{"paper_id":"47bc8322-7dfc-4d9d-813b-fba3ef6076be","body_text":"Case Report: Smudge Cells as a Valuable Prognostic Marker in Infectious Mononucleosis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Case Report: Smudge Cells as a Valuable Prognostic Marker in Infectious Mononucleosis Rajvardhan Kapshikar This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5487813/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Infectious mononucleosis is a very common infection. It is caused mostly by Epstein‒Barr virus (EBV), which belongs to herpesviridae or sometimes by the other member, Cytomegalovirus (CMV). It spreads through saliva. It has typical symptoms such as fever, extreme fatigue, sore throat and tonsillitis, enlarged lymph nodes in the neck, armpit, skin rashes, bodyache, and obstruction in the upper respiratory tract, and enlarged spleen and liver. It can lead to other complications such as anemia, encephalitis, meningitis, inflammation of the kidney, heart muscles, and rupture of the spleen. Laboratory diagnosis is costly. The physician may order heterophile antibody tests (monospot-test), EBV- or CMV- specific antibody tests, and viral DNA load. Patients with lower financial means do not want to go for such tests. This research indicates that a close examination of a blood sample for unusual lymphocytes and smudge cells (Downey cells) could also be the least expensive way to address this problem, although it is not a confirmatory test. Immunology Laboratory Diagnostics Applied & Industrial Microbiology Virology Pathology Infectious mononucleosis EBV herpes virus EBV smudge cells monospot-test Figures Figure 1 Figure 2 Introduction Infectious mononucleosis is caused by Epstein‒Barr virus (EBV). It is widespread and approximately ninety– to ninety-five percent of the world’s population is infected with EBV ( 1 – 4 ). Infectious mononucleosis can be caused by other viruses such as cytomegalovirus (CMV). Both belong to the Herpesviridae family ( 5 ). It can occur at any age and mainly affects mainly teenagers and young adults. The duration of EBV incubation is approximately one to two months. It typically presents as fever up to 102°F or higher, a sore throat with grayish patches on tonsils and below the tongue, and swollen lymph nodes in the neck region ( 6 ). The patient experienced severe fatigue, swollen tonsils, headache, and muscle aches. The skin develops maculopapular rashes. In many cases, the spleen and liver are enlarged (7,8). Many patients recover within a month, although fatigue lasts for several weeks. Currently, there is no vaccine available, and it is almost impossible to avoid its infection throughout life because of its contagious nature and widespread distribution ( 9 ). It spreads through the saliva of an infected person. In many patients' other complications such as encephalitis, and breathing complications may develop. It can be diagnosed by detection of antibodies against capsid proteins or nucleic acids. The viral load can be checked via quantitative PCR ( 3 ). The complete blood count (CBC) typically reveals lymphocytosis ( 6 ). In the case of CMV infection, the levels of only SGOT enzymes may be increased, whereas in the case of CMV infection, both SGOT and SGPT levels are increased ( 10 ). Ultrasonography may help to detect hepatosplenomegaly and swollen lymph nodes. MRI can be used to assess encephalitis ( 11 ). In the case of infection, physical checks by medical professionals and heterophile antibodies detection (Monospot test) are mostly ordered ( 12 ). Laboratory tests are costly, and many patients cannot afford them. In this study, we suggest that, along with CBC, where lymphocytosis is observed in autoanalyzer results, microscopic examination of a smear for more smudged cells (also called atypical lymphocytes) is more helpful. Atypical lymphocytes have weaker cell membranes; hence, when a blood smear is prepared, the cells have a smudged appearance ( 13 ). The diagnosis of chronic lymphocytic leukemia (CLL) is made using smudge cells. In patients with CLL, the proportion of smudge cells is consistently greater than 20% of the total lymphocyte count. In contrast, it is lower and varies over time in the case of infectious mononucleosis ( 14 – 19 ). The symptoms of infectious mononucleosis differ from those of chronic lymphoblastic leukemia. Case Report Clinical vignette The parents visited our laboratory for guidance along with a five-year-old