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12 year child diagnosed with recurring glandular fever. Is this related to hepatitis?

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My daughter is nearly 12 years old and 3 years ago I believe she had glandular fever taking 8 months to recover. Unfortunately, I believe she was not diagnosed properly by her GP. Firstly, she was acutely ill for approximately 2 weeks with an extremely sore pussy throat, swollen glands and extreme fatigue and weakness. The fatigue and intolerance to exercise continued for up to 8 months. She was prescribed repeated courses of antibiotics for supposed "tonsillitis" however the general fatigue and malaise with intermittent swollen glands continued for up 8 weeks. It was at this time that I insisted on her being tested for glandular fever as the Doctor had not thought this necessary up until this time. she tested positive for having a history a glandular fever, however she had never been ill like this before and the only time she had been symptomatic was in the previous two months. I believe if the blood test had been taken 2 months earlier then it would have show active glandular fever.
Over the next 3 years, my daughter returned to swimming competition at a state level and has just withdrawn from her first national competition due to what I believe my be a recurrence of the glandular fever. Having achieved this though, she has never had the same good health she had before the glandular fever 3 years ago. She has regularly suffered from intermittent swollen glands sometimes as big as a lemon in her neck! I have routinely checked her neck for swollen glands and if they are swollen we have made her rest from swimming training for 3-5 days. Any late nights have also been enough to cause her glands to swell and it would take her days to recover from a late night. Hence, her well being and ability to compete at such a high level has been very tightly tuned by an excellent diet, lots of sleep and well supervised training loads with extra rest as needed.
So, here we are 3 years later and she has been ill for the past 5 weeks and spent most oft his time on the couch. Her 1st symptoms were sudden tiredness, very swollen glands, high fever 38.5 plus and extreme lethargy. After 3-4 days she complained of acute pain in her upper right quadrant and on each side as well as the front of her abdomen. She also complained of a sharp pain if she took a XXXXXXX breath. Being an ex-nurse I was immediately alarmed by this pain and took her to the GP. The GP said the pain was muscular due to a virus and said her liver did not palpate as being enlarged. After missing school and resting totally for 10 days her fever stopped and she seemed to be recovering from what we thought had been a virus. She returned to swimming training albeit at a reduced training load. This in hindsight was probably the worst thing she could have done but we did not realise that she probably had a recurrence of glandular fever at this stage. After one week of appearing to be on the mend she crashed suddenly with the return of all the pains mentioned above, hight temperature this time 39.5 and extreme fatigue. After 2 days I took her back to the Doctor (a different GP at the same clinic) who did some bloods that showed elevated LFTS & ESR. She was diagnosed with hepatitis of unknown cause?????some virus that she would recover from is what we were told. With rapid weight loss (3 kg in 2-3 weeks from 34kg to 31kg) and continuing night time temps 38.5 - 39.5 the GP re-tested her bloods and did a abdo u/sound that showed widespread enlarged mesenteric lymphnodes and increased liver echogenicity. The LFTS were coming down but her ESR was slightlly increased on a few days prior (69 from 60) and her HB had dropped from 120 to 110 also in 3 days. We then took her to the childrens' hospital 1 week ago armed with her blood tests and u/sound. She has had more bloods done and we
are waiting for an appointment for her to see a paediatric gastroenterologist. My daughter remains the same although she is slightly better during the day than she was a few weeks ago. She is still very unwell at night with headaches, stiff neck, high temps although lower now around 37.6 -37.8 and general tiredness all the time. She has managed to regain 0.2kg this week but still has no appetite to eat anything and it is a real battle to get her to eat. She also has a very white coated tongue. PLEASE HELP! IS THIS A RECURRENCE OF HER GF? IT CERTAINLY SEEMS SO BUT CAN YOU GET HEPATITIS AS PART OF A RECURRENCE AND NOT THE ORIGINAL ATTACK? PLEASE ADVISE.

Posted Fri, 3 Aug 2012 in Child Health
Answered by Dr. Taher Kagalwala 5 hours later

I think that first of all, this is not a problem that pertains to an ENT specialist, which is what the flag mentions to the right of your query. I am a Pediatrician, and with your consent, may I address the question?

Glandular fever or what is medically known as Infectious mononucleosis is a viral illness caused by the Ebstein Barr Virus in about 85-90% of cases, but may also be caused by other rarer agents in the remaining 10%, which include toxoplasma, rubella, and even HIV. Some cases have no diagnosable organism.

Usually, primary glandular fever is self-improving over weeks, there being no definitive treatment that has been proved to be effective. Second or subsequent attacks in people with a normal immunity are exceedingly rare, and usually without symptoms.

The illness profile of your daughter does not clearly fit into this diagnosis. It may be useful to suggest to the doctor a confirmatory test such as the EBV viral culture, which may take 4-6 weeks, but will rest your mind about her diagnosis. The occurrence of hepatitis in EBV is not very common. You have not mentioned her liver enzymes, esp. the ALT, the AST, the GGTP and the ALP (these are, respectively, the alanine aminotransferase, the aspartate aminotransferase, the gamma glutamyl transpeptidase and the alkaline phosphatase) ... and her serum bilirubin levels, which will denote the extent of her liver affection.

I also need to know if other causes of gland enlargement and liver inflammation have been ruled out, e.g. Hepatitis B, which can cause this type of illness, though rarely without jaundice.

Your specific question was if a recurrence of glandular fever can cause the hepatitis but not the original attack is not something I am able to answer since hepatitis itself is rare in glandular fever, affecting only about 10% of patients, and recurrences of GF are usually, as I said earlier, without symptoms (unless the child herself has some immune disorder).

A good place to start would be to see an infectious diseases doctor rather than a gastroenterologist. In addition, your primary pediatrician should conduct the following additional tests - a full blood count, a liver ultrasound, and perhaps, refer her for a gland biopsy, which would uncover the exact diagnosis without the strain of continuing uncertainty.

The coated tongue may or may not be a specific sign. It may simply suggest a reduced attention to cleaning, or it may point to a co-existing fungal infection, or it may be a sign of viral fever.

Please revert to me with the questions I have asked of you: the results of the liver function tests, the details of her blood counts, and if possible, the result of a recent abdominal ultrasound.

Thank you for bearing with me on this long answer. I need to understand the problem a little more before I can dispense with meaningful advice. In the meanwhile, be calm and continue caring for your precious one as only a mother can.

Be blessed, and do accept my good wishes for her speedy recovery.

-Dr. Taher
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