The correct answer is 2. In the presence of unilateral and uniorificial hematic telorrhea, the most frequent cause is intraductal papilloma (50%), followed by ductal ectasia and carcinoma. When associated with palpable mass, 60% correspond to carcinoma. Paget's disease is of the eczematous type. In hyperprolactinemia, telorrhea is bilateral and pluriorificial. Mammography often does not show papillomas, being more useful ultrasound and galactography.

[HIDDEN] In the presence of unilateral and uniorificial hematic telorrhea, the most frequent cause is intraductal papilloma (50%), followed by ductal ectasia and carcinoma. When associated with palpable mass, 60% correspond to carcinoma. Paget's disease is of the eczematous type. In hyperprolactinemia, telorrhea is bilateral and pluriorificial. Mammography often does not show papillomas, being more useful ultrasound and galactography.

A 59-year-old woman consults a gynecologist for a spontaneous, spontaneous, uniorificial discharge from the right nipple (unilateral) without palpable nodularity. What is the most likely diagnosis?

Given the hematic nature of the discharge, the most likely diagnosis is infiltrating ductal carcinoma.

Mammography will indicate the diagnosis.

A rare case of intraductal papilloma with atypical ductal hyperplasia in a male breast: A pathological diagnosis.

Male breast cancer is itself a very rare condition and represents 0.5%-1% of all breast cancers diagnosed. Atypical ductal hyperplasia (ADH), intraductal papilloma (IP), and ductal carcinoma <iin situ</i are also very rare in a male breast. Only a few cases of ADH with gynecomastia have been reported in English literature until now. Here, we report a rare case of an IP with ADH associated with gynecomastia in an elderly male, who complained of right nipple pain, discharge, and tiny retroareolar mass. Mammography showed a subareolar nodule graded as the Breast Imaging-Reporting and Data System 4B. It is difficult to differentiate, both clinically and radiologically, between benign and malignant papillary lesions and invasive carcinoma, because of the similarity of findings. Hence, any male with palpable unilateral hard fixed lesions in the retroareolar region with complaints of nipple discharge, skin changes, or axillary lymphadenopathy should have a histopathological evaluation.

The role of breast ductoscopy in evaluation of nipple discharge: a chinese experience of 419 patients.

The aim of this study is to report our experience with ductoscopic evaluation for screening patients with nipple discharge and evaluate any potential indications and benefits of ductoscopy. From January 2010 to December 2012, 419 female patients with nipple discharge were enrolled in this study. All patients involved in this study showed no mass in ultrasound and mammography. Data concerning age, clinical characteristics of nipple discharge, nipple discharge cytology, ductoscopic and postsurgical diagnosis, and complications were statistically analyzed. Ductoscopy examinations were completed in 405 patients (96.66%). For these 405 patients, there were 519 ductoscopic investigations. 112 (27.65%) patients were found to have intraductal papillary lesions of which 62 were operated in our hospital. Postsurgical diagnosis showed 8 (12.9%) malignancy including 6 DCIS and 2 invasive ductal carcinomas. All of the 8 patients meet at least two criteria of pathologic nipple discharge (single duct, spontaneous, bloody nipple discharge). The other patients with nonpapillary lesions are still under surveillance. By univariate analysis, patients with unilateral, single duct, spontaneous and bloody nipple discharge were more likely to have intraductal papillary lesions. By multivariate analysis, unilateral, spontaneous, and bloody nipple discharge showed statistically significant correlations with intraductal papillary lesions revealed by ductoscopy. Ductoscopy is a safe and efficient investigation in preoperative screening of the patients with nipple discharge. Clinical characteristics have predictive value in selection of patients for ductoscopical investigation. Patients with clinical characteristics of unilateral, spontaneous, and bloody nipple discharge were more likely to have intraductal papillary lesions revealed by ductoscopy.

Management of nipple discharge.

In a series of 9,312 women who consulted one of the authors with a complaint of disease of the breast between 1959 and 1991, nipple discharge was the presenting symptom in 448 (4.8 percent). Nipple discharge was spontaneous in 243 (2.6 percent) and provoked in 205 (2.2 percent) of the patients. The ages of the patients ranged from 13 to 75 years (mean of 42.5 years) in the spontaneous and 16 to 70 years (mean of 37.8 years) in the provoked discharge group. When a palpable mass was found, biopsy was undertaken, while in instances of nipple discharge only, subareolar exploration was performed. Of the 115 patients in the spontaneous and 25 patients in the provoked groups who underwent biopsy, the most frequent cause of nipple discharge was intraductal papilloma (47.8 percent). Nipple discharge was the result of carcinoma in 35 patients (14.4 percent) in the spontaneous and six patients (2.9 percent) in the provoked group, respectively. In patients with a palpable mass, the incidence of carcinoma was 61.5 percent compared with 6.1 percent in patients with nipple discharge only. Patients presenting with nipple discharge should undergo biopsy or subareolar exploration based on the presence or absence of a palpable tumor. The patients in whom no clinical findings could be detected should have follow-up evaluation at regular intervals.

Nipple Adenoma: Case Report of a Rare Entity.

A nipple adenoma is a rare benign breast tumor. The commonest presentation of this rare entity is nipple erosion, serosanguinous discharge, induration, or tumor formation at the nipple. It often mimics malignant breast lesions or nipple eczema and is mistaken for Paget's disease of the nipple or dermatological pathology. It may be misdiagnosed pathologically as ductal carcinoma of the breast. This may cause a diagnostic delay or a faulty diagnosis. Treatment is the excision of the tumor with or without nipple excision. Here, we report a case of nipple adenoma that projected out of the nipple along with nipple erosion, serosanguinous discharge, and occasional bleeding from the adenoma. A 37- year-old woman presented with a tumor on her right nipple for eight months, with the erosion of the nipple and serosanguinous discharge. The patient gave a history of a small amount of bleeding occasionally. Axilla was normal. The patient was advised to have a mammosonography. It showed an oval-shaped, well-demarcated, hypoechoic, uniformly solid nodule in the right nipple. There was no microcalcification seen on mammography. A punch biopsy was done to establish the diagnosis. It showed ductal hyperplasia and papillary proliferation of glandular structures suggestive of nipple adenoma. Complete resection of the tumor with partial excision of the nipple was done with a satisfactory cosmetic result. Though very uncommon, the possibility of nipple adenoma should be thought of when a patient presents with nipple erosion and discharge with or without a clinically obvious tumor. Timely diagnosis with histopathological correlation is important since it allows for less invasive surgical methods. In our case, we could attain a cosmetically satisfactory outcome without a remnant tumor. Paget's disease of the nipple also has a similar clinical presentation, and it is a premalignant condition. The objective of presenting this case is to highlight the possibility of this rare benign condition, which may be easily missed clinically and also demands careful histopathological examination for its correct diagnosis.

Breast discharge: ultrasound and Doppler evaluation.

Nipple discharge causes discomfort and anxiety to many women. Nipple discharge is most commonly associated with endocrine alterations and/or medications. These often result in duct ectasia and/or fibrocystic changes that may lead to discharge from one or several ducts. The most common cause of clinically significant discharge is intraductal growth of the ductal epithelium, due to hyperplasia, micropapillary proliferation, solitary papillomas and/or ductal carcinoma (both in situ and invasive). The aim of the study was to evaluate the role of the gray-scale ultrasound and colour Doppler in the diagnosis of intraductal pathology in patients with nipple discharge. One hundred & seven patients were included in the study, (age range 23-65years). Standard mammographic views were taken. Ultrasound evaluation was performed for all cases; ductography for 20 cases and ductoscopy for 3 cases. US guided fine needle biopsy was done in 7 cases; microducectomy of affected duct was done in 20 cases and major duct excision in 5cases. Fibro-optic Ductoscopy is performed for 3 cases. Revision of biopsy specimens of 17 cases with intraluminal masses detected by US revealed: Six cases with intraductal carcinoma, intraductal papilloma in 7 cases, 1 case of ductal papillomatosis. Three cases showed atypical cells: Intraductal papilloma with atypia in 2 cases, proliferative hyperplasia with atypia in one case. Eighty eight cases had simple duct ectasia (51 bilateral multiple and 37 focal duct ectasia). No dilated ducts were detected in 2 cases. Fibro-optic Ductoscopy confirmed the presence of intraductal papilloma in one case, carcinoma in one case, no intraductal masses in the third case. A 6 months follow-up was requested for all cases with no detected intra luminal pathology. Ultrasound examination is highly sensitive (100%) but less specific (82.4%) in diagnosis of intraductal pathology. Colour & power Doppler are sensitive (94%) in detecting flow in intraductal echogenic masses to differentiate them from insipissated secretions. Colour and power Doppler raises specificity and diagnostic accuracy to 100%. Ductography is an underused procedure that is sensitive (100%) but less specific (60%) in characterization of intraductal filling defects. Ultrasonography is a mandatory complement to mammography in these cases, US guided fine needle biopsy is minimally invasive technique in confirming the diagnosis of suspicious mass. Ultrasound may also be a guide to fibro-optic ductoscope. Ductography - Nipple discharge - Intraductal carcinoma - Intraductal papilloma - In situ ductal carcinoma - Invasive ductal carcinoma - Duct ectasia - Breast ductoscopy.

[Diagnosis of a Non-Invasive Ductal Carcinoma, Assisted by Long-Term Follow-Up of Spontaneous Nipple Discharge - A Case Report].