child suffering for the previous month with an extreme fever of 107°F for at least a few hours. The patient was hospitalized for treatment for approximately fifteen days. He was sent home and again presented with the same symptoms four days later. He presented symptoms such as high-grade fever, headache, fatigue, sore throat, nasal congestion, and inability to pass through the stool. The child was convulsive and showed foam formation of saliva and complications in berating, hence being hospitalized. A child was unable to eat sufficient food for many days because of a throat infection. Four days after discharge, the patient again experienced symptoms and hence visited our center for guidance. Considering the conditions of the parents and child, I decided to perform a blood smear analysis. He had a sore throat with grayish patches on the palate and pharynx along with the previously shown symptoms in Fig. 1. He had shown convulsions one day before visiting the center. Methods The child was so restless and hence not allowed to collect the blood from the veins. A drop of blood was collected from the tip of the finger directly on the slide and a smear was prepared. The smear was air-dried and fixed with methanol for one minute. The samples were stained with field stain B, followed by gentle washing with tap water and then with field stain A for two minutes each respectively. Results The CBC reports were prepared in another laboratory ordered by physicians. It was performed at the time of admission and four days after the admission were as follows. The CBC at the time of admission of the patient showed the cell count as WBCs (44.12x10 9 /L, [4-9x10 9 ]), neutrophils (35.26x10 9 /L, [2-7x10 9 ]), lymphocytes (6.25x10 9 /L, [0.6–4.1 x10 9 ]), RBCs (4.32x10 9 /L, [3.5–5.5 x10 12 ]), hemoglobin (11.7 g/dL, [12–16]), HCT (32.6%, [36–48]), MCV (75.5 fL, [80–99]), MCH (27.1 pg, [26–32]), MCHC (35.9 g/dL, [32–36]), RDW CV (13.5%, [11.5–14.5]), RDW SD (40.9 fL, [37 − 5]), platelets (441x10 9 /L, [150–450 x10 9 ]), MPV (8.0 fL, [7.4–10.4]), PDW (15.4, [10–17]), PCT (0.355%, [0.1–0.28]), P-LCC (61x10 9 /L, [30–90]), and P-LCR (13.7%, [13–43]). Pathologists called this neutrophilic leukocytosis. The CBC at the time of admission of the patient showed the cell count as WBCs (16.86 x10 9 /L, [4-9x10 9 ]), neutrophils (13.0x10 9 /L, [2-7x10 9 ]), lymphocytes (2.15x10 9 /L, [0.6–4.1 x10 9 ]), RBCs (4.45x10 9 /L, [3.5–5.5 x10 12 ]), hemoglobin (12.1 g/dL, [12–16]), HCT (33.3%, [36–48]), MCV (75.0 fL, [80–99]), MCH (27.3 pg, [26–32]), MCHC (36.4 g/dL, [32–36]), RDW CV (13.3%, [11.5–14.5]), RDW SD (39.9 fL, [37 − 5]), platelets (404x10 9 /L, [150–450 x10 9 ]), MPV (8.1 fL, [7.4–10.4]), PDW (15.3, [10–17]), PCT (0.326%, [0.1–0.28]), P-LCC (54x10 9 /L, [30–90]), and P-LCR (13.5%, [13–43]). Blood smear analysis The blood smear was prepared via the above-mentioned field staining method. It was performed approximately fifteen days after admission and four days after discharge. Red blood cells were hypochromic and normocentric and consistent with the cell count of an automated machine. Although the leucocyte count was normal, the blood smear revealed many smudge cells. Representative smudge cells are shown in Fig. 2. Urine analysis Clear pale urine was collected. It is a pH of 6.0 [6-7.5], and a specific gravity of 1.015 g/mL, [1.005–1.030]. Traces of urobilinogen, bilirubin and ketone were detected, whereas proteins, glucose, red blood cells (RBCs), and white blood cells (WBCs) were not detected via indicator paper strips. Microscopic observation revealed no blood cells, such as red blood cells (RBCs) or leucocytes. It did not contain crystals, pus cells, urinary casts, or Candida cells. Biochemical tests The serum creatinine level was 0.3 mg/dL, [0.3–0.7]), serum sodium level was 136.9 mmol/L, [130–148]) (4.4 mmol/L, [3.5–5.5]), and the inflammation marker CRP level was 29.34 mgs/L, [< 10]). MRI It was performed before visiting our laboratory. Radiologists reported cerebral edema, and altered signal changes in the right temporal, parietal, occipital-temporal, cortical, and subcortical regions, which suggested gyral edema, and post-ictal changes. X-ray The radiologists had marked prominent bronchovascular markings suggesting bronchitis. Ultrasonography It was performed at another laboratory before arriving at our laboratory. Ultrasonography revealed minimal hepatomegaly, minimal ascites and enlarged lymph nodes