PH

CLINICAL REPORT

CASE STUDIES

SECTION EDITORS
C a ro l R u dy, M P H , A R N P, C P NA
R o ck wo o d C l i n i c Pe d i a t r i c s
S p o k a n e , Wa s h i n g t o n
Jo a n G re e n e , M S N , R N , C P N P
A n n a p o l i s Pe d i a t r i c s
A n n a p o l i s , M a ry l a n d
S a l ly Wa l s h , M S N , R N , C P N P
Pe d i a t r i c A s s o c i a t e s o f N o r wo o d
B o s t o n , M a s s a ch u s e t t s

Pa t r i c i a R ya n - K ra u s e , M S , R N , M S N , C P N P

DESCRIPTION OF CHILD
J.M. is a 25-month-old child in for her
scheduled 2-year well-child care visit.
Her previous visit to the office was 3
months ago when she was seen after
several days of rhinorrhea, a slight
cough, and low-grade fever. At that visit,
Jayne was diagnosed with a viral upper
respiratory infection (URI) and was
treated symptomatically. Her mother
has no medical questions or concerns.

PAST MEDICAL HISTORY

J.M. with the exception of an occasional
URI. She has never been hospitalized,
has no known allergies to medications
or foods, and is current with immunizations.

SOCIAL AND DEVELOPMENTAL

HISTORY
Jayne lives with her parents and 5-yearold brother in a single-family home
with a dog and cat. Jayne attends a
community-based child care setting 4
days a week. Jaynes development is
excellent in all areas. Her diet includes

A Toddler
With
Hepatomegaly

an adequate range of protein, iron, calcium, and carbohydrates. There are no

issues with elimination or sleep.

FAMILY/MEDICAL HISTORY
J.M.s parents are both 38 years-old and
are in good health. Family history is
non-contributory at this time.

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

figures are consistent with her past

growth along the 25th percentiles for
height and weight. Vital signs were:
pulse 90, respirations 18, temperature
98.8, and blood pressure 90/52. Her
physical exam was completely normal
with the exception of a liver edge palpable at 5 centimeters below the right
costal margin. J.M.s abdomen was soft,
non-tender with normal active bowel
sounds.

CASE STUDIES QUIZ

1. 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.

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 Church
St. 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

264

September/October 2003

PH
C

CLINICAL REPORT

QUESTIONS &
ANSWERS
Pa t r i c i a R ya n - K ra u s e , M S , R N , M S N , C P N P

1.What are your differentials?

A variety of conditions may present
with hepatomegaly. These include infections, tumors, metabolic, vascular, or
obstructive disorders (Treem, 2000).
Since J.M. is a healthy child with normal growth, no complaints, and no
symptoms, her evaluation should focus
on conditions that may present with
isolated physical findings rather than
conditions that include serious, significant symptoms.
2. How would you evaluate this child?
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. The following evaluations were ordered:
Complete blood count (CBC) with differential and smear, complete metabolic panel, liver function tests (LFTs),
toxoplasmosis, cytomegalovirus, Epstein-Barr Virus (EBV), hepatitis panel,
and an abdominal ultrasound. Although there are two possible evaluations for Epstein-Barr infection, the
monospot was not ordered for J.M. because its sensitivity is only 20% in
young children. This test is frequently
used to assess EBV infection in older
children (>5 years-old). It is easy to perform and has a sensitivity of 85% in
older children and a specificity of 97%
(Peter & Ray, 1998). In some patients the
monospot may be negative initially and
then become positive after 2-3 weeks of
illness. A more accurate test, particularly in a child of J.M.s age, is viral specific serology. In this evaluation, IgM
antibodies to the Epstein-Barr virus will
be elevated early in the course of the infection and will persist for weeks to
months. IgG antibodies will show a
gradual rise, then fall and persist
throughout a lifetime. Antibodies to the

September/October 2003

early antigens appear early in the infection, may persist for several weeks, and
may reappear with stress from other illness (Peter & Ray, 1998).
J.M.s CBC revealed white blood cells
in the upper range of normal (14.2), a
mildly depressed hemoglobin (10.5)

n 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.

and hematocrit (30.5), a high percentage of atypical lymphocytes (34%), and

a low percentage of segmented neutrophils (10%). Platelets were normal.
The smear revealed an abundance of
Downey cells, which are circulating ac-

(Data on page 264.)

tivated T-cells, found in the peripheral

blood. All values on the metabolic
panel were completely within normal
limits; LFTs showed a slight elevation
of aspartate aminotransferase (AST, 46)
with all other values normal. The hepatitis panel revealed no infection with
Hepatitis A, B, or C. Screenings for
cytomegalovirus and toxoplasmosis
were also negative. J.M.s Epstein-Barr
titers revealed significantly elevated
IgM, elevated IgG, and a positive EBV
early antigen.
J.M.s abdominal ultrasound revealed minor enlargement of both the
spleen and the liver. The ultrasound revealed no focal hepatic or splenic lesions, nodules, cysts, or masses consistent with malignancy, obstruction, or
other chronic disease.
3. What is your diagnosis?
J.M.s diagnostic evaluation suggests
infectious mononucleosis (IM). The
high percentage of atypical lymphocytes (34%) and mildly elevated WBCs
(14.2) are very common findings in all
age patients with IM. Often there are at
least 10% atypical lymphocytes. Leukocytosis is often an important finding in
a patient with a viral illness such as IM.
The mild anemia is likely virusinduced. The abundance of Downey
cells on the blood smear is also supportive of the diagnosis of IM. The EBV
titers indicate infection with this virus
and the elevated AST also supports the
diagnosis since 50% of patients with the
virus will have high hepatic transaminases, which do not produce jaundice.
Mononucleosis is an illness caused

