Case notes
A generally healthy 15-year-old girl presented to the pediatric emergency department with genital ulcers. One week earlier, she developed fever (100.4°F; 38°C), dysuria, and genital pain and received a diagnosis of lichen planus at another hospital. Neither topical steroids nor amoxicillin clavulanate proved helpful. The patient was then referred to our hospital.
She had no family history of rheumatologic illness or recurrent ulcers, and she denied any sexual activity. On admission, she was in good condition with a temperature of 99°F (37.2°C) and 2 ulcers on her right labia majora. These produced a white discharge ( Figure ). A complete blood count was normal, but elevations in aspartate aminotransferase (112 IU/L), alanine transaminase (116 IU/L), lactate dehydrogenase (1005 IU/L), and C-reactive protein (16 mg/L) were noted. Tests for herpes simplex virus, human immunodeficiency virus, and syphilis were negative. Bacterial cultures for Neisseria gonorrhoeae and chlamydia were also negative. The patient’s levels of complement components 3 and 4 were normal, as were her immunoglobulin levels.
After admission, the patient’s fever gradually rose to 103.6°F (39.8°C), and 3 days after admission, and an itchy, diffuse, maculopapular rash appeared over her trunk and limbs. Treatment with antihistamines and doxycycline was started for suspected rickettsial infection. However, on day 4 of her hospital stay, she had a sore throat with bilateral diffuse exudates, hepatosplenomegaly, and enlarged cervical and femoral lymph nodes. On that same day, day 12 of her symptoms, results from a mononucleosis spot test were positive, and IgM and IgG antibodies to the Epstein-Barr virus (EBV) viral capsid antigen were evident. Polymerase chain reaction (PCR) identified EBV (2.96 × 10 5 copies/mL).
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