around the umbilical region. Right renal Agenesis was noted. The spleen and pancreas were normal. The gall bladder revealed echogenic sludge. Culture tests Cerebrospinal fluid was collected at the hospital and analyzed by a trained pathologist at another pathology laboratory. CSF was negative for Gram staining and acid-fast staining. CSF was inoculated on blood agar and MacConkey agar plates and no growth was observed for thirty-six hours. There was no bacterial growth in the culture. No other significant changes were noted by the pathologists. Discussion When treating a patient suspected of having infectious mononucleosis, the doctor typically applies the Hoagland criteria ( 6 ). The physical examination of patients is performed for fever, tonsillitis, grayish patches below the tongue, tonsils and throat region, palpable lymph nodes in the neck region, and a palpable inflamed spleen. Physicians may ask for CBC, and a monospot test for the detection of heterophile antibodies. Quantitative PCR can be used to determine the virus titer. To check for any issues, the doctors could request more supportive tests, such as brain magnetic resonance imaging (MRI), and abdominal and neck ultrasonography. However, the common symptoms may lead to misdiagnosis with other viral, bacterial and fungal infections. In the case of infectious mononucleosis, the lymphocyte count is fifty percent of the total leucocyte count and ten percent of the atypical lymphocyte count. Patients in the current case study were reluctant to undergo viral titers testing because of the expense, and although the concerned doctors performed numerous tests before reaching a diagnosis, they were unable to conclude that the patients had infectious mononucleosis. Many small- and medium-sized diagnostic laboratories lack the funds necessary to perform DNA and antibody testing. The presence of smudge cells and atypical lymphocytes, which can be utilized when patients cannot pay for the expensive diagnoses, is reported in this study. Although antibody detection against viral proteins and viral DNA by quantitative PCR is advised for virus confirmation. Conclusion Physicians and pathologists should conduct a complete blood count and blood smear analysis for atypical lymphocytes and smudge cells when clinical examination indicates symptoms of infectious mononucleosis. Analyzing lymphocytosis through a total blood cells count, examining smudge cells and atypical lymphocytes on a blood smear are fast and cost-effective methods for investigating these conditions. Declarations Ethical consent Consent for publishing the data for the case study was obtained from the patient’s parents. This study did not intend for a drug trial. Source of financial support All the costs were financially supported by the Orange Diagnostics Clinics and Research Centre, Kolhapur, Maharashtra, India. This study did not receive any external funding. Conflict of interest The author reports no conflicts of interest in this work. Acknowledgment We thank the Orange Diagnostics Clinics and Research Centre, Kolhapur, for publishing this work. I thank the parents of the patient for their kind support and for providing all the previous reports. 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BMC Public Health 912. https://doi.org/10.1186/s12889-020-09049-x Ishii T, Sasaki Y, Maeda T, Komatsu F, Suzuki T, Urita Y (2019) Clinical differentiation of infectious mononucleosis that is caused by Epstein–Barr virus or cytomegalovirus: A single-center case–control study in Japan. J Infect Chemother 25(6):431–466. https://doi.org/10.1016/j.jiac.2019.01.012 Hoagland R (1965) Criteria for a diagnosis of infectious mononucleosis. Med Times 93:663–665 Doja A, Bitnun A, Ford Jones EL, Richardson S, Tellier R, Petric M, Heurter H et al (2006) Pediatric Epstein–Barr virus-associated encephalitis: 10-year review. J Child Neurol. ;21(5):384–391. https://doi.org/10.1177/08830738060210051101 Bartlett A, Williams R, Hilton M. Splenic rupture in infectious mononucleosis: A systematic review of published case reports. Injury. 