P384 More than meets the eye

Background A teenager with periorbital edema can be a challenging diagnosis since there are numerous diseases that can have this sign, both infectious and non-infectious Case-report A 14-year-old female presents in the Emergency Department (E.D.) with a bilateral periorbital edema and fatigue that started 5 days before. She denied itchiness, visual complaints, ocular pain or eye discharge. There was no eyelid inflammation and no peripheral edema. Blood tests were normal and proteinuria was excluded. She was sent home with an antihistamine, but came back to the E.D. 3 days later (day 8 of disease) with the same complaint. Apart from the periorbital edema and the fatigue, she had pharyngitis without tonsillar exudate, elevated aminotransferases and lactate dehydrogenase and relative lymphocytosis (52.9%). The Paul-Bunnel test was negative and the tests for viral capsular antigens (VCA IgM and IgG) for Epstein-Barr virus (EBV) were negative. She developed fever between day 8 and 10. She was referred to a Pediatric consultation and reevaluated at day 11. She still maintained periorbital edema and had a painful palpable liver edge. The abdominal ultrasound showed hepatosplenomegaly. She repeated the blood tests two weeks after and had lymphocytosis (5190/uL; 66.5%), elevated aminotransferases and lactate dehydrogenase, and she was EBV VCA IgM and IgG positive, which confirmed active infectious mononucleosis. The testing for autoimmune disease, thyroid disease, and human immunodeficiency virus (HIV) and hepatitis viruses were negative. Conclusion EBV can affect virtually any organ system and periorbital edema can be the first symptom of infectious mononucleosis. This is an atypical case for there was a lack of other more classic symptoms, like sore throat and lymphadenopathy, and the serology was negative at the beginning of the disease. This lead to a more exhaustive investigation in order to exclude autoimmune and thyroid diseases and viral infections like hepatitis and HIV.