Glandular fever, Epstein-Barr virus and hypoglossal nerve palsy
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A 9-year-old girl presented with a 4-day history of fever, coryza, sore neck and throat. She was tachycardic, normotensive and had sore bilateral enlarged cervical lymphadenopathy with halitosis. A diagnosis of glandular fever was made, and she was admitted for observation and intravenous fluids.
Blood tests showed an elevated C reactive protein of 73 and monocyte count (2.22×109/L) and a positive monospot. Epstein-Barr virus (EBV) serology was performed and was positive for EBV IgM but negative for EBV anti-Epstein-Barr nuclear antigen (EBNA) IgG, confirming acute infection.
During her admission, she developed isolated unilateral hypoglossal nerve palsy (figure 1). Neurological complications have been reported as a result of EBV1 but are most commonly facial nerve palsies. The aetiology is thought to be an autoimmune process causing localised inflammation2 and is exceedingly rare, with only a handful of case reports3 to date.
Figure 1
Hypoglossal nerve palsy by Dr J Derrick, Homerton University Hospital, 2019.
The lesion was on her right-hand side, causing right-sided tongue deviation.
She developed a tender hepatomegaly of 4–5 cm under the costal margin. Ultrasonographic appearance was normal and she clinically improved after a short course of high-dose steroids, which have been used in case reports; however, a recent Cochrane review suggests insufficient evidence for their efficacy in symptom control.3 4 The tongue palsy remained after 2 months, and a referral to neurology and Speech and Language Therapy (SALT) was made; an MRI head was performed which was normal.
Imaging is recommended in this context to exclude other underlying pathologies, such as a vascular event, tumour or demyelination/inflammatory process.
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