We report a case of a non-invasive ductal carcinoma revealed on long-term follow-up of spontaneous nipple discharge. The patient, a 36-year-old woman, had noticed spontaneous nipple discharge from both breasts over a 3-year period. Mammography and ultrasonography did not reveal any lesions in the breasts. The nipple discharge from her left breast stopped 36 months after initial clinical assessment. However, the nipple discharges from her right breast transformed into a bloody discharge from a single duct. Ultrasonography showed a tumor, 6mm in diameter, in the upper-outer quadrant of her right breast. A core needle biopsy for breast tumor led to a pathological diagnosis of non-invasive ductal carcinoma. We conducted a whole-body clinical examination but no metastatic lesions were detected. Subsequently, we performed breastconserving surgery and sentinel lymph node biopsy. The pathological diagnosis was non-invasive ductal carcinoma in situ. The tumor was positive for estrogen and progesterone receptors, but negative for HER2/neu. The Ki-67 labeling index was 5%. The surgical margin was negative. We diagnosed the tumor as TisN0M0=Stage 0. Endocrine therapy comprising tamoxifen (20mg/day)was initiated. Four years after surgery, she was well without any metastases.

Intraductal papillomas: diagnostic and surgical procedures.

A series of 98 patients with spontaneous nipple discharge, is reported. Diagnosis was based on: clinical examination, cytology of breast secretion, mammography and galactography. Surgical resection was recommended in the following cases: galactographic evidence of intraductal papilloma or papillomatosis, dubious or positive cytology, persisting hemorrhagic or sero-hemorrhagic secretion. The injection of vital staining before the operation allowed the precise location of the lesion. In the group of patients studied ten cases of ductal carcinomas (5 in situ and 5 smaller than 1 cm), 4 cases of atypical intraductal hyperplasia, 13 cases of solitary papilloma and 22 cases of multiple papillomatosis were diagnosed.

[The role of ductal galactography in the differential diagnosis of breast carcinoma].

The authors report on a series of 1009 consecutive patients submitted to clinical examination, mammography, cytology and galactography for the presence of nipple discharge. Galactography was performed mainly in the presence of hematic nipple discharge. Surgical biopsy was performed in 392 cases, and 52 cancers (31 invasive and 21 intraductal lesions) were diagnosed, which were suspected at palpation, mammography, cytology and galactography in 17, 17, 18 and 31 cases, respectively. Forty of 52 cancers were suspected on the basis of combined exam findings, while 8 cancers (7 intraductal and 1 invasive lesions) were submitted to biopsy on the basis of a galactographic diagnosis of multiple benign papilloma, an (invasive) lesion with a diagnosis of single papilloma, and 3 (invasive) lesions because of persistent hematic discharge. Cancer was suspected with only one exam in 14 cases: 3 at cytology, 2 at mammography, 1 at clinical examination and 8 at galactography. Hematic discharge alone is not a sufficient reason to indicate surgery, because its positive predictive value for cancer is low (< or = 10%), while cytology is of limited help because of its poor sensitivity (34.6%). In contrast, galactography (59.6% sensitivity) gives a greater contribution to differential diagnosis and is always indicated in the presence of hematic discharge. Galactographic evidence suspicious for cancer (67.3% positive predictive value) or for multiple papilloma (9.7% positive predictive value) is sufficient to advise open biopsy. The surgical removal of single papillomas is of questionable benefit, since single papillomas are benign lesions, with no clear evidence of progression to cancer. In our series, only one cancer was misdiagnosed as a single papilloma at galactography (0.5% positive predictive value).

[Differential diagnosis of nipple discharge].

An analysis of results of contrast mammography in 42 women having spontaneous, persistent and unilateral discharge from the nipple of the breast of serous, serous-hemorrhagic and hemorrhagic character was made. The cause of the discharge was found to be intraductal papillomas and cystadenopapillomas in 55% of the cases, breast cancer--in 2% which were not diagnosed by noncontrast mammography.

[Evaluation of bloody nipple discharge].

A 64-year old woman was referred for radiological evaluation of right sided bloody nipple discharge lasting for five months. Finally galactography supposed the diagnosis of an intraductal papilloma which was confirmed by surgery. Histopathologically an eight millimeter measuring intraductal papilloma with atypical ductal hyperplasia with signs of a carcinoma in situ was seen.

Nipple adenoma

A nipple adenoma is a rare benign tumour of the breast. The condition may also be known as : Florid papillomatosis of the nipple Florid adenomatosis Subareolar duct papillomatosis Erosive adenomatosis Signs and symptoms Nipple adenomas may be felt as a lump under the nipple or areola. They may come to attention because of nipple pain, ulceration, swelling or discharge. Diagnosis Definition A nipple adenoma is a type of intraductal papilloma that arises within the lactiferous ducts that are located within the nipple. Differential diagnosis The microscopic appearance of a nipple adenoma can be mistaken for carcinoma. Other conditions that have similar symptoms and signs as nipple adenoma include Paget's disease of the breast, other intraductal papillomas, ductal carcinoma in situ (DCIS), syringomatous adenoma of the nipple and subareolar sclerosing duct hyperplasia.

Ductal carcinoma in situ of the breast arising in a solitary intraductal papilloma.

Ductal disease is a broad group encompassing both benign and malignant entities which may overlap clinically and radiologically. Ductal carcinoma in situ (DCIS) is a noninvasive breast malignancy accounting for 20% of newly diagnosed breast cancer cases. It involves malignant epithelial cells confined to the duct(s). Although they are commonly diagnosed incidentally on screening mammography, DCIS may present with nipple discharge or a palpable lump. Benign diseases of the duct include intraductal papilloma and may present similarly with bloody or serous nipple discharge. Imaging evaluation will help in differentiating between the 2 entities and pathological examination will provide the final diagnosis. We present a case of a 72-year-old female who was presented with serous and bloody discharge and histology revealed intermediate grade ductal carcinoma in situ involving an intraductal papilloma.

Nipple discharge

A blocked or enlarged milk duct can result in nipple discharge. Intraductal papillomas are non-cancerous lesions and commonest in women age 30 to 50. Divided into central and peripheral papillomas, nipple discharge is more frequently observed when they are central. Up to half of women with intraductal papillomas may present with bloody nipple discharge, but it can also be straw-coloured. They are usually too small to feel and have a rare association with breast cancer. 15-20% of people with nipple discharge are found to have duct ectasia. This is usually in perimenopausal and menopausal women, who may have associated pain and retraction of the nipple. A lump may also be present. Ductal carcinoma in situ (DCIS) usually presents with abnormal findings on mammography, but can less frequently present with a lump or nipple discharge in women, whereas in men with DCIS, nipple discharge is the common presentation.

Solitary intraductal papilloma of the breast--a diagnostic dilemma and the role of conferencing between surgeons and cytologist.

A 40 year female, presented with the complaints of spontaneous, sticky, blood stained discharge from the nipple of the left breast since 6 months. On examination there was no lump palpable in either breast. Cytology of the nipple discharge (ND) showed scanty cellularity consisting of tight papillary clusters of ductal cells in a hemorrhagic and inflammatory background. The nuclei were bland and showed degenerative atypia. Mammography showed no significant lesion. Our patient underwent microdochechtomy. Histopathology showed intraductal papilloma. Limitations of cytology must be kept in mind by both, the pathologist and the surgeon. The cytological diagnosis of a papillary tumor is provisional and the definitive diagnosis must await histological examination. In view of rarity of this lesion, combined with the overlapping of cytologic features in benign and malignant papillary lesions, conferencing and communication with the surgeon should be an integral part of patient evaluation and management. In our case this approach resulted in less radical excision of breast tissue.

Predicting occult malignancy in nipple discharge.

This study was a retrospective analysis of patients who underwent minor or major duct surgery for pathological nipple discharge. The results of clinical examination, mammography, ultrasonography and cytodiagnosis of the nipple discharge were studied in order to predict those patients at risk of underlying or occult malignancy. Between January 2004 and December 2006, 55 female patients aged between 24 and 82 years old underwent major or minor duct excision, 49 of which were for pathological nipple discharge. Results of several preoperative investigations were compared with the surgical pathology to determine how their sensitivity and specificity faired in predicting malignant ductal pathology. Of the 49 patients undergoing surgery for nipple discharge, 21 were diagnosed with intraductal papilloma, 19 with duct ectasia, 6 with carcinoma, 2 with benign breast disease and 1 with lobular carcinoma in situ. In all of the patients determined to have malignancy, none demonstrated malignant changes on mammography or ultrasonography. Only 2 of the 6 patients with malignancy were found to have atypical cells on cytological analysis. The sensitivity of blood detected in nipple discharge at predicting malignancy was 0.83, specificity of 0.53, positive predictive value of 0.20 and negative predictive value 0.96. Despite the various tests used in the assessment of pathological nipple discharge, this study highlights their limited help at predicting the cause. This, together with several other studies, demonstrates that ductal surgery remains the only reliable way of providing a diagnosis, in addition to being the major therapeutic measure.

Nipple discharge screening.

Nipple discharge is a common complaint among women. It is classified as normal or abnormal depending on features such as laterality, cycle variation, quantity, color or presentation (i.e., induced vs spontaneous). It can be related to benign conditions, such as intraductal papilloma, duct ectasia, plasma cell mastitis or galactorrhea; or to malignant conditions such as ductal, lobular or papillary carcinoma. Techniques used in nipple discharge evaluation include mammography, ultrasound, cytology (which could be assisted by a mammary pump), duct endoscopy, ductography, immunochemical methods and at least surgical excision of the pathological ducts for diagnosis and treatment in the same procedure.

Intraductal papilloma

Intraductal papillomas of the breast are benign lesions with an incidence of approximately 2-3% in humans. They result from abnormal proliferation of the epithelial cells lining the breast ducts. Two types of intraductal papillomas are generally distinguished. The central type develops near the nipple. They are usually solitary and often arise in the years nearing menopause. On the other hand, the peripheral type are often multiple papillomas arising at the peripheral ducts, and are usually found in younger women. The peripheral type are associated with a higher risk of malignancy. They are the most common cause of bloody nipple discharge in women age 20-40 and generally do not show up on mammography due to their small size. They may be detectable on ultrasound. A galactogram is the most definitive test but is somewhat invasive. The masses are often too small to be palpated or felt. A galactogram is therefore necessary to diagnose the type of lesion.

