Description

A woman in her 20s visited our hospital with a chief complaint of eyelid oedema subsequent to fever and sore throat. Upper eyelid oedema (figure 1A) was observed in addition to fever of 39.8°C and painful neck lymphadenopathy. Blood examination revealed 7% of atypical lymphocytes and acute liver injury with aspartate aminotransferase 439 U/L and alanine aminotransferase 402 U/L, and echography demonstrated hepatosplenomegaly. She was diagnosed with infectious mononucleosis (IM). Her eyelid oedema almost disappeared 3 days after the admission prior to fever resolution (figure 1B). Epstein-Barr virus (EBV) immunoglobulin M at the time of admission revealed to be positive later; hence the diagnosis of acute EBV infection was made. She was relieved only with rest and symptomatic treatment and discharged from hospital 10 days later.

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Figure 1

(A) Bilateral upper eyelid oedema of young febrile woman. (B) It almost disappeared only 3 days after.

The mechanism or sensitivity and specificity are still unknown; however, bilateral upper eyelid oedema is one of the unique and classical manifestations of acute EB infection or IM. It was first reported in the 1950s and named ‘Hoagland sign’.1 The oedema is observed as a hypoechoic area and reported as dacryoadenitis.2 A rare case of a man and a similarly Japanese case also have been reported.3 4 It is interesting that this sign usually present only for acute few days of the clinical presentation,5 so there has been no literature describing the improvement process of the transient oedema. The differentials of acute bilateral upper eyelid oedema without general oedema reported to also include allergic reactions such as contact dermatitis or angioedema, Kawasaki disease, trichinosis and bilateral periorbital cellulitis.6 7 However, physicians may differentiate them according to associated symptoms and findings. We hope this case will help clinicians for the differential diagnosis of fever accompanied with no other specific symptoms or signs among young adults.