2016; 47 (3):531–538. https://doi.org/10.1016/j.injury.2015.10.071 Zhong L, Krummenacher C, Zhang W, Hong J, Feng Q, Chen Y et al (2022) Urgency and necessity of Epstein–Barr virus prophylactic vaccines. npj Vaccines Nat Res 7(1):159. https://doi.org/10.1038/s41541-022-00587-6 Sachithanandham J, Kannangai R, Pulimood SA, Desai A, Abraham AM, Abraham OC et al (2014 Jul-Sep) Significance of Epstein–Barr virus (HHV-4) and CMV (HHV-5) infection among subtype-C human immunodeficiency virus-infected individuals. Indian J Med Microbiol 32(3):261–269. https://doi.org/10.4103/0255-0857.136558 Hou R, Wu J, He D, Yan Y, Li L (2019) Anti-N-methyl-D-aspartate receptor encephalitis associated with reactivated Epstein–Barr virus infection in pediatric patients: Three case reports. Med (Baltim) 98(20):e15726. https://doi.org/10.1097/md.0000000000015726 Schuster V, Kreth HW (1992) Epstein–Barr virus infection and associated diseases in children. II. Diagnostic and therapeutic strategies. Eur J Pediatr 151(11):794–798. https://doi.org/10.1007/bf01957926 Higuchi T, Eiki O, Hiroshi H, Kenta I (2021) Smudge cells due to infectious mononucleosis. IDCases 23:e01057. https://doi.org/10.1016/j.idcr.2021.e01057 Go RS (2009) Smudge cells, serum albumin, and prognosis in B-cell chronic lymphocytic leukemia. Journal of Clinical Oncology. July 6;27(12) https://doi.org/10.1200/JCO.2009.23.8188 Gulati G, Ly V, Uppal G, Gong J (2017) Feasibility of Counting Smudge Cells as Lymphocytes in Differential Leukocyte Counts Performed on Blood Smears of Patients with Established or Suspected Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma. Lab Med 48(2):137–147. https://doi.org/10.1093/labmed/lmx002 Jerez J, Ernst DM (2020) High percentage of smudge cells in a patient with COVID19: Rediscovering their utility. eJHaem 1(1):374–375. https://doi.org/10.1002/jha2.52 Nowakowski GS, Hoyer JD, Shanafelt TD, Geyer SM, LaPlant BR, Call TG et al (2007) Using smudge cells on routine blood smears to predict clinical outcome in chronic lymphocytic leukemia: A universally available prognostic test. Mayo Clinic Proceedings. ;82(4):449–453. https://doi.org/10.4065/82.4.449 Nowakowski GS, Hoyer JD, Shanafelt TD, Zent CS, Call TG, Bone ND et al (2009) Percentage of smudge cells on routine blood smear predicts survival in chronic lymphocytic leukemia. J Clin Oncol 27(11):1844–1849. https://doi.org/10.1200/jco.2008.17.0795 Sall A, Seck M, Fall S, Sall FB, Faye BF, Ndiaye FS et al (2022) Smudge cells percentage on blood smear is a reliable prognostic marker in chronic lymphocytic leukemia. Hematol Transfus Cell Therapy 44(1):63–69. https://doi.org/10.1016/j.htct.2021.04.002 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-5487813\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":true,\"archivedVersions\":[],\"articleType\":\"Case Report\",\"associatedPublications\":[],\"authors\":[{\"id\":380288949,\"identity\":\"b3b93ffe-68ad-46a4-bebd-24c595e0fe6a\",\"order_by\":0,\"name\":\"Rajvardhan Kapshikar\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEUlEQVRIie3PMUvDQBTA8VcOziV2fiGQfALhlUC0Sz6G85WCt6ToJIEOPSjkO0gGv4JF6HxQsEs/QCAO7eKcSVzUXopIhiY6Ct6fEO7C+/EIgM32B8PvVwHA3j8+/fqst78l4HAWHoj4iUCDjFR96SKuOt1Vwyy+7pfzly06XN5frnZmS+yfqePEg5MQ3Ww8vHt+OidCZ7Ior8iQcRjp48QHDogbRlSICAXhZJGLmujRsp2wN9zMDJGvqAXJQS6rTuIB54jpypAkcpUWIvCS7i3unPMLTNfkFsmt11N68OAlN2Zb+7/gOmMl0pT6hVzWJAhy+VhVaey3EWDmweYHOkxSy/hXvap5C1T3tM1ms/2/9nkyWohVG9WAAAAAAElFTkSuQmCC\",\"orcid\":\"\",\"institution\":\"Orange Diagnostics Clinics and Research Centre, Kolhapur, Maharashtra India\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Rajvardhan\",\"middleName\":\"\",\"lastName\":\"Kapshikar\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2024-11-20 05:34:03\",\"currentVersionCode\":1,\"declarations\":{\"humanSubjects\":true,\"vertebrateSubjects\":false,\"conflictsOfInterestStatement\":false,\"humanSubjectEthicalGuidelines\":true,\"humanSubjectConsent\":true,\"humanSubjectClinicalTrial\":false,\"humanSubjectCaseReport\":true,\"vertebrateSubjectEthicalGuidelines\":false},\"doi\":\"10.21203/rs.3.rs-5487813/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-5487813/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":69830658,\"identity\":\"b252f65d-460a-4da9-b7f4-ec49415fde0c\",\"added_by\":\"auto\",\"created_at\":\"2024-11-25 15:35:22\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":901807,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cem\\u003eGrayish patch marked by an arrow on the palate of an infected five-year-old child (after twenty days of hospitalization)\\u003c/em\\u003e\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Figure1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5487813/v1/64cc75e9015e73cb948b0446.png\"},{\"id\":69829702,\"identity\":\"d0486367-fa3c-4c5a-960e-b9a225eedf72\",\"added_by\":\"auto\",\"created_at\":\"2024-11-25 