Diagnostic value of endoscopic appearance during ductoscopy in patients with pathological nipple discharge.

To explore the features of ductoscopic appearance that may be diagnostic in patients with pathologic nipple discharge (PND) and to discuss the diagnostic criteria for intraductal tumors. We reviewed 247 patients with PND but without a palpable mass who were evaluated using either surgical biopsy or excision. Data concerning patient age, duration of discharge, discharge color, and the details of endoscopic appearance were analyzed according to the pathological results. The postoperative diagnosis in 61 patients (24.70%) was a nonmass lesion, and 186 patients (76.52%) had an intraductal tumor. Among those with intraductal lesions, 10 patients (4.05%) had a malignant tumor, including 4 (1.62%) with ductal carcinoma in situ and 6 (2.43%) with invasive ductal carcinoma. On univariate analysis, patients of older age with spontaneous and bloody discharge were more likely to suffer from intraductal lesions. On logistic regression analysis, bloody nipple discharge, morphology, and a broad lesion base revealed by ductoscopy showed a statistically significant correlation with malignancy (p = 0.001, p < 0.001, p = 0.022, respectively). Both clinical features and endoscopic appearance are significant for the precise diagnosis of an intraductal lesion seen on ductoscopy. The endoscopic features of bloody discharge, morphology, and a broad lesion base are independent risk factors for malignancy and represent new criteria for the diagnosis of patients with PND.

Unilateral nipple discharge in a man without a palpable mass diagnosed as breast cancer.

A 69-year-old man without a family history of breast cancer presented to his primary care physician with a 1-year history of clear, unilateral nipple discharge (ND) without an associated palpable breast mass. His laboratory findings were significant for hyperprolactinaemia at 28 ng/mL. Diagnostic work up including mammography, ultrasound and core needle biopsy ultimately revealed a ductal carcinoma in situ and a rare papillary variant of invasive ductal carcinoma. The patient was referred to a multidisciplinary oncology team and underwent a right total mastectomy followed by adjuvant hormonal therapy. The patient made a good postoperative recovery and remains without evidence of recurrence 6 months from surgery. Male breast cancer is rare, but its incidence is increasing. Male breast cancer presenting as ND without a palpable mass is uncommon. Early recognition of breast symptoms in men can lead to earlier diagnoses and improved outcomes.

Breast imaging in patients with nipple discharge.

Nipple discharge is a common symptom in clinical practice, representing the third leading breast complaint, after pain and lumps. It is usually limited and has a benign etiology. The risk of malignancy is higher when the discharge is uniductal, unilateral, spontaneous, persistent, bloody, or serous, as well as when it is accompanied by a breast mass. The most common causes of pathologic nipple discharge are papilloma and ductal ectasia. However, there is a 5% risk of malignancy, mainly ductal carcinoma in situ. The clinical examination is an essential part of the patient evaluation, allowing benign nipple discharge to be distinguished from suspicious nipple discharge, which calls for imaging. Mammography and ultrasound should be used together as first-line imaging methods. However, mammography has low sensitivity in cases of nipple discharge, because, typically, the lesions are small, are retroareolar, and contain no calcifications. Because the reported sensitivity and specificity of ultrasound, it is important to use the correct technique to search for intraductal lesions in the retroareolar region. Recent studies recommend the use of magnetic resonance imaging in cases of suspicious nipple discharge in which the mammography and ultrasound findings are normal. The most common magnetic resonance imaging finding is non-mass enhancement. Surgery is no longer the only solution for patients with suspicious nipple discharge, because short-time follow-up can be safely proposed.

Galactography

Causes for nipple discharge include duct ectasia, intraductal papilloma, and occasionally ductal carcinoma in situ or invasive ductal carcinoma. The standard treatment of galactographically suspicious breast lesions is to perform a surgical intervention on the concerned duct or ducts: if the discharge clearly stems from a single duct, then the excision of the duct (microdochectomy) is indicated; if the discharge comes from several ducts or if no specific duct could be determined, then a subareolar resection of the ducts (Hadfield's procedure) is performed instead. To avoid infection, galactography should not be performed when the nipple discharge contains pus. See also Galaxy References Projectional radiography Breast imaging Cancer screening

Management of nipple discharge by clinical findings.

In a review of 249 office patients who complained of nipple discharge, breast nodularity and duct ectasia was the cause in three quarters. The clinical diagnosis was made by observing that more than one duct was involved and by the color of the discharge. On average, the patients were 10 years younger than those with cysts and 20 years younger than those with carcinoma. In half, the discharge could persist or recur for months or years. Nipple discharge was not commonly associated with carcinoma, and when it was, the carcinoma was almost always palpable. Nipple discharge, including bloody discharge, should be regarded as a sign of a benign breast disorder, not of breast cancer. Duct papillomas can be recognized by exploring the single profusely discharging duct, regardless of the color of the discharge. Other than patients with an obvious lump, the only patients who require surgical exploration are those with a single profusely discharging duct, not because cancer is a significant possibility but merely to rid the patient of the nuisance of the continuing discharge from a duct papilloma. Of 249 patients with nipple discharge, breast nodularity and duct ectasia was the cause in 75 percent. The median age of these patients was the mid 30s. The discharge was chronic or recurring in half. Only 4 percent of all the patients with nipple discharge had an associated breast cancer. When cancer was present, an obvious lump was usually palpable. Bloody discharge was much more likely to be associated with benign breast disorders than cancer. A single profusely discharging duct should be explored regardless of the discharge color because of the likelihood of finding a duct papilloma.

[Intraductal metachronic papilloma: Clinical case].

The association of gynecomastia and bloody nipple discharge (thelorragia) leads us to the diagnosis of intraductal papilloma. This is a very rare benign tumor in children. A 2 year old male child was referred due to gynecomastia and bloody nipple discharge of the left breast. A mastectomy was performed. At the age of 4 he returned with identical symptoms but in the right breast. A right mastectomy was also required. An excellent clinical outcome was present in the follow up. The pathology reported intraductal papilloma with no evidence of malignancy or atypia. The intraductal papilloma rarely affects children, there are 15 reported cases. Ultrasound is the most useful diagnostic method. In male patients, mastectomy is recommended to ensure definitive diagnosis and treatment.

Intraductal Papilloma with Benign Pathology on Breast Core Biopsy: To Excise or Not?

The management of intraductal papillomas on core biopsy continues to be controversial. Papillomas with atypia are typically excised. However, it is unclear whether surgical excision is warranted for benign lesions. A retrospective review of our institution's pathology and radiology databases from January 2009 through May 2014 identified 119 patients with a diagnosis of benign papilloma without atypia on core biopsy. We determined the rate of carcinoma identification on surgical excision. The average patient age was 52.8 years (range 24-84 years). Indication for core biopsy included: abnormal imaging (n = 106), nipple discharge (n = 21), or palpable mass (n = 24). Seventy-five patients underwent surgical excision after core biopsy. Sixteen patients (21.3 %) had atypia in the excision specimen (combination atypical ductal hyperplasia, n = 11; atypical lobular hyperplasia, n = 8; lobular carcinoma-in situ, n = 3), 15 (93.8 %) of which were in the surrounding breast tissue. Two patients (2.7 %) had malignancy (ductal carcinoma-in situ and micropapillary carcinoma-in situ). As a result of surgical findings, 12 % of patients had a change in management. In comparing those with benign findings on surgical pathology and those whose disease was upstaged, there was no statistically significant difference in family history of breast cancer, indication for core biopsy, mammographic findings, or location of papilloma. Benign papillomas diagnosed on core biopsy are rarely upstaged to malignancy on surgical excision. However, at least 21 % of patients may have atypical findings in the surrounding tissue, which could change clinical management. Surgical excision should be considered in patients with benign papillomas.

Twenty-year outcome following central duct resection for bloody nipple discharge.

Patients found with pathologic nipple discharge present a diagnostic dilemma to surgeons. No one diagnostic test, including cytology or radiologic imaging, has proved superior to any other in the differentiation of benign versus malignant sources of pathologic nipple discharge. Ductoscopy has been introduced as a way to assist with identification of potential sources of pathologic nipple discharge. Ductoscopy is also useful in the resection of deep or peripheral masses that may be missed with standard blind resection. This report evaluates the risk of missed malignancy following central duct resection (CDR). Records of 56 patients who underwent CDR for pathologic nipple discharge greater than 15 years previous were reviewed. Data including type of nipple discharge, future biopsy, and pathology reports were all examined. Of the 56 patients, 36 had bloody, 18 serous, and 2 green initial discharges. Fifty-seven percent were found to have intraductal papilloma as the source of discharge, with fibrocystic disease and ductal ectasia providing the next most common causes. One woman was found to have ductal cancer and one lobular carcinoma in situ at time of CDR. Patients were followed for a mean period of 22 years. Fourteen women required future biopsy. Of these, 10 had benign disease and 4 had cancer, 3 on the ipsilateral side. The 3 women with breast cancer were 9, 13, and 17 years from initial resection. CDR for pathologic nipple discharge is an effective way to diagnose and treat pathologic nipple discharge without missing underlying cancers.

Nipple discharge from the breast.

Abnormal nipple discharge is rare, constituting only 3-5% of mammary consultation. In the present paper 267 patients with primary nipple discharge operated on at Institut Gustave-Roussay (IGR) in Villejuif, France, between January 1, 1960 and December, 1974 were evaluated. In all cases, the nipple discharge was symptomatic, spontaneous, and represented the primary reason for the patient's consultation. During the same period 1,145 cases of nipple discharge were treated at IGR. Of the 1,145 cases with symptomatic nipple discharge, 267 patients (23%) required surgical intervention. Among these, fibrocystic disease and duct ectasia were the leading causes of nipple discharge occurring in 42% of surgical specimens. Twenty one per cent of the patients had carcinoma and 35% were found to have intraductal papilloma. The overall incidence of malignancy, however, was 4.8% among the 1,145 women with nipple discharge. On the average, patients with nipple discharge due to malignancy were ten years older than those with benign lesions (Table 2). Approximately 25% of patients with malignant discharge and 5% with benign discharge have associated tumor. Over 60% of the patients with both discharge and a mass had malignancy.

