Sir,

Infectious mononucleosis, caused by the human B-lymphotropic herpes Epstein–Barr virus, commonly affects adolescents and young adults. The incubation period from contact to infection is normally 6–7 weeks. Cutaneous manifestations are a frequent feature of the disease, with various presentations possible during the course of the infection [1].

A first-year high school student presented with periorbital edema and fever persisting for fourteen days. The patient developed a generalized burning rash with facial involvement during the course of the illness. Upon physical examination, the patient displayed periorbital edema, widespread maculopapular exanthem, and joint involvement, particularly affecting the ankles and wrists. Laboratory findings showed a positive monospot test, elevated C-reactive protein (34), and fever (38°C). The patient presented with sleep disturbance, mild pharyngitis, joint pain, and dysuria, without respiratory or gastrointestinal involvement. Treatment included clarithromycin 500 mg 1 tablet daily for seven days prior to the rash and added antihistamines subsequently, and prednisolone 25 mg daily for seven days. The patient was referred to the pediatric department for follow-up. Blood tests confirmed EBV infection with lymphocytosis (WBC 12,000–18,000/mL, >10% atypical lymphocytes), mildly decreased platelets, and elevated liver enzymes (alanine transaminase (ALT)/aspartate aminotransferase (AST) 2–3x normal). EBV serology showed positive VCA IgM antibodies. The topical treatment regimen was comprehensive and location-specific. For the face, group II topical corticosteroids were prescribed, following a tapering schedule. The trunk and extremities were treated with group a IV topical corticosteroid, following a similar tapering schedule. The patient was well informed. After one month of follow-up at the pediatric department, a complete resolution of hepatic dysfunction was observed, with normalization of all liver blood tests: ALT decreased to 18, alkaline phosphatase to 73, bilirubin to 6, and LDH to 147 [1–3].

Figure 1: The patient presented with periorbital edema and widespread maculopapular exanthem affecting the face, torso, and upper extremities.

Cutaneous manifestations frequently occur in patients with IM. Two main types of skin rashes typically occur in patients with acute IM. The first is a slight erythematous maculopapular eruption of 24–48 hours duration, which occurs in 5–15% of all patients with IM. The second is a severe pruritic maculopapular rash in almost all patients receiving antimicrobial treatment. Other less frequent cutaneous manifestations of EBV infection in IM are the Gianotti–Crosti syndrome, unilateral laterothoracic exanthem, immune thrombocytopenic purpura, cold urticaria, and erythema nodosum. Palatal petechiae occur on the hard and soft palate in 50% of patients during the first several days of IM. The administration of antimicrobial treatment to a patient with infectious mononucleosis caused by an EBV infection should be avoided. Skin rash occurs in 90–100% of all IM patients treated with ampicillin or amoxicillin. Normally, the skin rash develops several days after the administration. While the skin rash is well-known after treatment with ampicillin and amoxicillin, it may also appear after treatment with other antibiotics [4–7].

This case illustrated typical cutaneous manifestations in IM, with the possibility that concurrent clarithromycin administration may have influenced the presentation. The management approach demonstrated the effectiveness of combined systemic and topical corticosteroid therapy in managing severe cutaneous manifestations.

REFERENCES

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2.Chovel-Sella A, Ben-Amitai D, Banin E, Gardner R, Smith P, Wilson J, et al. Incidence of rash after amoxicillin treatment in children with infectious mononucleosis. Pediatrics. 2013;131:1424-7.

3.Ebell MH, Call M, Shinholser J, Gardner J. Epstein–Barr virus infectious mononucleosis. Am Fam Physician. 2016;94:372-9.

4.Thompson AE, Hanifin JM, Smith KJ. Drug-induced skin reactions in infectious mononucleosis. JAMA Dermatol. 2021;157:442-8.

5.Kang S, Lee JS, Park YM, Brown R, Davis T, Wilson M, et al. Long-term outcomes of cutaneous manifestations in EBV infection. J Clin Virol. 2022;88:104-11.

6.Chen M, Zhang L, Hong W, Park J, Lee K, Smith R, et al. Macrolide-induced exanthems in viral infections. N Engl J Med. 2020;382:1678-80.

7.Houssini GS, Douhi Z, Soughi M, Elloudi S, Baybay H, Moukafih B, et al. DRESS syndrome and liver involvement:A study of 72 patients. Our Dermatol Online. 2024;15:122-7.