Splenic Infarction Caused by a Rare Coinfection of Epstein-Barr Virus, Cytomegalovirus, and Mycoplasma pneumoniae

Abstract

Epstein-Barr virus (EBV), cytomegalovirus (CMV), and Mycoplasma pneumoniae are common pathogens of respiratory infection among children and young adults. Although single infection of 1 of these pathogens is common enough, their coinfection has been rarely reported. A 19-year-old woman presented with severe upper abdominal pain for 5 hours as well as flu-like symptoms and jaundice for 2 to 3 weeks. Initial tests found pancytopenia, abnormal liver functions, and presence of atypical lymphocytes in blood smear; the computed tomography of the abdomen revealed para-aortic lymphadenopathy, splenomegaly, and a wedge-shaped focal hypodensity lesion at the periphery of the spleen that was later diagnosed as splenic infarction. Her presentation raised suspicion of infectious mononucleosis. Nevertheless, monospot test, human immunodeficiency virus screening, and hepatitis viral serology were all negative, except that her M pneumoniae immunoglobulin M was found positive. Azithromycin was promptly given, but her fever and abdominal pain persisted. A strong suspicion of mononucleosis led to serological tests for EBV and CMV, which confirmed coinfection of EBV and CMV. By hospital day 7, her fever and abdominal pain had subsided and her liver function became normal. This case exemplifies the challenges in the diagnosis of coinfection of multiple respiratory pathogens and its associated complications. Greater awareness among clinicians would ensure an earlier and more accurate diagnosis of coinfection of EBV/CMV with other respiratory pathogen(s).

Splenic infarct in a patient with Infectious Mononucleosis: a rare presentation

“…All cases showed improvement. Imaging was done earlier in two cases at day 7 with a CT scan, and day 10 with an MRI, respectively, showing no changes to mild aggravation in the latter [10,16]. Hence, we recommend a follow up in 4–6 weeks based on the limited follow-up imaging results.…”

Splenic infarction associated with acute infectious mononucleosis due to Epstein–Barr virus infection

“…However, there were no deaths in our study, and clinical outcomes were favorable. Of the 19 patients, nine underwent follow-up imaging: CT in four cases [van Hal et al, 2005;Gang and Kim, 2013;Kobe et al, 2013;Li et al, 2014], US in three [Cull and Stein, 2012;Gavriilaki et al, 2013;Machado et al, 2015], MRI in one [Breuer et al, 2008], and one case did not mention the imaging method [Trevenzoli et al, 2001]. Seven patients showed improvement in a median follow-up time of 67 days (range, 30-128 days) [Trevenzoli et al, 2001;van Hal et al, 2005;Cull and Stein, 2012;Gang and Kim, 2013;Gavriilaki et al, 2013;Kobe et al, 2013;Machado et al, 2015].…”

“…Seven patients showed improvement in a median follow-up time of 67 days (range, 30-128 days) [Trevenzoli et al, 2001;van Hal et al, 2005;Cull and Stein, 2012;Gang and Kim, 2013;Gavriilaki et al, 2013;Kobe et al, 2013;Machado et al, 2015]. However, one patient had aggravated findings on follow-up MRI after 10 days [Breuer et al, 2008], while another patient had no change on follow-up CT performed within 7 days [Li et al, 2014]. It might be helpful to perform follow-up image examination after at least 4 weeks in order to determine the improvement in splenic infarction associated with IM.…”

Outcomes of M. pneumoniae pneumonia with mixed infection

“…Another study of 286 children with MPP showed that 84 (29.4%) had a mixed infection with a respiratory virus, and the highest co-detection rate was observed in young children [6]. Li et al reported a case of mixed infection with Epstein-Barr virus, cytomegalovirus, and M. pneumoniae; their case exemplifies the challenges in the diagnosis of mixed infection with multiple respiratory pathogens and the associated complications [7]. With regard to the prognosis of MPP accompanied by mixed infection, a study on adults showed that bacterial mixed infection with a respiratory virus may worsen patient outcome, including the severity and mortality of CAP [8].…”