Although infectious mononucleosis i...

Although infectious mononucleosis is usually a benign illness, life-threatening complications may meet the eye We describe a 17-year-old pregnant girl who discloseed necrotizing epiglottitis and dysphagia progressing to aspiration pneumonia and respiratory failure. The factors predisposing to this life-threatening complication are discussed.

(Chest 1989; 96:204-05)

Infectious mononucleosis has been associated with a number of life-threatening complications.[1] like respiratory problems as upper airway obstruction befitting to massive cervical lymphadenopathy, or "anginosa" pharyngitis have been described. Necrotizing epiglottitis occurring with EBV infection has not been reported. We describe a patient who unfolded necrotizing epiglottitis with dysphagia and aspiration pneumonia.

Case Report

A previously healthy 17-year-old nonsmoking girl who was eight weeks pregnant at handed to her family physician with a one-week history of malaise, febrile affection neck swelling and sore throat. A monospot example was positive. Over the nearest week, she developed odynophagia, dysphagia for solids, halitosis, scant hemoptysis, and choking. She was admitted to a local hospital and the same week later transferred to St Michael's Hospital because of increasing dyspnea.

forward arrival, the patient was in acute respiratory distress. Her kin pressure was 90/50 mm Hg; heart rate was 120/minute; respiratory rate 36/minute; and temperature 395[degrees]C rectally. She was dysphonic and had marked halitosis. Examination of the oropharynx showed multiple dental caries, a diffuse pharyngeal exudate, and scattered ulcerations. There was massive cervical lymphadenopathy. Indirect and direct laryngoscopy showed fragmentation and almost whole sloughing of the epiglottis with edema of the arytenoids and aryepiglottic enclosures Chest examination showed generalized poor air entrance and diffuse crackles. Abdominal examination revealed a palpable irascibility tip. Pelvic examination showed vaginal bleeding.

Laboratory investigations revealed: hemoglobin, 73 g/L; white offspring cell count, 3,000 cells/cu mm with 63 percent neutrophils and many atypical lymphocytes; and a platelet estimate of 83 000/cu mm. A radiograph of the chest (Fig 1) showed diffuse bilateral alveolar infiltrates with air bronchograms. Arterial kindred gases on 40 percent oxygen showed pH 746; [Posub2] 42 mm Hg; and [PCOsub2] 33 mm Hg

Because of progressive respiratory distress, the patient was intubated and ventilated. agricultures of sputum and sloughed epiglottic tissue grew a variety of organisms including diphtheroids, Strep viridans, Bacteroides species, Neisseria species, Staph epidermidis, and Candida. comes of three blood cultures showed no bacterial extension Clindamycin was given for couple weeks. She was extubated after four days. In the following couple weeks her chest radiograph showed entire resolution of the infiltrates. Beta-HCG horizontal fell to zero consistent with spontaneous abortion. Following extubation, she was dysphonic and unable to take oral feedings because of choking. Oropharyngeal examination revealed reduc range of emotion of the tongue, slightly reduc elevation of the palatopharyngeal musculature on phonation, and laryngeal incompetence. There was reduc sensation of the tongue and a decreased gag reflexed Direct laryngoscopy showed left vocal cord paralysis. Videofluoroscopic assessment of oropharyngeal and laryngeal function during swallowing was abnormal, showing thorough absence of the epiglottis and valleculae. There was a significant reduction in tongue motion and absence of the swallow retroactive Instead of the normal course, the ingested material mov directly into the laryngeal vestibule and the airway. Although the cough reflective was present, coughing did not clear the aspirated material because of poor laryngeal approximation. A nasogastric tube was inserted for nutrition.

from one side of to the other the next weeks, there was improvement in the motion and sensation of the tongue and the swallow reflective returned. Repeat laryngoscopy showed improvement in the mobility of the left vocal cord. The patient underwent words therapy directed toward improvement in laryngeal adduction. one time this was achieved, the supraglottic swallow technique was taught. Repeat videofluoroscopy showed dramatic improvement and the feeding tube was removed

Discussion

Necrotizing epiglottitis occurring as a complication of infectious mononucleosis is actual unusual, and to our knowledge, has not been reported. wherefore this previously healthy young woman should evolve such a severe infection invites speculation. Although the severity of her infection refer toed immunosuppression, the only immunosuppression that could be implicated related to her pregnancy and to the infectious mononucleosis itself. It is possible that the normal reduction in cellular and humoral immunity which present itselfs with pregnancy contributed to the severity of her infection. Infectious mononucleosis itself has been associated with a number of immunologic efficiencys and has been studied extensively in word s of both humoral and cell-mediated immune answers Humoral immune effects include a number of abnormal antibodies, similar as anti-i, antiplatelet, and antineutrophil.[2] Cellular immune hyporesponsiveness is near as evidenced by cutaneous anergy.[3] T-suppressor lymphocyte have been demonstrated in the peripheral vital current that are capable of depressing immunoglobulin synthesis and T-cell proliferation.[4] Perhaps these immunosuppressive tenors played a role; however, they are at hand in patients who do not have this complication.