be considered as a potential di-agnosis. If a concurrent strep infection istreated with amoxicillin, it is commonfor a patient to develop a macular-papular rash 7-10 days after starting theantibiotic (Newcom, 2001).

A cephalosporin is an appropriatetreatment choice for non-allergic patientswith GABHS in whom there is a high in-dex of suspicion for IM. In addition topharyngitis, there is often lymph-adenopathy of the anterior and posteriorcervical chains. These nodes are oftenfirm and non-tender (Jenson 2000). Mildsplenomegaly is found in 50% of patients,

and hepatomegaly is found in 10% of pa-tients. Tremendous enlargement of theliver or spleen is not common.

Although IM is less typically a dis-ease of early childhood in the UnitedStates, it needs to be considered whensymptoms or physical findings are pre-sent. According to Jenson (2000, p. 979),“the majority of cases of primary EBVin infants and young children are clini-cally silent.” This was the case with J.M.If a young child is symptomatic withIM, the symptoms often include vagueor non-specific symptoms like anorexia,decreased energy, and low-grade fever(Newcom, 2001).

4.What is the treatment and prognosisfor this infection?

Once the diagnosis of IM in any agegroup is confirmed by blood work, themanagement is supportive and symp-tomatic. Rest is indicated for the patientwith significant fatigue. This symptomis more typical of adolescent and olderpatients than of younger, essentiallywell, children. Activity may be re-sumed as fatigue improves. Fever andgeneral muscle aches are managed withacetaminophen; GABHS pharyngitis, ifpresent, is treated with an appropriatenon-penicillin antibiotic and salt watergargles. Hydration should be main-tained by adequate fluid intake.

The most critical aspect of manage-ment is prevention of splenic rupture.

A patient with a palpable spleen mustbe restricted from contact sports for atleast the duration of the enlargement(Jenson, 2000). Sometimes contactsports are restricted for a month if thespleen is enlarged. Antiviral medica-tions are not recommended. Occasion-ally, corticosteroids are prescribed forcomplications of the virus, such as po-tential airway obstruction. These areprescribed at 1 mg/kg/day up to amaximum of 60 mg/day (PDR, 2002).

Most patients recover completelyfrom IM after an uneventful course.Rare complications include autoim-mune hemolytic anemia lasting severalmonths, neurologic symptoms such ascranial nerve palsies that resolve spon-taneously, and, very rarely, liver diseaseand liver failure (Jenson, 2000).

Since J.M. had no symptoms of ill-ness, she continued to be a healthy, ac-tive toddler. If she were to be retested ata future date, her EBV titers would in-dicate that she had had infection in thepast. It is uncommon to acquire thisvirus repeatedly. It would be impossi-ble to accurately determine the sourceof J.M.’s infection. Her daycare settingis a possible source of infection, sincethere may be exchange of saliva fromtoys and hand-to-mouth activity amongyoung children. Household transmis-sion is less likely (Jenson, 2000). Despiteits infrequency, IM is an important di-agnosis to consider when confrontedwith vague symptoms or unusual find-ings in apparently well children.

REFERENCESJenson, H. (2000). Epstein-Barr virus. In R.

Behrman, R. Kleigman, & H. Jenson (Eds.),Nelson textbook of pediatrics (pp. 977-981).Philadelphia: W.B. Saunders.

Newcom, P. (2001). Infectious mononucleosis: A clinical review. ADVANCE for Nurse Practi-tioners, 9(9), 37-41

Peter, J. & Ray, C. (1998). Infectious mononucleosis.Pediatrics in Review, 19(8), 276-279.

Treem, W. (1990). Large liver. In M. Schwartz, E.Charney, T. Curry, & S. Ludwig (Eds.), Pediatricprimary care:A problem oriented approach (pp. 271-281). Chicago: Year Book Medical Publishers.

Ryan-Krause

Leukocytosis is often an

important finding in a

patient with a viral illness

such as IM.