Hoagland Sign as an Aid for Antimicrobial Stewardship—A Case Report

Abstract

Hoagland sign is an early and transient bilateral painless upper eyelid edema observed in patients with Epstein-Barr virus (EBV)-related infectious mononucleosis. This sign can predate the appearance of exudative pharyngitis and cervical lymphadenopathy. Usually, this sign disappears by first week of infection. Here, we describe the occurrence of late onset Hoagland sign in a 14-year old boy who presented to us on 10th day of fever. Hoagland sign appeared after 10 days from symptom onset in our patient. Despite persistence of fever, the presence of Hoagland sign which appeared prior to confirmation of EBV infection was a helpful indicator for stopping antibiotics. In view of tonsillar hypertrophy with potential airway compromise and biochemical parameters suggestive of possible secondary hemophagocytic lymphohistiocytosis, he was initiated on steroids with which defervescence and prompt resolution of symptoms occurred. EBV can present as acute undifferentiated febrile syndrome which might result in inappropriate use of antibiotics. This case highlights the importance of using clinical clues like Hoagland sign to optimize antimicrobial stewardship.

Hoagland sign in primary care

“…Periorbital oedema in the context of EBV-associated infectious mononucleosis was first described by Colonel Robert J. Hoagland in 1952 (Hoagland, 1952), hence it is eponymously known as Hoagland sign. The exact pathophysiology is not fully known; however, it is thought to occur due to disrupted lymphatic drainage around the eye due to EBV replication in nasopharyngeal lymphoid tissues (Nair et al., 2020). Hoagland sign can be an early clinical manifestation in EBV-associated infectious mononucleosis, usually preceding other symptoms.…”

“…Hoagland sign can be an early clinical manifestation in EBV-associated infectious mononucleosis, usually preceding other symptoms. Therefore, it may be useful in differentiating EBV-associated infectious mononucleosis from other infectious diseases with similar clinical manifestations (Nair et al., 2020).…”