Breast Nipple Discharge -- Differential Diagnosis

Intraductal papilloma Duct ectasia Fibrocystic changes and mastitis Intraductal carcinoma Paget disease of the nipple

[A Case of Neuroendocrine Carcinoma with Long-Term Abnormal Nipple Discharge].

We diagnosed invasive breast ductal cancer in a 42-year-old woman. About 10 years previously, she noticed an abnormal nipple discharge, and core needle biopsy indicated intraductal papilloma of the breast. However, the secretion continued, and we performed core needle biopsy again, which suggested invasive breast ductal cancer. Ultrasonography showed a hypoechoic tumor and an irregular low echo area. Breast MRI showed cystography tuberculum in the whole left breast. Pathological findings indicated solid papillary carcinoma with neuroendocrine differentiation, T2N0M0, stage ⅡA, ER(+), PgR(+), HER2 0. In this case, although needle biopsy was performed, the patient's long-term course provided key insights into the diagnosis. Moreover, the long-term bloody discharge from the nipple was a pathognomonic finding of intraneural secretory breast cancer, and it seemed important to take this morbus into consideration and follow-up on it.

Breast sonography in localizing the cause of nipple discharge: comparison with galactography in 52 patients.

The purpose of this study was to evaluate breast sonography in localizing abnormalities in the discharging duct in patients with spontaneous nipple discharge. Fifty-two patients with unilateral bloody or serous nipple discharge and normal findings on palpation and mammography underwent breast sonography before surgical duct excision. The results of sonography were compared with the findings of galactography and histologic examination of the surgical specimen. The final diagnosis was benign in 47 cases (90%) and malignant in 5 cases (10%). Sonography visualized an echogenic intraductal tumor in 36 (69%) of 52 cases, dilated duct(s) without an intraductal tumor in 6 cases (12%), and no abnormality in 10 cases (19%). Eighty percent of papillomatous lesions, 58% of other benign lesions, and 20% of malignant lesions were sonographically positive. The abnormal duct was surgically removed after methylene blue staining in 38 cases, after sonographically guided wire localization in 11 cases, after both wire localization and methylene blue staining in 1 case, and with review of the diagnostic galactographic images in 2 cases. Sonography was found to be a valuable method for localizing intraductal abnormalities, especially papillomatous lesions, in patients with nipple discharge with no other clinical or radiologic findings. Preoperative sonographically guided wire localization can be used successfully instead of conventional methylene blue staining in cases with problems in cannulation of the discharging duct. Galactography remains the primary diagnostic method, especially in depicting malignant causes of nipple discharge, which may be seen only as duct dilatation on sonography.

International Classification of Diseases for Oncology

M8501/2 Comedocarcinoma, noninfiltrating (C50._) Ductal carcinoma in situ, comedo type DCIS, comedo type M8501/3 Comedocarcinoma, NOS (C50._) M8502/3 Secretory carcinoma of breast (C50._) Juvenile carcinoma of breast M8503/0 Intraductal papilloma Duct adenoma, NOS Ductal papilloma M8503/2 Noninfiltrating intraductal papillary adenocarcinoma (C50._) Noninfiltrating intraductal papillary carcinoma Intraductal papillary adenocarcinoma, NOS Intraductal papillary carcinoma, NOS Ductal carcinoma in situ, papillary DCIS, papillary M8503/3 Intraductal papillary adenocarcinoma with invasion (C50._) Infiltrating papillary adenocarcinoma Infiltrating and papillary adenocarcinoma M8504/0 Intracystic papillary adenoma Intracystic papilloma M8504/2 Noninfiltrating intracystic carcinoma M8504/3 Intracystic carcinoma, NOS Intracystic papillary adenocarcinoma M8505/0 Intraductal papillomatosis, NOS Diffuse intraductal papillomatosis

Intraductal Papilloma -- Introduction

Intraductal papilloma is a benign tumor found within breast ducts. The abnormal proliferation of ductal epithelial cells causes growth. A solitary intraductal papilloma is usually found centrally posterior to the nipple affecting the central duct. Multiple intraductal papillomas are located peripherally, found in any breast quadrant affecting the peripheral ducts. [1] Women of all ages can develop intraductal papillomas. Breast tumor risk factors include contraceptive use, hormone replacement therapy, lifetime estrogen exposure, and family history. [2] Patients with symptoms often present with spontaneous bloody or clear nipple discharge. An intraductal papilloma may be occasionally palpable. However, most patients with intraductal papillomas are asymptomatic. Small intraductal papillomas often will show no signs or symptoms. [1] Working up an intraductal papilloma is imperative due to the possibility of harboring occult carcinoma. [3] It is classified as a high-risk precursor lesion due to its association with atypia, ductal carcinoma in situ (DCIS), and carcinoma. [1] Surgical excision with complete tumor removal is the recommended treatment. [4]

The role of nipple discharge cytology in the diagnosis of breast disease: a study of 1948 nipple discharge smears from 1530 patients.

In this study a review of 1948 nipple discharge (ND) samples from 1530 patients in the age range of 18-83 years was undertaken to determine whether cytological findings from ND smears could provide useful diagnostic information regarding various breast lesions. The study included 1494 females and 36 males and was carried out during a period of 20 years 8 months. The clinical information in all patients was obtained from clinicians (coauthors), medical records and a review of biopsies in 205 patients who had undergone surgery following the cytodiagnosis. Of the ND samples examined, 1480 were unilateral while 468 were from 234 bilateral ND. The cytodiagnoses were: benign 624, inadequate (despite two to three repeat samples) 492, inflammatory 96, papillary lesion not otherwise specified (NOS) 229, suspicious 22 (21 females, one male) and malignant 67 (63 females, four males). A breast biopsy in the 22 suspicious cases revealed breast carcinoma in 18 cases (females n = 17, male n = 1), atypical ductal hyperplasia (female n = 1), fibroadenoma (female n = 1) and a papilloma in two females. In the 67 cases with a diagnosis of malignancy 65 revealed a breast carcinoma in the biopsy (female n = 62, male n = 3) while one female was diagnosed as fibroadenoma and one male as florid gynaecomastia. In 63 cases (females n = 61; males n = 2) with clinical lumpy areas consistent with the diagnosis of fibrocystic condition in ND, the biopsy confirmed a fibrocystic process. In 53 of 229 cases with ND findings suggestive of a papillary lesion (NOS) the biopsy revealed a papilloma in 41 cases while in 12 cases no lesion was found. In the remaining cases of all the groups only a clinical follow-up and appropriate investigations were performed with no untoward outcome. Based on our study it is felt that cytological examination of ND smears seems to be a reasonably specific method in the diagnosis of malignant and suspicious cases but may be somewhat less specific for other diagnoses.


Of course it is a typical picture (EBV, CMV, VH6, Toxoplasma), of which you will not see so clearly at the emergency room door when you are on call. Be careful with the bad blood in answer 3, because an acute toxoplasmosis can behave like this and also give a macular exanthema, although the one of this girl is related to the intake of amoxicillin. By the way, I add a note, if instead of a girl of 17 years so clear it were a young man/girl with risky sexual relations, do not forget the HIV primoinfection as a cause of mononucleosis syndrome.

Of course it is a typical picture (EBV, CMV, VH6, Toxoplasma), of which you will not see so clearly at the emergency room door when you are on call. Be careful with the bad blood in [HIDDEN], because an acute toxoplasmosis can behave like this and also give a macular exanthema, although the one of this girl is related to the intake of amoxicillin. By the way, I add a note, if instead of a girl of 17 years so clear it were a young man/girl with risky sexual relations, do not forget the HIV primoinfection as a cause of mononucleosis syndrome.

A 17-year-old woman comes to the emergency department with a high fever, pharyngeal pain and cervical lymphadenopathy. She had previously been diagnosed with acute pharyngitis and was treated with amoxicillin, and later presented with a generalized macular skin rash. Laboratory tests showed slight leukocytosis with lymphocytosis and presence of activated lymphocytes, slight thrombopenia and slightly increased transaminases. What would be the most likely diagnosis of this clinical picture?

It is a typical picture of infectious mononucleosis.

Screening tests for diagnosis of cervical lymphadenopathy presenting as prolonged fever.

During a two years period, 16 cases having cervical lymphadenopathy presenting as prolonged fever were studied in Abbassia fever hospital, Cairo, Egypt. Patients were subjected to careful history, thorough clinical examination, complete blood picture, tuberculin test, chest x-ray, Monospot test, indirect fluorescent antibody test for toxoplasmosis, detection of cytomegalovirus antibodies and lymph node biopsy with histopathological examination. Ten within normal subjects were taken as controls. The patients were grouped on histopathological basis into 5 groups: (1) One (6%) of the cases was non-specific lymphadenitis diagnosed by clinical examination of the scalp and leucocytosis with polymorphonuclear predominance. (2) Reactive lymphadenitis included 6 (38%) of the cases. Infectious mononucleosis cases were diagnosed by clinical triad of fever, pharyngitis and cervical lymphadenopathy, relative lymphocytosis, monocytosis and positive monospot test. Cytomegalovirus case was diagnosed by lymphocytosis, monocytosis and negative monospot test. Toxoplasmosis cases were diagnosed by monocytosis, negative tuberculin test and positive indirect fluorescent antibody test. (3) Granulomatous lymphadenitis comprised 6 (3%) of the cases. Tuberculous cases were diagnosed by high ESR and highly positive tuberculin test. Sarcoidosis cases were diagnosed by negative tuberculin test and presence of hilar lymphadenopathy. (4) Non-Hodgkin lymphoma case (6%) was diagnosed by clinical deterioration and total lymph node biopsy. 15) Systemic infections were diagnosed by clinical examination, blood culture for salmonellae and brucellae, Widal and Brucella agglutination tests. It is concluded from this study that screening tests are important aids in the diagnosis of cases of cervical lymphadenopathy presenting by prolonged fever especially if lymph node biopsy and histopathological examination are not available or contraindicated. Tub

Infectious mononucleosis-like syndrome probably attributable to Coxsackie A virus infection.