15:27:22\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":252355,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cem\\u003eSmudge cells (450X magnification and photographed with a mobile camera, and screenshots were cropped and enlarged to show details)\\u003c/em\\u003e\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Figure2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5487813/v1/b634e99f7f55dd0667e31bbe.png\"},{\"id\":69830659,\"identity\":\"9d4b92ae-7e1b-46d2-ba8b-496c980efdba\",\"added_by\":\"auto\",\"created_at\":\"2024-11-25 15:35:26\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":1248524,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5487813/v1/7af79c2f-0ed0-49f4-871c-61d21a1172a3.pdf\"}],\"financialInterests\":\"The authors declare no competing interests.\",\"formattedTitle\":\"\\u003cp\\u003e\\u003cstrong\\u003eCase Report: \\u003c/strong\\u003eSmudge Cells as a Valuable Prognostic Marker in Infectious Mononucleosis\\u003c/p\\u003e\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eInfectious mononucleosis is caused by Epstein‒Barr virus (EBV). It is widespread and approximately ninety\\u0026ndash; to ninety-five percent of the world\\u0026rsquo;s population is infected with EBV (\\u003cspan additionalcitationids=\\\"CR2 CR3\\\" citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e). Infectious mononucleosis can be caused by other viruses such as cytomegalovirus (CMV). Both belong to the Herpesviridae family (\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e). It can occur at any age and mainly affects mainly teenagers and young adults. The duration of EBV incubation is approximately one to two months. It typically presents as fever up to 102\\u0026deg;F or higher, a sore throat with grayish patches on tonsils and below the tongue, and swollen lymph nodes in the neck region (\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e). The patient experienced severe fatigue, swollen tonsils, headache, and muscle aches. The skin develops maculopapular rashes. In many cases, the spleen and liver are enlarged (7,8). Many patients recover within a month, although fatigue lasts for several weeks. Currently, there is no vaccine available, and it is almost impossible to avoid its infection throughout life because of its contagious nature and widespread distribution (\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e). It spreads through the saliva of an infected person. In many patients' other complications such as encephalitis, and breathing complications may develop. It can be diagnosed by detection of antibodies against capsid proteins or nucleic acids. The viral load can be checked via quantitative PCR (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e). The complete blood count (CBC) typically reveals lymphocytosis (\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e). In the case of CMV infection, the levels of only SGOT enzymes may be increased, whereas in the case of CMV infection, both SGOT and SGPT levels are increased (\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e). Ultrasonography may help to detect hepatosplenomegaly and swollen lymph nodes. MRI can be used to assess encephalitis (\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e). In the case of infection, physical checks by medical professionals and heterophile antibodies detection (Monospot test) are mostly ordered (\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e). Laboratory tests are costly, and many patients cannot afford them. In this study, we suggest that, along with CBC, where lymphocytosis is observed in autoanalyzer results, microscopic examination of a smear for more smudged cells (also called atypical lymphocytes) is more helpful. Atypical lymphocytes have weaker cell membranes; hence, when a blood smear is prepared, the cells have a smudged appearance (\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e). The diagnosis of chronic lymphocytic leukemia (CLL) is made using smudge cells. In patients with CLL, the proportion of smudge cells is consistently greater than 20% of the total lymphocyte count. In contrast, it is lower and varies over time in the case of infectious mononucleosis (\\u003cspan additionalcitationids=\\\"CR15 CR16 CR17 CR18\\\" citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e). The symptoms of infectious mononucleosis differ from those of chronic lymphoblastic leukemia.