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Case records of the Massachusetts General Hospital. Case 36-2014. An 18-year-old woman with fever, pharyngitis, and double vision.

Dr. Nicholas A. Morris (Neurology): An 18-year-old woman was admitted to this hospital because of fever, pharyngitis, facial swelling, and diplopia. The patient had been well until 2 weeks before the current admission, when a headache and sore throat developed, without a fever. On evaluation at her physician’s office, a rapid test for streptococcal pharyngitis was negative, and she returned home. During the next 2 days, throat pain persisted and oral intake decreased. She was admitted to the observation unit of another hospital because of dehydration, weakness, and fevers, with a temperature as high as 39.4°C. A chest radiograph was normal. The patient reportedly had a white-cell count of less than 2000 per cubic millimeter, positive tests for IgG and IgM antibodies to Epstein–Barr virus (EBV)–specific viral capsid antigen and antibodies to EBV nuclear antigen, and negative tests for heterophile antibodies, influenza A and B viruses, and IgM and IgG antibodies to cytomegalovirus (CMV). A pharyngeal culture grew group C streptococcus. Cultures of the blood and urine were sterile. A diagnosis of infectious mononucleosis with possible bacterial superinfection was made. Intravenous fluids were administered, and her condition improved. On day 2, treatment with erythromycin was begun and she was discharged home. ‎Nine days before the current admission, trismus, pain on opening the mouth, and swelling on the right side of the face and jaw developed. The patient returned to the emergency department of the same hospital; parotitis was diagnosed, and ibuprofen was administered. Pain persisted on the right side of the jaw and was associated with temperatures as high as 38.3°C and swelling and erythema of the right parotid gland and face. Six days before the current admission, the patient was seen at a second hospital; prednisone and narcotic analgesic agents were administered, and massage of the parotid gland was performed. She returned home. Fevers persisted, and edema of the right lateral side of the face and neck worsened. Three days later, she was seen by her physician and was admitted to the second hospital. Computed tomography (CT) of the head and neck reportedly revealed no evidence of retropharyngeal or peritonFrom the Departments of Medicine (K.R.O.), Pediatrics (K.R.O.), Radiology (J.M.J.), and Pathology (J.A.B.) and the Center for Global Health (K.R.O.), Mas‐ sachusetts General Hospital; the Depart‐ ments of Medicine (K.R.O.), Pediatrics (K.R.O.), Radiology (J.M.J.), and Pathol‐ ogy (J.A.B.), Harvard Medical School; and the Department of Ophthalmology (S.K.F.), Massachusetts Eye and Ear Infir‐ mary — all in Boston.