Clinical diagnosis
Case 122
【Progress】She got antibiotics and steroid for approximately one week. Her symptoms were getting relieved and laboratory test revealed improvement of liver function, leading to be discharged.
【Discussion】
There are minute crypts on the surface of tonsil that is susceptible to be infected by microorganism. Tonsils are first line immune system protecting our body from infectious bacteria and virus. There are two palatine tonsils, lingual tonsil, two auditory (Eustachian) tube tonsils and epi-pharyngeal (adeno) tonsil. These tonsils situate like a circle in oral and nasal lumen, called Waldeyer’s ring. In other words, palatine tonsil and lingual tonsil situate to play a role of gatekeeper to microorganism infection via oral lumen, auditory duct tonsil does via auditory duct and epi-pharyngeal tonsil does via nasal lumen. In our patient, CT showed marked swollen palatine tonsils and swollen epi-pharynx tonsil, implying tonsillitis.
There are five kinds of mononuclear cells in blood; T cell, B cell, natural killer cells, monocytes and macrophages. Tonsils contain M cells, B cells and T cells. M cells sample antigens and transport to the mucosa associated lymphoid tissue (MALT) and act a trigger or initiation of immune system. B cells alerted by M cells secret Ig A and T cells alerted by M cells secret Ig G, and leucocytes alerted by M and T cells infiltrate from blood and attack bacteria. Tonsillitis is caused by virus (adenovirus, rhinovirus, coronavirus) and bacteria (streptococcus, staphylococcus, streptococcus pneumoniae)( (1-4). In our patient, laboratory test revealed the count of lymphocytes and monocyte was much greater than that of leukocytes, implying our patient fell into infectious mononucleosis.
Infectious mononucleosis is caused by EB (Epstein Barr) virus which is type V of the eight known virus that infect to humans. EB virus infect to B cells and the proliferated infected B cells spread to the whole body throughout the reticular endothelial system including liver, spleen and lymph nodes (5-8). Fever is the immune response by cytokine release from B cells invasion by EB virus. In our patient, she experienced high fever, AST and ALT elevation, and swollen lymph node. T cells response is a key to control proliferating EB virus-infected B cells. A rapid and efficient T cells response leads to the control of the primary EB virus infection and lifelong suppression of EB virous infection. When the T cells response is not effective, excessive and uncontrolled proliferation of B cells occurs, inducing B cell lymphomas and Burkitt lymphoma (5-8). Fortunately, our patient was getting improved relatively rapidly and markedly, expecting the life-long control of this disease.
【Summary】
We present a twenty two-year-old female suffering from throat pain, swallowing disturbance, nausea, malaise, general fatigue and high fever. Laboratory test revealed elevation of the count of mononuclear cells: lymphocytes and monocytes, and elevation of liver deviation enzymes. CT showed marked tonsillitis: swollen palate tonsil and epi-pharynx tonsil. We should keep in mind that tonsils own crypts on the surface which trap the microorganisms and play a role of gatekeeper: palate tonsil and lingual tonsil for oral space and epi-pharynx and auditory tonsil for nasal and auditory space respectively. Tonsils contain immune cells: M cells which samples and transport to lymphocytes, B cells which secret Ig A and T cells which secret Ig G. Tonsillitis is caused by virus (adenovirus, rhinovirus, coronavirus) and bacteria (streptococcus, staphylococcus, streptococcus pneumoniae). Infectious mononucleosis is caused by EB (Epstein Barr) virus that infect to B cells and the proliferated infected B cells spread to the whole body throughout the reticular endothelial system including liver, spleen and lymph nodes. Fever is the immune response by cytokine release from B cells invasion by EB virus. When the T cells response is not effective, excessive and uncontrolled proliferation of B cells occurs, inducing B cell lymphomas and Burkitt lymphoma. Fortunately, our patient was getting improved relatively rapidly and markedly, expecting the control of this disease.
【References】
1."The Lymphatic System". act.downstate.edu. Retrieved 2017-01-29.
2.Chapter: Ear, Nose and Throat Histopathology in L. Michaels (1987). Normal Anatomy, Histology; Inflammatory Diseases. Springer London. ISBN 9781447133322.
3.Kato A et al, B-lymphocyte lineage cells and the respiratory system, Journal of Allergy and Clinical Immunology, Volume 131, pages 933-957, 2013
4."Tonsils Make T-Cells, Too, Ohio State Study Shows". Ohio State University. Ohio State University, Comprehensive Cancer Center. March 4, 2012. Retrieved March 27, 2014.
5.Vine LJ, et al. Characteristics of Epstein-Barr virus hepatitis among patients with jaundice or acute hepatitis. Aliment Pharmacol Ther. 2012 Jul;36(1):16-21. doi: 10.1111/j.1365-2036.2012.05122.x. Epub 2012 May 3.
6.Doğan I, et al. Acute hepatitis induced by Epstein-Barr virus infection: a case report. Turk J Gastroenterol. 2007 Jun;18(2):119-21.
7.Kofteridis DP, et al. Epstein Barr virus hepatitis. Eur J Intern Med. 2011 Feb;22(1):73-6. doi: 10.1016/j.ejim.2010.07.016. Epub 2010 Aug 19.
2018.9.26