Infectious mononucleosis (IM) is a clinical syndrome most often attributable to Epstein-Barr virus (EBV). Characteristic clinical features of EBV IM include bilateral upper lid edema, exudative or nonexudative pharyngitis, bilateral posterior cervical adenopathy, and splenomegaly ± maculopapular rash. Laboratory features of EBV IM include atypical lymphocytes and elevated levels of serum transaminases. Leukopenia and thrombocytopenia are not uncommon. The syndrome of IM may also be attributable to other infectious diseases, eg, cytomegalovirus (CMV), human herpes virus-6 (HHV-6), or Toxoplasma gondii. Less commonly, viral hepatitis, leptospirosis, brucellosis, or parvovirus B(19) may present as an IM-like infection. To the best of our knowledge, only 2 cases of IM-like infections attributable to Coxsackie B viruses (B(3) and B(4)) have been reported. We present the first reported case of an IM-like syndrome with sore throat, fatigue, atypical lymphocytes, and elevated levels of serum transaminases likely due to Coxsackie A in an immunocompetent adult.

Infectious disease capsules: a pox on your house.

A 31-year-old, previously healthy white man presented to the emergency department with complaints of malaise, fevers, shortness of breath, a non-productive cough, and a "rash." His physical exam revealed a temperature of 100.2F, a pulse of 129 bpm, respiratory rate of 14 BPM, and blood pressure of 140/74 mm Hg. He was alert, oriented, and in no distress. His oropharynx was dry, his neck was supple, and cervical lymphadenopathy was absent. He had tachycardia, bilateral wheezes, and rhonchi with prolonged expirations. There was a diffuse vesicular eruption enveloping his entire body with involvement sparing his palms and soles (Figures 1 and 2). Laboratory values showed a hemoglobin of 16.0 g/dL and a white blood cell count of 7100 cells/pL, with 39%neutrophils, 23% bands, and 35% lymphocytes. His platelet count was mildly decreased to 86,000 x 103/pL. Chest radiograph revealed bilateral diffuse interstitial infiltrates. A diagnosis of acute varicella-zoster virus pneumonia (varicella pneumonia) was made, and the patient was started on IV acyclovir (10 mg/kg every 8 hours). Upon further questioning, the patient stated that his daughter had been diagnosed with "chickenpox" 7 days ago. The patient had numerous exposures to chickenpox in the past but had never developed clinical expressions of varicella. He was not at risk for HIV infection, not having multiple sexual partners, IV drug abuse, or blood transfusions. During the 1 day of in-hospitalization, his fever abated and the pulmonary signs diminished. Following discharge, IV acyclovir was replaced by valacyclovir to complete a 7-day course of therapy.

[Acute infection associated with HIV: clinical and laboratory picture].

Very few case reports evaluate clinical and laboratory parameters of acute HIV infection. This paper describes seven such cases, four being mononucleosis like disease and one lymphocytic meningitis. Clinical manifestations were fever (7/7), lymphadenopathy (7/7), enlarged liver size (7/7) pharyngitis (6/7), malaise (4/7) and anorexia (4/7). Inversion of the normal T4/T8 ratio was present in 3/5 patients, all with normal absolute values for T4 cells. Moderate transaminase increases were found in 5/6; 5/7 had atypical lymphocytes in blood smear and 5/5 had abnormal mucoprotein levels. All patients had a total remission of clinical symptoms within two weeks. However, the abnormal lymph nodes and the enlarged liver persisted. Follow-up for ten months showed 4/7 patients with all abnormalities resolved and 3/7 still with persistent enlarged lymph nodes.

Acute human immunodeficiency virus syndrome in an adolescent.

Acute human immunodeficiency virus (HIV) seroconversion illness is a difficult diagnosis to make because of its nonspecific and protean manifestations. We present such a case in an adolescent. A 15-year-old boy presented with a 5-day history of fever, sore throat, vomiting, and diarrhea. The patient also reported a nonproductive cough, coryza, and fatigue. The patient's only risk factor for HIV infection was a history of unprotected intercourse with 5 girls. Physical examination was significant for fever, exudative tonsillopharyngitis, shotty cervical lymphadenopathy, and palpable purpura on both feet. Laboratory studies demonstrated lymphopenia and mild thrombocytopenia. Hemoglobin, serum creatinine, and urinalysis were normal. The following day, the patient remained febrile. Physical examination revealed oral ulcerations, conjunctivitis, and erythematous papules on the thorax; the purpura was unchanged. Serologies for hepatitis B, syphilis, HIV, and Epstein-Barr virus were negative. Bacterial cultures of blood and stool and viral cultures of throat and conjunctiva showed no pathogens. Coagulation profile and liver enzymes were normal. Within 1 week, all symptoms had resolved. The platelet count normalized. Repeat HIV serology was positive, as was HIV DNA polymerase chain reaction. Subsequent HIV viral load was 350 000, and the CD4 lymphocyte count was 351/mm3. HIV is the seventh leading cause of death among people aged 15 to 24 in the United States, and up to half of all new infections occur in adolescents. Our patient presented with many of the typical signs and symptoms of acute HIV infection: fever, fatigue, rash, pharyngitis, lymphadenopathy, oral ulcers, emesis, and diarrhea. Other symptoms commonly reported include headache, myalgias, arthralgias, aseptic meningitis, peripheral neuropathy, thrush, weight loss, night sweats, and genital ulcers. Common seroconversion laboratory findings include leukopenia, thrombocytopenia, and elevated transaminases. The suspicion of acute HIV illness should prompt virologic and serologic analysis. Initial serology is usually negative. Diagnosis therefore depends on direct detection of the virus, by assay of viral load (HIV RNA), DNA polymerase chain reaction, or p24 antigen. Both false-positive and false-negative results for these tests have been reported, further complicating early diagnosis. Pediatricians should play an active role in identifying HIV-infected patients. Our case, the first report of acute HIV illness in an adolescent, emphasizes that clinicians should consider acute HIV seroconversion in the appropriate setting. Recognition of acute HIV syndrome is especially important for improving prognosis and limiting transmission. It is imperative that we maintain a high index of suspicion as primary care physicians for adolescents who present with a viral syndrome and appropriate risk factors.

Prospective study of the natural history of infectious mononucleosis caused by Epstein-Barr virus.

Knowledge regarding the clinical characteristics and natural history of acute infectious mononucleosis is based largely on older, often retrospective, studies without systematic follow-up. Differences in diagnosis, methodology, or treatment between historical and current practice might affect an understanding of this illness. Using a prospective case series design, we enrolled 150 persons with an acute illness serologically confirmed as Epstein-Barr virus infection. The goal of the study was to assess symptoms, physical examination findings, laboratory tests, and functional status measures during the acute presentation and 1, 2, and 6 months later. Acutely, infectious mononucleosis was characterized by the symptoms of sore throat and fatigue and substantial functional impairment. Objective physical and laboratory examination findings included pharyngitis and cervical lymphadenopathy, a moderate absolute and atypical lymphocytosis, and mildly elevated transaminase levels. The traditional signs of fever and splenomegaly were relatively uncommon. By 1 month, most symptoms and signs and all laboratory tests had returned to normal. Fatigue, cervical lymphadenopathy, pharyngitis, and functional health status improved more slowly. In contemporary practice most of the classical illness features of infectious mononucleosis are observed. Symptoms, signs, and poor functioning might be protracted in some patients.

[A case with infectious mononucleosis-like syndrome caused by human herpes virus-6 infection].

A 26-year-old female was admitted because of multiple fractures in lower extremities. While in the hospital, she developed a high fever and generalized skin eruption. Physical examination revealed bilateral cervical lymphadenopathy and mild hepatosplenomegaly. The white cell count was 11,200 with 11% atypical lymphocytes. Serum GOT, GPT, LDH were markedly elevated. Infectious mononucleosis was suspected, but the serological test for EB virus did not show evidence of acute EB virus infection. Anti-HSV, CMV, hepatitis A virus antibody titers also did not show significant change during the coarse. The serological test for HHV-6 only showed increased titer of IgM and IgG antibodies. Rapidly elevated IgG antibody titer was indicative of reactivation of HHV-6. So, she was diagnosed as mononucleosis-like syndrome caused by HHV-6, probably reactivated infection. Her symptoms gradually disappeared during a month.

[THE FEATURES OF THE COURSE OF INFECTIOUS MONONUKLEOSIS OF DIFFERENT ETIOLOGY IN CHILDREN].