\\u003c/p\\u003e\"},{\"header\":\"Case Report\",\"content\":\"\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eClinical vignette\\u003c/h2\\u003e \\u003cp\\u003eThe parents visited our laboratory for guidance along with a five-year-old child suffering for the previous month with an extreme fever of 107\\u0026deg;F for at least a few hours. The patient was hospitalized for treatment for approximately fifteen days. He was sent home and again presented with the same symptoms four days later. He presented symptoms such as high-grade fever, headache, fatigue, sore throat, nasal congestion, and inability to pass through the stool. The child was convulsive and showed foam formation of saliva and complications in berating, hence being hospitalized. A child was unable to eat sufficient food for many days because of a throat infection. Four days after discharge, the patient again experienced symptoms and hence visited our center for guidance. Considering the conditions of the parents and child, I decided to perform a blood smear analysis. He had a sore throat with grayish patches on the palate and pharynx along with the previously shown symptoms in \\u003cb\\u003eFig.\\u0026nbsp;1.\\u003c/b\\u003e He had shown convulsions one day before visiting the center.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cp\\u003eThe child was so restless and hence not allowed to collect the blood from the veins. A drop of blood was collected from the tip of the finger directly on the slide and a smear was prepared. The smear was air-dried and fixed with methanol for one minute. The samples were stained with field stain B, followed by gentle washing with tap water and then with field stain A for two minutes each respectively.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003eThe CBC reports were prepared in another laboratory ordered by physicians. It was performed at the time of admission and four days after the admission were as follows.\\u003c/p\\u003e \\u003cp\\u003eThe CBC at the time of admission of the patient showed the cell count as WBCs (44.12x10\\u003csup\\u003e9\\u003c/sup\\u003e/L, [4-9x10\\u003csup\\u003e9\\u003c/sup\\u003e]), neutrophils (35.26x10\\u003csup\\u003e9\\u003c/sup\\u003e/L, [2-7x10\\u003csup\\u003e9\\u003c/sup\\u003e]), lymphocytes (6.25x10\\u003csup\\u003e9\\u003c/sup\\u003e/L, [0.6\\u0026ndash;4.1 x10\\u003csup\\u003e9\\u003c/sup\\u003e]), RBCs (4.32x10\\u003csup\\u003e9\\u003c/sup\\u003e/L, [3.5\\u0026ndash;5.5 x10\\u003csup\\u003e12\\u003c/sup\\u003e]), hemoglobin (11.7 g/dL, [12\\u0026ndash;16]), HCT (32.6%, [36\\u0026ndash;48]), MCV (75.5 fL, [80\\u0026ndash;99]), MCH (27.1 pg, [26\\u0026ndash;32]), MCHC (35.9 g/dL, [32\\u0026ndash;36]), RDW CV (13.5%, [11.5\\u0026ndash;14.5]), RDW SD (40.9 fL, [37\\u0026thinsp;\\u0026minus;\\u0026thinsp;5]), platelets (441x10\\u003csup\\u003e9\\u003c/sup\\u003e/L, [150\\u0026ndash;450 x10\\u003csup\\u003e9\\u003c/sup\\u003e]), MPV (8.0 fL, [7.4\\u0026ndash;10.4]), PDW (15.4, [10\\u0026ndash;17]), PCT (0.355%, [0.1\\u0026ndash;0.28]), P-LCC (61x10\\u003csup\\u003e9\\u003c/sup\\u003e/L, [30\\u0026ndash;90]), and P-LCR (13.7%, [13\\u0026ndash;43]). Pathologists called this neutrophilic leukocytosis.\\u003c/p\\u003e \\u003cp\\u003eThe CBC at the time of admission of the patient showed the cell count as WBCs (16.86 x10\\u003csup\\u003e9\\u003c/sup\\u003e/L, [4-9x10\\u003csup\\u003e9\\u003c/sup\\u003e]), neutrophils (13.0x10\\u003csup\\u003e9\\u003c/sup\\u003e/L, [2-7x10\\u003csup\\u003e9\\u003c/sup\\u003e]), lymphocytes (2.15x10\\u003csup\\u003e9\\u003c/sup\\u003e/L, [0.6\\u0026ndash;4.1 x10\\u003csup\\u003e9\\u003c/sup\\u003e]), RBCs (4.45x10\\u003csup\\u003e9\\u003c/sup\\u003e/L, [3.5\\u0026ndash;5.5 x10\\u003csup\\u003e12\\u003c/sup\\u003e]), hemoglobin (12.1 g/dL, [12\\u0026ndash;16]), HCT (33.3%, [36\\u0026ndash;48]), MCV (75.0 fL, [80\\u0026ndash;99]), MCH (27.3 pg, [26\\u0026ndash;32]), MCHC (36.4 g/dL, [32\\u0026ndash;36]), RDW CV (13.3%, [11.5\\u0026ndash;14.5]), RDW SD (39.9 fL, [37\\u0026thinsp;\\u0026minus;\\u0026thinsp;5]), platelets (404x10\\u003csup\\u003e9\\u003c/sup\\u003e/L, [150\\u0026ndash;450 x10\\u003csup\\u003e9\\u003c/sup\\u003e]), MPV (8.1 fL, [7.4\\u0026ndash;10.4]), PDW (15.3, [10\\u0026ndash;17]), PCT (0.326%, [0.1\\u0026ndash;0.28]), P-LCC (54x10\\u003csup\\u003e9\\u003c/sup\\u003e/L, [30\\u0026ndash;90]), and P-LCR (13.5%, [13\\u0026ndash;43]).