Medical Mystery: Abdominal Pain — The Answer

Abstract

The Medical Mystery in the August 4 issue¹ involved a 40-year-old man who presented with a four-day history of pain in the left upper quadrant of the abdomen, accompanied by fatigue, fever, sweating, and sore throat. A computed tomographic scan was obtained; it revealed multiple splenic infarcts ( Figure 1 ) due to acute infectious mononucleosis. Laboratory studies on admission showed an elevated white-cell count (13,800 per cubic millimeter) with 51 percent lymphocytes, 31 percent of which were atypical, as well as the following abnormal liver-function values: aspartate aminotransferase, 123 U per liter; alanine aminotransferase, 244 U per liter; alkaline phosphatase, 216 U per liter; and total bilirubin, 0.9 mg per deciliter (15.4 μmol per liter). Transthoracic echocardiography revealed no abnormalities, and blood cultures showed no growth. An initial monospot test was negative, as were serologic studies for cytomegalovirus and hepatitis A, B, and C viruses. At a follow-up visit with a primary care physician one week later, a repeated monospot test was positive, and a polymerase-chain-reaction analysis for Epstein–Barr virus DNA from the previous week was found to be positive.