Aim - to study the effect of different pathogens (EBV, CMV, HHV-6, and MIXT) on the severity of clinical-paraclinical manifestations of infectious mononucleosis in children. The clinical and laboratory study performed for 410 children aged from 10 months up to 12 years with infectious mononucleosis. The association of herpes viruses, mainly EBV, CMV and HHV type 6, takes part in the formation of the clinical picture of IM in (52,9%) of cases. The sole participation of EBV in the development of IM was observed only in (34,1%), CMV (9,02%) and HHV-6 in (3,17%) patients. The etiology of infectious mononucleosis in children affects the acuity, severity, and intensity of the clinical and paraclinical signs of the disease. Infectious mononucleosis VEB etiology is manifested by acute onset (79,5%), intoxication (70,5%), subfebrile and febrile fever up to 7 days (61,03%), lacunar tonsillitis (85,8%), hepatomegaly ( 88,2%), splenomegaly (63,8%), mostly moderate (81,7%) with lymphocytosis (62,9%) and monocytosis (20,5%). For CMV mononucleosis - acute onset (89,9%), severe course (29,8%), febrile and high fever for up to 7 (56,7%) or more days, neutrophilic leukocytosis (73,55) with atypical mononuclear cells (64,7%) and anemia (29,7%). Severe (33,3%), with prolonged high fever (50%), exanthema syndrome (33,3%), pharyngitis without tonsillitis (66,7%), leukocytosis (66,7%) with accelerated ESR (66,7%) and monocytosis (33,3%) are characteristic of HHV-6 infection. For MIXT - acute onset (78,3%), intoxication (79,7%), lacunar tonsillitis (92,9%), hepatomegaly (84,1%) and splenomegaly (67%), low-grade and febrile fever from 3- x (27,1%) up to 7 days (35,05%), lymphocytosis (55,3%) with neutropenia (57,4%), atypical mononuclear cells (48,2%) and hypochromic anemia (17,29 %).

Infectious mononucleosis

Acute HIV infection can mimic signs similar to those of infectious mononucleosis, and tests should be performed for pregnant women for the same reason as toxoplasmosis. People with infectious mononucleosis are sometimes misdiagnosed with a streptococcal pharyngitis (because of the symptoms of fever, pharyngitis and adenopathy) and are given antibiotics such as ampicillin or amoxicillin as treatment. Other conditions from which to distinguish infectious mononucleosis include leukemia, tonsillitis, diphtheria, common cold and influenza (flu).

Lymphadenopathy

Lymph node enlargement is recognized as a common sign of infectious, autoimmune, or malignant disease. Examples may include: Reactive: acute infection (e.g., bacterial, or viral), or chronic infections (tuberculous lymphadenitis, cat-scratch disease). The most distinctive sign of bubonic plague is extreme swelling of one or more lymph nodes that bulge out of the skin as "buboes." The buboes often become necrotic and may even rupture. Infectious mononucleosis is an acute viral infection usually caused by Epstein-Barr virus and may be characterized by a marked enlargement of the cervical lymph nodes. It is also a sign of cutaneous anthrax and Human African trypanosomiasis Toxoplasmosis, a parasitic disease, gives a generalized lymphadenopathy (Piringer-Kuchinka lymphadenopathy). Plasma cell variant of Castleman's disease - associated with HHV-8 infection and HIV infection

Infectious mononucleosis

Differential diagnosis About 10% of people who present a clinical picture of infectious mononucleosis do not have an acute Epstein–Barr-virus infection. A differential diagnosis of acute infectious mononucleosis needs to take into consideration acute cytomegalovirus infection and Toxoplasma gondii infections. Because their management is much the same, it is not always helpful, or possible, to distinguish between Epstein–Barr-virus mononucleosis and cytomegalovirus infection. However, in pregnant women, differentiation of mononucleosis from toxoplasmosis is important, since it is associated with significant consequences for the fetus. Acute HIV infection can mimic signs similar to those of infectious mononucleosis, and tests should be performed for pregnant women for the same reason as toxoplasmosis.

A case of cytomegalovirus mononucleosis associated with pleural effusion.

A 5 year old boy had a spiky fever accompanied by a mild pharyngitis, cervical lymphadenopathy and hepatosplenomegaly. Laboratory findings revealed leukocytosis with 26% atypical lymphocytes, and liver dysfunction. A chest X-ray showed pneumonia and a considerable amount of pleural effusion. Serum antibody titers for cytomegalovirus (CMV) were elevated significantly and CMV-DNA (polymerase chain reaction) was detected in the pleural effusion. Only 13 cases of pleural effusion associated with infectious mononucleosis have been reported previously in the literature, but there was no documentation that proved CMV infection. The case reported here suggests that the pleural effusion was caused by the infiltration of mononuclear cells to the pleura as a result of systemic inflammation, and the possible alternative of host immune response against CMV was related to recent Varicella zoster virus infection.

Lymphocytosis -- Etiology

Infectious: Viral infections: Epstein-Barr Virus (EBV): Infectious Mononucleosis (IM) is a classic example of viral infections associated with lymphocytosis. Acute IM is a disease characterized by fever, lymphadenopathy, pharyngitis, splenomegaly, and various hematologic manifestations, among which lymphocytosis is the most common and presents in up to two-thirds of cases. [1] Cytomegalovirus (CMV): CMV can cause a disease indistinguishable from EBV IM. Human Immunodeficiency Virus (HIV): Although chronic HIV infection resulted in lymphopenia and decreased CD4+ lymphocytes count, primary HIV infection can lead to an acute febrile mononucleosis-like illness with associated lymphocytosis. A negative heterophile test can help distinguish the two. [2] Other Viruses: Influenza, hepatitis, mumps, measles, rubella, and human T Lymphocytic virus type 1 (HTLV-1), adenovirus, to name a few. Bacterial Infections: Most of the acute bacterial infections will cause neutrophilia; however, notable exceptions include: Bartonella henselae : Bartonella henselae leads to cat scratch disease, a disease transmitted by scratch or bite from an infected cat, that leads mostly to self-limited lymphadenopathy, but can be associated with ocular or neurologic manifestations. Lymphocytes are large and atypical. Bordetella Pertussis : Pertussis is characterized by increased lymphocytes that are small with a deeply cleaved nucleus, clinical correlation is needed to differentiate from some lymphoid malignancies that might share the morphologic appearance. Other: Brucellosis, syphilis, malaria Parasitic Infections: Toxoplasma Gondii: symptomatic  toxoplasmosis occurs most commonly in immunocompromised hosts. Lymphocytosis with atypical lymphocytes is a hematologic hallmark of the disease, that can present as a mononucleosis-like illness. [3] Other: Babesiosis Mycobacterial Tuberculosis

Pediatrics_Nelson

Initial laboratory tests of regional lymphadenopathy include a complete blood count and inflammatory markers. Infectious mononucleosis is characterized by lymphocytosis with atypical lymphocytes; thrombocytopenia and elevated hepatic enzymes are common. Cultures of infected skin lesions and tonsillar exudates should be obtained. Isolation of group A streptococci from the oropharynx suggests, but does not confirm, streptococcal cervical lymphadenitis. A blood culture should be obtained from children with systemic signs and symptoms of bacteremia. Serologic testing for EBV and for B. henselae should be obtained if there are appropriate findings. The most reliable test for diagnosis of acute EBV infection is the IgM antiviral capsid antigen (Fig. 99-1). Heterophil antibody is also diagnostic but is not reliably positive in children younger than 4 years with infectious mononucleosis.

[Retrospective evaluation of patients who were diagnosed as infectious mononucleosis between 1984-2005].

In this study, the clinical and laboratory features of 26 infectious mononucleosis (IMN) cases who have been diagnosed between the years of 1984-2005 were evaluated retrospectively. The mean age of the patients was 26+/-11 years, the rate of being hospitalized was 65%, and mean hospitalization period was 9.2+/-6 days. Fever (81%), weakness (50%), sore throat (50%), headache (50%) and swollen neck (35%) were the most common symptoms, while in the physical examination cervical lymphadenopathy (81%), splenomegaly (69%), hyperemic pharynx (65%), hepatomegaly (54%) and tonsillitis (50%) were observed. Laboratory results yielded leukocytosis in 21%, leucopenia in 12%, anemia in 44%, thrombocytopenia in 5% and elevated transaminase levels in 84% of the patients. Of the patients 15 (57.7%) had the history of using antibiotics before the diagnosis. Serological diagnosis was performed by Paul-Bunnel test and/or IgM positivity against Epstein-Barr virus (EBV) viral capsid antigen (VCA). Tonsillo-pharyngitis secondary to edema and respiratory distress due to lymphadenopathy pressure were detected in four patients, whereas pancytopenia was established only in one patient, as complications. This study emphasized that, although IMN is a self-limited infection, the diagnostic difficulties may arise when the clinical course is atypical, and rarely seen life-threatening complications may also develop during IMN course.

Case of haemophagocytic lymphohistiocytosis following Epstein-Barr virus infection.

Haemophagocytic lymphohistiocytosis (HLH) is a rare diagnosis that carries a high degree of mortality. We present this case of a previously healthy 22-year-old woman, who was admitted acutely ill to the hospital. One week prior, she had been seen by her primary care physician for fatigue and malaise. At that time, she was noted to have anterior and posterior cervical lymphadenopathy. She was referred to the emergency room and was diagnosed with acute Epstein-Barr virus (EBV) mononucleosis based on her clinical symptoms and positive heterophile antibody test. She was discharged after an uneventful 48-hour stay on the wards. She represented 7 days after discharge with cough, fatigue, nausea, vomiting, epigastric abdominal pain, diarrhoea, weight loss and subjective fevers. She had also reported haematemesis, epistaxis and melaena. Vital signs included temperature 36.9°C, blood pressure 90/50 mm Hg, heart rate 130 beats per minute and respiratory rate 32 breaths per minute. Physical examination was notable for an acutely ill appearing woman with scleral icterus, hepatosplenomegaly and palpable cervical and axillary lymphadenopathy. Complete blood count showed pancytopaenia with haemoglobin 59 g/L (normal 120-160 g/L), white blood cell count 2.7×10<sup9</sup/L (normal 4-10.5×10<sup9</sup/L) and platelet count 50×10<sup9</sup/L (normal 150-450×10<sup9</sup/L). The white blood cell count differential included 58% neutrophils (normal 38%-77%) with immature neutrophils in band form elevated at 45% (normal <14%), 16% lymphocytes (normal 20%-48%), 7% monocytes (normal <12%) and no eosinophils (normal <6%). Blood smear revealed anisocytosis, poikilocytosis and hypochromia. Coagulation panel showed elevated levels of d-dimer level at 1.39 µg/mL (normal <0.45 µg/mL), prolonged prothrombin time at 34.4 s (normal 11-15 s), prolonged activated partial thromboplastin time of 55.6 s (normal 25-34 s), prolonged international normalised ratio at 3.31 (normal <1.1) and low fibrinogen 60 mg/dL (normal >200 mg/dL). Lipid panel showed cholesterol at 114 mg/dL (normal 125-200 mg/dL), triglycerides 207 mg/dL (normal 30-150 mg/dL), high-density lipoprotein cholesterol 10 mg/dL (normal 40-60 mg/dL) and low-density lipoprotein cholesterol 63 mg/dL (normal <100 mg/dL). Other lab abnormalities included elevated ferritin of 6513 ng/mL (normal 10-150 ng/mL) and elevated lactate dehydrogenase of 1071 unit/L (normal 95-240 unit/L). Soluble interleukin-2 receptor alpha level was elevated at 60 727 units/mL (normal 223-710 units/mL). Fluorodeoxyglucose-positron emission tomography (FDG-PET) scan showed abnormal tracer localisation within the paratracheal, hilar, pelvic, abdominal and subcarinal lymph nodes, along with FDG-PET positive hepatosplenomegaly. A bone marrow biopsy showed hypercellular marrow (95% cellularity) with trilineage haematopoiesis, haemophagocytic cells, polytypic plasmacytosis and T-cell lymphocytosis, along with positive latent membrane protein-1 immunohistochemical staining for EBV. EBV quantitative DNA PCR showed >1 million copies. These findings were consistent with a diagnosis of HLH secondary to EBV infection. Despite intense therapy with the HLH-94 protocol, the patient expired from her illness after a prolonged hospital course.