\\u003c/p\\u003e\\n\\u003ch3\\u003eBlood smear analysis\\u003c/h3\\u003e\\n\\u003cp\\u003eThe blood smear was prepared via the above-mentioned field staining method. It was performed approximately fifteen days after admission and four days after discharge. Red blood cells were hypochromic and normocentric and consistent with the cell count of an automated machine. Although the leucocyte count was normal, the blood smear revealed many smudge cells. Representative smudge cells are shown in \\u003cb\\u003eFig.\\u0026nbsp;2.\\u003c/b\\u003e\\u003c/p\\u003e\\n\\u003ch3\\u003eUrine analysis\\u003c/h3\\u003e\\n\\u003cp\\u003eClear pale urine was collected. It is a pH of 6.0 [6-7.5], and a specific gravity of 1.015 g/mL, [1.005\\u0026ndash;1.030]. Traces of urobilinogen, bilirubin and ketone were detected, whereas proteins, glucose, red blood cells (RBCs), and white blood cells (WBCs) were not detected via indicator paper strips. Microscopic observation revealed no blood cells, such as red blood cells (RBCs) or leucocytes. It did not contain crystals, pus cells, urinary casts, or Candida cells.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eBiochemical tests\\u003c/h2\\u003e \\u003cp\\u003eThe serum creatinine level was 0.3 mg/dL, [0.3\\u0026ndash;0.7]), serum sodium level was 136.9 mmol/L, [130\\u0026ndash;148]) (4.4 mmol/L, [3.5\\u0026ndash;5.5]), and the inflammation marker CRP level was 29.34 mgs/L, [\\u0026lt;\\u0026thinsp;10]).\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eMRI\\u003c/h3\\u003e\\n\\u003cp\\u003eIt was performed before visiting our laboratory. Radiologists reported cerebral edema, and altered signal changes in the right temporal, parietal, occipital-temporal, cortical, and subcortical regions, which suggested gyral edema, and post-ictal changes.\\u003c/p\\u003e\\n\\u003ch3\\u003eX-ray\\u003c/h3\\u003e\\n\\u003cp\\u003eThe radiologists had marked prominent bronchovascular markings suggesting bronchitis.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec11\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eUltrasonography\\u003c/h2\\u003e \\u003cp\\u003eIt was performed at another laboratory before arriving at our laboratory. Ultrasonography revealed minimal hepatomegaly, minimal ascites and enlarged lymph nodes around the umbilical region. Right renal Agenesis was noted. The spleen and pancreas were normal. The gall bladder revealed echogenic sludge.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec12\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eCulture tests\\u003c/h2\\u003e \\u003cp\\u003eCerebrospinal fluid was collected at the hospital and analyzed by a trained pathologist at another pathology laboratory. CSF was negative for Gram staining and acid-fast staining. CSF was inoculated on blood agar and MacConkey agar plates and no growth was observed for thirty-six hours. There was no bacterial growth in the culture. No other significant changes were noted by the pathologists.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eWhen treating a patient suspected of having infectious mononucleosis, the doctor typically applies the Hoagland criteria (\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e). The physical examination of patients is performed for fever, tonsillitis, grayish patches below the tongue, tonsils and throat region, palpable lymph nodes in the neck region, and a palpable inflamed spleen. Physicians may ask for CBC, and a monospot test for the detection of heterophile antibodies. Quantitative PCR can be used to determine the virus titer. To check for any issues, the doctors could request more supportive tests, such as brain magnetic resonance imaging (MRI), and abdominal and neck ultrasonography. However, the common symptoms may lead to misdiagnosis with other viral, bacterial and fungal infections. In the case of infectious mononucleosis, the lymphocyte count is fifty percent of the total leucocyte count and ten percent of the atypical lymphocyte count. Patients in the current case study were reluctant to undergo viral titers testing because of the expense, and although the concerned doctors performed numerous tests before reaching a diagnosis, they were unable to conclude that the patients had infectious mononucleosis. Many small- and medium-sized diagnostic laboratories lack the funds necessary to perform DNA and antibody testing. The presence of smudge cells and atypical lymphocytes, which can be utilized when patients cannot pay for the expensive diagnoses, is reported in this study. Although antibody detection against viral proteins and viral DNA by quantitative PCR is advised for virus confirmation.