Atypical presentation of Epstein-Barr virus infectious mononucleosis with bilateral dacryoadenitis in an elderly patient: a case report.

BACKGROUND: Epstein-Barr virus (EBV) infection is a highly prevalent condition and the primary cause of infectious mononucleosis (IM), typically affecting adolescents and young adults. Although IM is generally self-limited, EBV may involve multiple organ systems, presenting with atypical or localized manifestations. Ocular involvement is uncommon and includes conditions, such as conjunctivitis, uveitis, and, more rarely, dacryoadenitis. Acute dacryoadenitis remains an infrequent manifestation of EBV infection and is most commonly reported in younger patients; its occurrence in elderly patients is particularly unusual.

CASE PRESENTATION: A 71-year-old woman presented with a 4-week history of bilateral upper eyelid edema following an episode of tonsillitis and cervical lymphadenopathy. Initial treatment with antibiotics and corticosteroids resulted in transient improvement, followed by relapse. Clinical examination revealed bilateral upper eyelid swelling with erythema, tearing, and S-shaped deformity, suggestive of lacrimal gland involvement. Laboratory investigations were unremarkable. As EBV infection was not included in the initial differential diagnosis, heterophile antibody testing was not obtained. Magnetic resonance imaging confirmed bilateral lacrimal gland enlargement without evidence of mass or infiltrative disease; whereas computed tomography imaging demonstrated unremarkable paranasal sinuses, with no significant abnormalities. Serological testing revealed positivity for Epstein-Barr virus viral capsid antigen IgM and IgG, consistent with recent infection. Given the transient response to short-term corticosteroids and select studies demonstrating the efficacy of prolonged therapy, oral prednisone was initiated at 1 mg/kg/day for the first week, followed by a three-week taper, resulting in rapid clinical improvement and complete resolution of symptoms. No recurrence was observed at 6-month follow-up.

CONCLUSIONS: This case expands current knowledge of Epstein-Barr virus infectious mononucleosis by demonstrating an atypical presentation with bilateral dacryoadenitis in an elderly patient. The clinical course underscores the challenges in distinguishing viral from bacterial etiologies and highlights the importance of accurate diagnosis to guide management, as corticosteroid therapy may be beneficial in selected cases.