An Unusual Presentation of Glandular Fever.

Epstein-Barr virus (EBV) is an ubiquitous DNA herpesvirus with >90% of adults >40 years of age showing a serological response. While in their youth, primary EBV infection may pass unnoticed, young adults have a high incidence of infectious mononucleosis (IM). This is characterized by a triad of pharyngitis, cervical lymphadenopathy, and fever because of a self-limiting lymphoproliferative disease. Common complications include but are not limited to hepatitis, splenomegaly, encephalitis, and haemophagocytic lymphohistiocytosis (HLH) with evidence that Caucasian males and smokers are more likely to suffer severe disease. Here we present a 21-year-old male who presented with a 2-week history of fever, dry cough, and a 4-week history of pharyngitis. He had no exposure to unwell contacts and denied any new sexual partners. Examination revealed general pallor with tender bilateral cervical lymphadenopathy and pharyngeal erythema. Admission bloods revealed pancytopenia (WCC 1.5 × 10<sup9</sup/L, Plt 84 × 10<sup9</sup/L, and Hb 82 g/L) with normal reticulocyte count and raised mean corpuscular volume (114 fL). Serum vitamin B12 and folate were low with serum ferritin raised (1027 <iµ</ig/L) suggesting a proinflammatory state. Admission liver function tests, coeliac serology, autoimmune panel (ANA, ANCA, and anti-dsDNA), hepatitic (hepatitis A, B, and E), human immunodeficiency virus (HIV), toxoplasmosis, parvovirus, and CMV serology were normal. The monospot test on day 1 of the presentation was negative. Ultrasound (US) of the abdomen on day 3 of the presentation revealed isolated splenomegaly (16.8 cm). Day 4 EBV serology (VCA IgM, VCA IgG, and EBNA IgG) was negative as such haematological investigations including JAK2, serum free light chains, and BCR-ABL were undertaken alongside cervical lymph node core biopsy. Repeat Monospot testing on day 7 came back positive. Repeat EBV serology now showed equivocal EBV VCA IgG (0.77 OD) and positive VCA IgM (9.04 OD) with concurrent new hepatitis. Histopathology of the core biopsy revealed Sternberg-reed cells and a mixed immunoblastic reaction in keeping with resolving IM. This case highlights the need for physicians to have a strong clinical suspicion of IM and understand the multiple ways in which IM may be present as well as the time lag to positivity in serological testing.

Lymphocytosis

Causes of absolute lymphocytosis include: acute viral infections, such as infectious mononucleosis (glandular fever), hepatitis and Cytomegalovirus infection other acute infections such as pertussis some protozoal infections, such as toxoplasmosis and American trypanosomiasis (Chagas disease) chronic intracellular bacterial infections such as tuberculosis or brucellosis chronic lymphocytic leukemia acute lymphoblastic leukemia lymphoma post-splenectomy state CARD11-related congenital B cell lymphocytosis (rare, also known as BENTA disease) Causes of relative lymphocytosis include: age less than 2 years; acute viral infections; connective tissue diseases, thyrotoxicosis, Addison's disease, splenomegaly with splenic sequestration of granulocytes.

Herpes labialis

Signs and symptoms Herpes infections usually show no symptoms; when symptoms do appear they typically resolve within two weeks. The main symptom of oral infection is inflammation of the mucosa of the cheek and gums—known as acute herpetic gingivostomatitis—which occurs within 5–10 days of infection. Other symptoms may also develop, including headache, nausea, dizziness and painful ulcers—sometimes confused with canker sores—fever, and sore throat. Primary HSV infection in adolescents frequently manifests as severe pharyngitis with lesions developing on the cheek and gums. Some individuals develop difficulty in swallowing (dysphagia) and swollen lymph nodes (lymphadenopathy). Primary HSV infections in adults often results in pharyngitis similar to that observed in glandular fever (infectious mononucleosis), but gingivostomatitis is less likely.

Infectious mononucleosis

Other tests Epstein–Barr nuclear antigen detection. While it is not normally recognizable until several weeks into the disease and is useful for distinguishing between a recent-onset of infectious mononucleosis and symptoms caused by a previous infection. Elevated hepatic transaminase levels are highly suggestive of infectious mononucleosis, occurring in up to 50% of people. By blood film, one diagnostic criterion for infectious mononucleosis is the presence of 50% lymphocytes with at least 10% atypical lymphocytes (large, irregular nuclei), while the person also has fever, pharyngitis, and swollen lymph nodes. The atypical lymphocytes resembled monocytes when they were first discovered, thus the term "mononucleosis" was coined. A fibrin ring granuloma may be present.

[Agranulocytosis as a complication of acute infectious mononucleosis].

Acute infections mononucleosis is the most common clinical manifestation of primary Epstein-Barr virus (EBV) infection occurring during adolescence. It is a benign lymphoproliferative, usually self-limiting disease. Complications are relatively rare, but they may occur, especially hematological. Most common are autoimmune hematolytic anemia and thrombocytopenia, and they respond to corticoid therapy. Deuteration of white blood cells is rather rare, whereas mild neutropenia is a normal finding during the course of acute disease. On the other hand, agranulocytosis is extremely rate, and almost every case has been reported in the literature. Filgrastim--the recombinant human granulocyte colony-stimulating factor (G-CSF) stimulates the activation, proliferation and maturation of progenitor granulocyte cells. This drug is usually applied in treatment of iatrogenic neutropenia, during chemotherapy of malignancies and in some idiopathic and cyclic neutopenias. A female patient, 18 years of age, has been hospitalized at the Clinic of Infectious Diseases in Novi Sad on two occasions. First because of severe acute infectious mononucleosis with acute hepatitis and jaundice 10 days after onset of symptoms. Physical examination revealed severe intoxication, dehydration, icteric skin, mucosis and massive hepatosplenomegaly. The diagnosis was confirmed by ELISA IgM, EBV VCA positive and ELISA IgG EBV VCA and IgG EBVNA negative results. The patient was discharged from hospital after 24 days without complaints and with normal physical and laboratory findings. For several days she felt well, but gradually severe fatigue and malaise occurred and she became febrile again. That was the reason why she was hospitalized again, two weeks later. This time she was febrile, extremely intoxicated with general lymphadenopathy, catarrhal gingivostomatitis and massive splenomegaly. The first laboratory findings showed severe neutropenia (absolute count of granulocytes was 0.156 x 10/l, with only 12% segmented neutrophils). Mild anemia--3.05 x 10/l was also registered, while the platelet count was normal. Other biochemical analyses were normal, the Coombs' test negative, while the serological response was also normal. Bone marrow puncture was performed and normocellular bone marrow was registered, somewhere hypercellular due to hyperplasia of granulocyte progenitor cells from promyelocytes to normal maturated cells. Anemia showed megaloblastoid proliferation, while megakaryocytes were normal. High doses of corticosteroids were applied (dexamethasone 160 mg daily) and filgrastim 5 micrograms every other day. From the very beginning of therapy the patient felt better, whereas granulocytes responded with elevation as soon as 48 hours after initiation of therapy. On the sixth day the treatment was stopped because the level of granulocytes was normal and the patient has completely recovered. She was discharged from hospital 4 weeks later with mild meteorism, but normal physical and laboratory findings and mild splenomegaly registered only by ultrasonography. During the last 10 years only several cases of severe leukopenia with acute infectious mononucleosis had been reported in literature. In all cases it was associated with some other hematological complications and it occurred in young adults without previously registered immunodeficiency. We have no knowledge about application of filgrastim in treatment of EBV-induced agranulocytosis, but the International Association for Studying Agranulocytosis and Aplastic Anemia reported that in 4% of patients Epstein-Barr virus can cause agranulocytosis even a year after the occurrence of acute disease.

