What's causing student's fever, jaundice?

A high school student who had been spending her summer studying for the SATs became ill in early August with fever, decreased energy, and nausea.

Her parents initially thought it was a flulike illness. But her fever continued, and, a few days later, she developed pain in the right side of her abdomen and began vomiting. Her urine was dark, and the white part of her eyes appeared yellow.

When she presented to the emergency department, she had a high fever. She appeared very tired and ill, with a yellow tinge to her eyes and skin and tenderness in the right upper part of her abdomen. Blood work showed she had mild anemia. Her platelets were low, and bilirubin, a waste product, and liver enzymes were high.

An ultrasound of her abdomen showed the wall of her gallbladder was markedly thickened, more than four times normal. However, there was no fluid surrounding the gallbladder, ordinarily seen with inflammation of the gallbladder (cholecystitis), and there was no gallstone or sign of obstruction, which is often seen with cholecystitis. The ultrasound also showed her spleen was mildly enlarged.

She had traveled to India the previous year, but did not recall getting sick there. Her mother's gallbladder was removed in her 30s, and, many years before, her aunt had also had jaundice (yellow eyes and skin) in India that had gotten better on its own, though she was not sure what the diagnosis was.

Because of the concern of infection, blood cultures were drawn, and she was started on intravenous antibiotics and admitted to the hospital.

With the fevers, jaundice, and elevated liver enzymes, her doctors initially worried about viral hepatitis. Hepatitis A is common in India, where it can be transmitted through contaminated food.

But hepatitis usually involves inflammation of the liver and does not typically involve the gallbladder. Furthermore, most children born in the United States after 1999 are vaccinated against hepatitis A, and this patient recalled having been vaccinated against both hepatitis A and hepatitis B.

Typhoid fever, caused by the bacteria Salmonella typhi, was also a concern raised by the young woman's doctors. It usually presents with fever, lethargy, abdominal pain, and enlarged liver, but does not usually involve the gallbladder.

The appearance of her markedly thick gallbladder, along with her low blood counts, raised the concern for cancer.

She was observed on antibiotics, and further tests were taken. The tests for viral hepatitis came back negative, as did her blood culture, which ruled out typhoid fever and other bacterial illnesses.

The test for EBV, the virus that causes infectious mononucleosis (commonly called "mono") came back positive.

Infectious mononucleosis is most common in adolescents and young adults, and usually presents with fever, sore throat, low energy, and enlarged lymph nodes. It can often take several weeks to resolve. It usually presents with elevation in liver enzymes, but does not typically involve the gallbladder.

As there was no reason to keep taking the antibiotics, they were stopped, and she continued to be monitored in the hospital.

Her fever lasted two more days and then resolved, and her overall energy level improved. Her bilirubin and liver enzymes started to drop. Her abdominal ultrasound was repeated four days after her initial one, and the thickness of her gallbladder had decreased remarkably. A few days later, before she was discharged, her gallbladder was almost back to normal.

Her doctors reviewed the medical literature and found there have been about 20 reported cases of patients with infectious mononucleosis presenting with inflammation of the gallbladder.

Because it is a viral illness, "mono" resolves on its own without any specific treatment. Thankfully, the patient improved within two weeks and went back to studying for her SATs.