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Department of Internal Medicine, Self-Defense Forces Central Hospital, Tokyo, JapanGraduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
A 26-year-old woman presented with a chief complaint of nausea for 2 days. On the previous day, she had been diagnosed with tonsilitis by her previous doctor because of fever and sore throat, and had started treatment with amoxicillin. On examination, bilateral enlarged tonsils with white spots were observed. Blood tests showed elevation of hepatic transaminase and lactate dehydrogenase levels. We suspected acute hepatitis because of her recent consumption of undercooked beef and elevation of hepatitis type A antibody. At 1 week after initiating amoxicillin treatment, she complained of generalized rashes. Flushing of the face, avoiding the eye area, with painless posterior cervical adenopathy and generalized erythematous papules and macules on the trunk and limbs, except below the knees, were confirmed (Figs. 1a and 1b). What is the diagnosis?
Fig. 1The patient's skin manifestation at 1 week after initiating amoxicillin treatment. Generalized erythematous papules and macules involving her arms (a) and legs except below the knees (b) were observed.
Blood tests revealed the presence of atypical lymphocytes. Epstein-Barr (EB) virus capsid antigen (VCA) IgM and VCA-IgG antibodies were confirmed to be elevated without elevation of EB virus nuclear antigen titer. Because the patient reported sexual contact with her boyfriend at 2 and 23 days before the onset of symptoms, the diagnosis of EB virus infectious mononucleosis was made. The generalized rashes were therefore caused by treatment with amoxicillin.
3. Discussion
Infectious mononucleosis is characterized by fever, tonsillar pharyngitis, and lymphadenopathy and mainly caused by EB virus infection [
], fever, pharyngitis, and lymphadenopathy can also be caused by group A streptococcus, cytomegalovirus (CMV), and acute human immunodeficiency virus (HIV) or Toxoplasma gondii [
]. Lymphocytosis, an increased proportion of atypical lymphocytes, and elevated hepatic transaminase levels are primary diagnostic clues to suspect infectious mononucleosis. Skin eruption during EB virus infection is characterized by generalized maculopapular, urticarial, or petechial rash involving the palms and soles following administration of amoxicillin or other antibiotics [
]. The differential diagnosis for these skin lesions is Gianotti–Crosti syndrome, Stevens–Johnson syndrome, or virus infections such as varicella zoster virus and enterovirus [
]. Clinicians should be aware that use of antibiotics such as amoxicillin in patients with EB virus infectious mononucleosis can often lead to generalized maculopapular rash.
Funding
This work was supported by the Japan Medical Education Foundation (https://www.jmef.or.jp/). The funders had no role in the preparation of the manuscript or the decision to publish.
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