Eosinophilic myocarditis

The DRESS syndrome is a severe immunological drug reaction. It differs from other drug reactions in that it: a) is caused by a particular set of drugs; b) typically occurs after a delay of 2 to 8 weeks following intake of an offending drug; c) presents with a specific set of signs and symptoms (i.e. modest or extreme elevations in blood eosinophil and atypical lymphocyte counts; acute onset of a skin rash; lymphadenopathy; fever; neuralgia; and involvement of at least one internal organ such as the liver, lung, or heart; d) develops in individuals with particular genetic predispositions; and e) involves reactivation of latent viruses, most commonly human herpesvirus 6 or more rarely human herpes virus 5 (i.e. human cytomegalovirus), human herpesvirus 7, and human herpesvirus 4 (i.e. Epstein–Barr virus). These viruses usually become dormant after infecting humans but under special circumstances, such as drug intake, are reactivated and may contribute to serious diseases such as the

List of skin conditions

Giant condyloma acuminatum (Buschke–Löwenstein tumor, giant condyloma of Buschke–Löwenstein tumor) Hand-foot-and-mouth disease Heck's disease (focal epithelial hyperplasia) Hemorrhagic fever with renal syndrome Hepatitis B Hepatitis C Herpangina Herpes gladiatorum (scrum pox) Herpes simplex Herpes zoster oticus (Ramsay–Hunt syndrome) Herpetic keratoconjunctivitis Herpetic sycosis Herpetic whitlow HIV-associated pruritus Human monkeypox Human T-lymphotropic virus 1 infection Human tanapox Immune reconstitution inflammatory syndrome (immune recovery syndrome) Infectious mononucleosis (glandular fever) Inflammatory skin lesions following zoster infection (isotopic response) Intrauterine herpes simplex Kaposi sarcoma Lassa fever Lipschütz ulcer (ulcus vulvae acutum) Measles (rubeola, morbilli) Milker's nodule Modified varicella-like syndrome Molluscum contagiosum Myrmecia Neonatal herpes simplex Ophthalmic zoster

InternalMed_Harrison

Person with AIDS <100 CD4+ T cells/μL; CMV seropositivity Retinitis; gastrointestinal Ganciclovir, valganciclovir, Oral valganciclovir disease; neurologic disease foscarnet, or cidofovir 1192 often involves sexually active young adults. With incubation periods of 20–60 days, the illness generally lasts for 2–6 weeks. Prolonged high fevers, sometimes with chills, profound fatigue, and malaise, characterize this disorder. Myalgias, headache, and splenomegaly are common, but in CMV (as opposed to Epstein-Barr virus) mononucleosis, exudative pharyngitis and cervical lymphadenopathy are rare. Occasional patients develop rubelliform rashes, often after exposure to ampicillin or certain other antibiotics. Less common are interstitial or segmental pneumonia, myocarditis, pleuritis, arthritis, and encephalitis. In rare cases, Guillain-Barré syndrome complicates CMV mononucleosis. The characteristic laboratory abnormality is relative lymphocytosis in peripheral blood, with >10% atypical

Pharyngitis -- History and Physical

If viral in etiology, associated symptoms often include coughing, rhinorrhea, conjunctivitis, headache, and a rash. Group A beta-hemolytic streptococcal pharyngitis typically has an acute onset, lacks signs of a viral upper respiratory infection such as a cough or rhinorrhea, and is associated with fever, tonsillar exudates, and cervical adenopathy. Pharyngitis due to the Epstein-Barr virus, otherwise known as infectious mononucleosis,  can cause headaches, fever, tonsillar hypertrophy, lymphocytosis, and atypical lymphocytes. Myalgia and fatigue are commonly reported symptoms. Infectious mononucleosis can have both anterior and posterior cervical lymphadenopathy. Patients can have persistent lymphadenopathy and fatigue for up to 3 weeks. It is important to assess for hepatomegaly or splenomegaly. If a morbilliform rash develops after amoxicillin for presumed Group A beta-hemolytic streptococci, infectious mononucleosis should be suspected.

Cervical lymphadenopathy

Classification Cervical lymphadenopathy can be thought of as local where only the cervical lymph nodes are affected, or general where all the lymph nodes of the body are affected. Causes Infection Pericoronitis Staphylococcal lymphadenitis Mycobacterial lymphadenitis Rubella Cat scratch fever Infectious mononucleosis Streptococcal pharyngitis Viral respiratory infection Toxoplasmosis Tuberculosis Brucellosis Primary herpes simplex infection (primary herpetic gingivostomatitis) Syphilis (secondary) Cytomegalovirus Human immunodeficiency virus Histoplasmosis Chicken pox

Diagnosis of atypical cases of infectious mononucleosis.

The variable manifestations of infectious mononucleosis rarely cause clinicians to suspect primary Epstein-Barr virus or cytomegalovirus infection; consequently, costly diagnostic tests and unnecessary treatments are undertaken. Seventeen cases of clinically atypical and 11 cases of clinically typical infectious mononucleosis were diagnosed through screening for atypical and apoptotic lymphocytes in the peripheral blood samples by means of an automated hematologic analyzer. Atypical and typical cases did not differ significantly with respect to peripheral white blood cell counts; percentages of lymphocytes, atypical lymphocytes, CD4(+) lymphocytes, human leukocyte antigen--DR positivity in CD3 lymphocytes, or apoptotic cells in blood smear after incubation; or levels of aspartate aminotransferase, alanine aminotransferase, and lactate dehydrogenase. Only the percentage of CD8(+) lymphocytes was significantly higher in patients with typical infectious mononucleosis than it was in patients with atypical infectious mononucleosis. Because certain atypical cases of infectious mononucleosis display laboratory abnormalities that are characteristic of typical infectious mononucleosis, enhanced awareness can help in the diagnosis.

List of MeSH codes (C02)

– african swine fever – circoviridae infections – hepadnaviridae infections – hepatitis b – hepatitis b, chronic – herpesviridae infections – bell palsy – chickenpox – cytomegalovirus infections – cytomegalovirus retinitis – encephalitis, herpes simplex – encephalitis, varicella zoster – epstein-barr virus infections – burkitt lymphoma – infectious mononucleosis – leukoplakia, hairy – herpes simplex – herpes genitalis – herpes labialis – kaposi varicelliform eruption – keratitis, herpetic – keratitis, dendritic – stomatitis, herpetic – herpes zoster – herpes zoster ophthalmicus – herpes zoster oticus – zoster sine herpete – infectious bovine rhinotracheitis – malignant catarrh – marek disease – pseudorabies – roseolovirus infections – exanthema subitum – sarcoma, kaposi – papillomavirus infections – warts – condylomata acuminata – epidermodysplasia verruciformis – papovaviridae infections

Primary Epstein-Barr virus infection shortly after primary Cytomegalovirus infection: a case report.

Infectious mononucleosis (IM) and mononucleosis-like illnesses are common viral infectious diseases which are often accompanied by a high fever, pharyngitis and lymphadenopathy in adults, although such infection in childhood is generally subclinical. Most cases of IM are caused by the Epstein-Barr virus (EBV) or Cytomegalovirus (CMV). However, it is difficult to diagnose IM only with subjective symptoms, and thus EBV and CMV are nearly indistinguishable in clinical practice. A 20-year-old healthy Japanese woman had a 2-day history of high fever and consulted us. She had sex for the first time 6 months earlier. Her virus antibodies showed that she was infected with primary CMV. About 5 months later, she again experienced high fever and lymph node enlargement at the posterior cervical region. Her virus antibodies showed that she was infected with primary EBV at that time. Herein, we report a healthy adult Japanese woman with primary EBV infection relatively soon after primary CMV infection. It is very interesting to compare the symptoms and/or clinical data after EBV and CMV infection in the same patient within a short period of time. Our patient was diagnosed based only on subjective symptoms, physical examination and laboratory data, without tests of such virus-related antibodies. Therefore, clinicians should bear in mind that primary EBV infection and/or primary CMV infection is possible when patients have symptoms such as high fever, pharyngitis and lymphadenopathy, even in healthy adults.

Atypical exanthema in a patient with infectious mononucleosis.

A 19-year-old male with a sore throat developed numerous, indistinct, erythematous, maculopapular lesions on the trunk. The eruptions, which mimicked secondary syphilis, continued for seven weeks and faded away without pigmentation or scarring. The laboratory examinations revealed lymphocytosis with atypical lymphocytes, seroconversion of Epstein-Barr virus titers, and elevation of transaminase in liver function.

Pediatrics_Nelson

The characteristic triad of EBV infectious mononucleosis is fever, pharyngitis, and lymphadenopathy. The pharynx shows enlarged tonsils and exudate and, sometimes, anenanthem with pharyngeal petechiae. Lymphadenopathy ismost prominent in the anterior and posterior cervical andsubmandibular lymph nodes and less commonly involvesaxillary and inguinal lymph nodes. Other findings includesplenomegaly in 50% of cases, hepatomegaly in 10% to 20%, and maculopapular or urticarial rash in 5% to 15%. A diffuse,erythematous rash develops in approximately 80% of mononucleosis patients treated with amoxicillin. Compared with EBV infection, infectious mononucleosis-like illness caused by CMV has minimal pharyngitis and often more prominentsplenomegaly; it often presents with fever only. The mostcommon manifestation of toxoplasmosis is asymptomaticcervical lymphadenopathy, but approximately 10% of casesof acquired toxoplasmosis develop chronic posterior cervical lymphadenopathy and fatigue, usually

Epstein–Barr virus-associated lymphoproliferative diseases

During the infection's acute phase, individuals generally have high levels of infective EBV in their oral/nasal secretions plus high blood levels of EBV, atypical lymphocytes, CD8 T cells, and memory B cells (up to 50% of the latter cells are EBV+). The tonsils and cervical lymph nodes in these cases are hyperplasic and contain mixtures of normal-appearing lymphocytes, activated lymphocytes, plasma cells, and Reed–Sternberg-like cells. Many of these normal-appearing and activated B cells and a small percentage of the tissue's T and NK cells are EBV+ with the virus being mostly in its lytic cycle rather than latent phases. The diagnosis of mild IM cases is often overlooked or made based on clinical and routine laboratory findings. These cases as well as asymptomatic and more severe cases of EBV infection are diagnosed definitively as EBV-associated by finding during the initial infection period the Epstein–Barr virus, IgM antibody to EBV viral-capsid antigen (VCA-IgM), IgG antibody to