Cytomegalovirus Primary Infection in an Immunocompetent Female with Mononucleosis Features: A Review of Mononucleosis-Like Syndromes

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Shohinee Sarma
Derek Henry Wallace Little
Tooba Ali
Emily Jones
Shariq Haider




The clinical triad of fever, pharyngitis, and lymphadenopathy was first described in 1889 as “glandular fever” and later defined as infectious mononucleosis. We present a case report and review of mononucleosis-like syndromes in an immunocompetent patient. The review of common etiologies includes Epstein-Barr virus (EBV), acute human immunodeficiency virus (HIV), human herpesvirus 6 (HHV-6), cytomegalovirus (CMV), and Toxoplasmosis gondii.

Case Vignette

A 37-year- old, immunocompetent female presented with a three-week history of fever, pharyngitis, fatigue, night sweats, and abdominal pain. Physical examination revealed hepatosplenomegaly, but no lymphadenopathy, rashes, or tender joints. Investigations showed lymphocytosis and a normal peripheral smear. A Hematology consultation excluded hematologic malignancy. Her CD4/CD8 ratio was 0.2 in keeping with a viral infection, but EBV monospot test was negative. Serology for hepatitis B and C were negative. Human immunodeficiency virus (HIV) testing was not done in the absence of risk factors. Quantitative PCR for CMV was positive with a value of 965.25 units/mL. The patient was diagnosed with CMV viremia and treated with a two-week course of valganciclovir with resolution of symptoms. A two-month follow-up revealed a normal complete blood count and resolving hepatosplenomegaly.


In immunocompetent patients presenting with symptoms of mononucleosis, the differential diagnosis should include EBV, CMV, HHV-6, acute HIV and Toxoplasmosis gondii. CMV commonly affects young patients and is less associated with tonsillitis, pharyngitis, and lymphadenopathy. HHV-6 can present with headaches, encephalitis, and abdominal pain. Consideration of acute HIV mononucleosis should prompt early serologic testing. Toxoplasmosis is often associated with undercooked food or cat excrement, requiring anti-IgM antibody testing to distinguish from EBV. Although EBV infectious mononucleosis may be suspected, the general practitioner should consider a complete review of other infectious etiologies.

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