A 17-year-old girl is brought to the office due to a 14-day history of fever, neck "lumps," sore throat, and malaise. She has severe fatigue and has not been able to attend classes. She also has had difficulty swallowing because of throat pain. The patient has no cough, abdominal pain, nausea, or vomiting. She has no chronic medical conditions. Temperature is 38.7 C (101.7 F), blood pressure is 120/76 mm Hg, pulse is 86/min, and respirations are 24/min. Physical examination shows an uncomfortable patient who is breathing loudly through the mouth. There are no oral lesions. Tonsils are erythematous and markedly enlarged with bilateral exudates. Multiple tender, mobile, posterior cervical lymph nodes are palpable. Heart sounds are normal without murmurs. Lungs are clear without wheezing or rales. The abdomen is soft and nontender; the spleen is palpable 2 cm below the left costal margin. Which of the following complications is this patient most at risk for developing?

Question

A 17-year-old girl is brought to the office due to a 14-day history of fever, neck "lumps," sore throat, and malaise.  She has severe fatigue and has not been able to attend classes.  She also has had difficulty swallowing because of throat pain.  The patient has no cough, abdominal pain, nausea, or vomiting.  She has no chronic medical conditions.  Temperature is 38.7 C (101.7 F), blood pressure is 120/76 mm Hg, pulse is 86/min, and respirations are 24/min.  Physical examination shows an uncomfortable patient who is breathing loudly through the mouth.  There are no oral lesions.  Tonsils are erythematous and markedly enlarged with bilateral exudates.  Multiple tender, mobile, posterior cervical lymph nodes are palpable.  Heart sounds are normal without murmurs.  Lungs are clear without wheezing or rales.  The abdomen is soft and nontender; the spleen is palpable 2 cm below the left costal margin.  Which of the following complications is this patient most at risk for developing?

Quizplus · Accepted Answer

11ec25c8_d5ff_54f8_bc81_b9751b3875b8_MD0003_00 This patient has prolonged fever and fatigue in the setting of pharyngitis, splenomegaly, and posterior cervical lymphadenopathy, findings suggestive of infectious mononucleosis (IM). Initial symptoms may last up to 1 month, with fatigue potentially lasting several months. IM is typically due to Epstein-Barr virus and is usually diagnosed by a positive heterophile antibody (Monospot) test. IM is treated with supportive care and generally resolves without sequelae. However, patients with marked oropharyngeal inflammation and severe tonsillar enlargement are at risk for acute airway obstruction, a rare but potentially fatal complication. Presentation includes dysphagia (eg, pooling oral secretions) and respiratory distress (eg, tachypnea, mouth breathing), as seen in this patient. Treatment includes corticosteroids to decrease airway edema. (Choice B) Acute rheumatic fever is a potential sequela of group A streptococcal (GAS) pharyngitis. GAS pharyngitis causes fever, sore throat, and tender anterior cervical lymphadenopathy but is not associated with splenomegaly or prolonged fatigue. Even without treatment, symptoms of GAS pharyngitis usually resolve within a week. (Choice C) Aspiration pneumonia is most common in the setting of neuromuscular disease or tracheal/esophageal instrumentation (eg, mechanical ventilation), especially in elderly patients. It is unlikely in a previously healthy adolescent and is not associated with IM. (Choice D) Coronary artery aneurysm is a potential sequela of Kawasaki disease. Although fever and lymphadenopathy are features of Kawasaki disease, this patient does not meet additional diagnostic criteria (eg, conjunctival injection, extremity edema, rash, mucous membrane changes). (Choice E) Ludwig angina, a potentially fatal cellulitis of the submandibular space, is caused by bacterial spread from adjacent infection, most commonly dental abscesses. Tooth infection is unlikely in this patient with localized tonsillar erythema and swelling. (Choice F) Retropharyngeal abscess can cause fever, dysphagia, and respiratory distress; however, it typically develops in young children as a complication of a viral upper respiratory infection. It is not associated with IM. (Choice G) Acquired subglottic stenosis, or narrowing of the larynx below the vocal cords, may present as hoarseness and labored breathing (eg, stridor) but is usually a complication of endotracheal intubation, not infection. Educational objective: Acute airway obstruction is a rare but potentially fatal complication of infectious mononucleosis. Patients have dysphagia and respiratory distress, with examination findings of marked oropharyngeal inflammation and severe tonsillar enlargement. Treatment includes corticosteroids. References: Common questions about infectious mononucleosis. (http://www.ncbi.nlm.nih.gov/pubmed/25822555) Infectious mononucleosis. (http://www.ncbi.nlm.nih.gov/pubmed/26424648)

A 17-Year-Old Girl Is Brought to the Office Due to a 14-Day