Epstein-Barr Virus (EBV), a member of the Herpesviridae family, is globally prevalent. While most children infected are asymptomatic, around 25% develop infectious mononucleosis (IM) characterized by fever, sore throat, and lymphadenopathy. IM can lead to multisystem involvement, including rare pulmonary manifestations like pneumonia. In literature, pulmonary nodules are exceedingly rare in immunocompetent children. Here we discuss a unique case of nodular lung findings in a patient with IM to highlight the diverse clinical manifestations of EBV infection.

An 11-year-old male previously healthy male presented to the emergency room (ER) with one week of fever, neck pain and sore throat. In the ER, vitals were unremarkable. Physical examination revealed a non-fluctuant, right larger than left submandibular lymphadenopathy with mild tenderness to palpation. CT soft tissue and neck with IV contrast revealed bilateral cervical and supraclavicular lymphadenopathy. CT chest noted multiple small scattered noncalcified pulmonary nodules. Clinical symptoms work-up was significant for WBC 15.4 TH/cmm, CRP 3.00 mg/dL, LDH mildly elevated at 394 U/L, and uric acid 6.0 mg/dL. Histoplasmosis and Bartonella antibody panels were negative. ENT was consulted and he was started on 0.15 mg/kg of Decadron for four doses to minimize airway swelling and IV Unasyn for infectious coverage. EBV serologies were also obtained showing IgG positive, IgM positive, Nuclear Ag IgG negative, and Early Ag IgG positive, indicating the patient’s lymphadenitis and suspicious apical pulmonary nodules were secondary to infectious mononucleosis. The patient’s family was notified of the diagnosis and strict return precautions and counseling were given.

Pulmonary manifestations in EBV-related illnesses are relatively uncommon, but can present as pneumonia. In immunosuppressed patients, EBV can cause lymphoproliferative disorders (PTLD) or lymphoma which can present as pulmonary nodules. In literature, pulmonary nodules rarely occur in an immunocompetent child. Pulmonary nodules could be part of the clinical presentation of IM in otherwise healthy children and in an appropriate setting, a close follow-up with complete resolution is adequate to rule out malignancy. Our patient was managed conservatively with close monitoring and regular follow- up. The decision on follow up imaging should be individualized based on clinical signs and symptoms and imaging characteristics. The discussed case emphasizes the importance of understanding and recognizing the variable presentations of EBV even in the most unlikely of patients.