Tongue Icterus, Rare Presentation of Infectious Mononucleosis

Source: NEJM

Case of tongue icterus in 12-year-old

A yellow tongue often goes way in its own time and in most cases is harmless. Only a few conditions causing yellow tongue, for example, jaundice are more serious and require treatment. A common cause of yellow tongue is build-up of skin cells and bacteria on the tongue. The build-up is often because of poor dental hygiene. Whereas jaundice is one of the few serious causes of yellow tongue. This article describes the case of a 12-year-old boy who presented to the hospital with jaundice, sclera, and tongue icterus with dark urine. The boy presented to the hospital with a 4-day history of sore throat, pallor, abdominal pain and dark urine with a history of 3 days.

Examination showed jaundice, scleral and tongue icterus (Panel A) and dark urine (Panel B). Similarly, laboratory studies showed decreased levels of haemoglobin and increased unconjugated bilirubin with normal lactate dehydrogenase level. According to the case study, laboratory findings showed haemoglobin level of 6.1 g per decilitre (reference range, 11.0 to 14.5), a “lactate dehydrogenase level of 6405 U per litre (reference range, 470 to 750), and an unconjugated bilirubin level of 115 μmol per litre (6.7 mg per decilitre; reference value, <12 μmol per litre [<0.7 mg per decilitre])”.

Investigations and diagnosis

Doctors further performed a direct antiglobulin test which was positive with presence of cold agglutinins. Urinalysis was positive for haemoglobin with no signs of granular casts or presence of red cells on microscopy.

Further testing for heterophile antibody was also positive. Qualitative polymerase-chain reaction (PCR), serologic tests for Epstein-Barr virus and quantitative PCR showed a viral load of 36,000 IU per millilitre.

Based on these findings, doctors diagnosed the patient with EBV-induced acute haemolytic anaemia. Fever, malaise, sore throat and lymphadenopathy are common presentations of infectious mononucleosis caused by EBV. However, acute haemolytic anaemia is a rare complication that occurs in only 1% to 3% of cases. Doctors treated the patient with high-dose intravenous methylprednisolone for 2 days, followed by oral prednisone with a tapering dose over the next 7 weeks. The patient was also given 5 units of packed red cells. His recovery period was uneventful with gradual resolution of tongue icterus as the levels of bilirubin normalised.


An Icteric Tongue

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Dr. Aiman Shahab is a dentist with a bachelor’s degree from Dow University of Health Sciences. She is an experienced freelance writer with a demonstrated history of working in the health industry. Skilled in general dentistry, she is currently working as an associate dentist at a private dental clinic in Karachi, freelance content writer and as a part time science instructor with Little Medical School. She has also been an ambassador for PDC in the past from the year 2016 – 2018, and her responsibilities included acting as a representative and volunteer for PDC with an intention to make the dental community of Pakistan more connected and to work for benefiting the underprivileged. When she’s not working, you’ll either find her reading or aimlessly walking around for the sake of exploring. Her future plans include getting a master’s degree in maxillofacial and oral surgery, settled in a metropolitan city of North America.


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