Reprint requests: Patricia Ryan-Krause, MS, RN, MSN, CPNP, Yale University School of Nursing, 100 Church
St. 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

273

PH CASE STUDIES
C
by the Epstein-Barr virus. It is common
world-wide but presents differently
across cultures and socioeconomic settings. In many developing countries or
in poor areas of developed countries,
many children are infected between the
ages of 3 and 6 years with mild or subclinical infection (Peter & Ray, 1998). In
more economically stable areas, the infection is often symptomatic and occurs
between the second and fourth decade
of life. The most common mode of
transmission is through saliva. It is not
especially easy to transmit IM through
even close household contact. Transmission occurs through intimate contact, hence the nickname, Kissing Disease. It is not spread via aerosol
contamination or fomites (Peter & Ray,
1998). The incubation period is between
30 and 50 days in older children and
adolescents but may be shorter in
young children (Jenson, 2000).
In older patients, the common presentation often includes fatigue, malaise, lymphadenopathy, fever, and sore
throat. On physical exam, the pharyngitis often resembles Group A Beta Hemolytic Streptococcal disease (GABHS)
with petechiae on the soft palate and enlarged exudative tonsils. Five percent of
patients with IM will also have documented GABHS pharyngitis (Jenson,
2000). Conversely, if a patient with documented GABHS pharyngitis does not
improve after 48 hours of antibiotics, IM
should be considered as a potential diagnosis. If a concurrent strep infection is
treated with amoxicillin, it is common
for a patient to develop a macularpapular rash 7-10 days after starting the
antibiotic (Newcom, 2001).
A cephalosporin is an appropriate
treatment choice for non-allergic patients
with GABHS in whom there is a high index of suspicion for IM. In addition to
pharyngitis, there is often lymphadenopathy of the anterior and posterior
cervical chains. These nodes are often
firm and non-tender (Jenson 2000). Mild
splenomegaly is found in 50% of patients,

274

Volume 17 Number 5

Ryan-Krause

and hepatomegaly is found in 10% of patients. Tremendous enlargement of the

liver or spleen is not common.
Although IM is less typically a disease of early childhood in the United
States, it needs to be considered when
symptoms or physical findings are present. According to Jenson (2000, p. 979),
the majority of cases of primary EBV
in infants and young children are clinically silent. This was the case with J.M.
If a young child is symptomatic with
IM, the symptoms often include vague
or non-specific symptoms like anorexia,
decreased energy, and low-grade fever
(Newcom, 2001).

eukocytosis is often an

important finding in a
patient with a viral illness
such as IM.

4.What is the treatment and prognosis

for this infection?
Once the diagnosis of IM in any age
group is confirmed by blood work, the
management is supportive and symptomatic. Rest is indicated for the patient
with significant fatigue. This symptom
is more typical of adolescent and older
patients than of younger, essentially
well, children. Activity may be resumed as fatigue improves. Fever and
general muscle aches are managed with
acetaminophen; GABHS pharyngitis, if
present, is treated with an appropriate
non-penicillin antibiotic and salt water
gargles. Hydration should be maintained by adequate fluid intake.
The most critical aspect of management is prevention of splenic rupture.

A patient with a palpable spleen must

be restricted from contact sports for at
least the duration of the enlargement
(Jenson, 2000). Sometimes contact
sports are restricted for a month if the
spleen is enlarged. Antiviral medications are not recommended. Occasionally, corticosteroids are prescribed for
complications of the virus, such as potential airway obstruction. These are
prescribed at 1 mg/kg/day up to a
maximum of 60 mg/day (PDR, 2002).
Most patients recover completely
from IM after an uneventful course.
Rare complications include autoimmune hemolytic anemia lasting several
months, neurologic symptoms such as
cranial nerve palsies that resolve spontaneously, and, very rarely, liver disease
and liver failure (Jenson, 2000).
Since J.M. had no symptoms of illness, she continued to be a healthy, active toddler. If she were to be retested at
a future date, her EBV titers would indicate that she had had infection in the
past. It is uncommon to acquire this
virus repeatedly. It would be impossible to accurately determine the source
of J.M.s infection. Her daycare setting
is a possible source of infection, since
there may be exchange of saliva from
toys and hand-to-mouth activity among
young children. Household transmission is less likely (Jenson, 2000). Despite
its infrequency, IM is an important diagnosis to consider when confronted
with vague symptoms or unusual findings in apparently well children.

REFERENCES
Jenson, 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 Practitioners, 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.), Pediatric
primary care:A problem oriented approach (pp. 271281). Chicago: Year Book Medical Publishers.

JOURNAL OF PEDIATRIC HEALTH CARE