\\u003c/p\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003ePhysicians and pathologists should conduct a complete blood count and blood smear analysis for atypical lymphocytes and smudge cells when clinical examination indicates symptoms of infectious mononucleosis. Analyzing lymphocytosis through a total blood cells count, examining smudge cells and atypical lymphocytes on a blood smear are fast and cost-effective methods for investigating these conditions.\\u003c/p\\u003e \"},{\"header\":\"Declarations\",\"content\":\"\\u003cdiv id=\\\"Sec15\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eEthical consent\\u003c/h2\\u003e \\u003cp\\u003e Consent for publishing the data for the case study was obtained from the patient\\u0026rsquo;s parents. This study did not intend for a drug trial.\\u003c/p\\u003e \\u003c/div\\u003e\\u003cp\\u003e \\u003ch2\\u003eSource of financial support\\u003c/h2\\u003e \\u003cp\\u003eAll the costs were financially supported by the Orange Diagnostics Clinics and Research Centre, Kolhapur, Maharashtra, India. This study did not receive any external funding.\\u003c/p\\u003e \\u003c/p\\u003e\\u003cp\\u003e \\u003ch2\\u003eConflict of interest\\u003c/h2\\u003e \\u003cp\\u003eThe author reports no conflicts of interest in this work.\\u003c/p\\u003e \\u003c/p\\u003e\\u003ch2\\u003eAcknowledgment\\u003c/h2\\u003e \\u003cp\\u003eWe thank the Orange Diagnostics Clinics and Research Centre, Kolhapur, for publishing this work. I thank the parents of the patient for their kind support and for providing all the previous reports.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eCohen JI, Jaffe ES, Dale JK, Pittaluga S, Heslop HE, Rooney CM et al (2011) Characterization and treatment of chronic active Epstein\\u0026ndash;Barr virus disease: a 28-year experience in the United States. \\u003cem\\u003eBlood\\u003c/em\\u003e ;117(22):5835\\u0026ndash;5849 \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1182/blood-2010-11-316745\\u003c/span\\u003e\\u003cspan address=\\\"10.1182/blood-2010-11-316745\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eDowd JB, Palermo T, Brite J, McDade TW, Aiello A (2013) Seroprevalence of Epstein\\u0026ndash;Barr virus infection in U.S. children ages 6\\u0026ndash;19, 2003\\u0026ndash;2010. 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Injury. 2016; 47 (3):531\\u0026ndash;538. https://doi.org/10.1016/j.injury.2015.10.071\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eZhong L, Krummenacher C, Zhang W, Hong J, Feng Q, Chen Y et al (2022) Urgency and necessity of Epstein\\u0026ndash;Barr virus prophylactic vaccines. npj Vaccines Nat Res 7(1):159. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1038/s41541-022-00587-6\\u003c/span\\u003e\\u003cspan address=\\\"10.1038/s41541-022-00587-6\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSachithanandham J, Kannangai R, Pulimood SA, Desai A, Abraham AM, Abraham OC et al (2014 Jul-Sep) Significance of Epstein\\u0026ndash;Barr virus (HHV-4) and CMV (HHV-5) infection among subtype-C human immunodeficiency virus-infected individuals. 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Eur J Pediatr 151(11):794\\u0026ndash;798. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1007/bf01957926\\u003c/span\\u003e\\u003cspan address=\\\"10.1007/bf01957926\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHiguchi T, Eiki O, Hiroshi H, Kenta I (2021) Smudge cells due to infectious mononucleosis. IDCases 23:e01057. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1016/j.idcr.2021.e01057\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.idcr.2021.e01057\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eGo RS (2009) Smudge cells, serum albumin, and prognosis in B-cell chronic lymphocytic leukemia. \\u003cem\\u003eJournal of Clinical Oncology.\\u003c/em\\u003e July 6;27(12) \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1200/JCO.2009.23.8188\\u003c/span\\u003e\\u003cspan address=\\\"10.1200/JCO.2009.23.8188\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eGulati G, Ly V, Uppal G, Gong J (2017) Feasibility of Counting Smudge Cells as Lymphocytes in Differential Leukocyte Counts Performed on Blood Smears of Patients with Established or Suspected Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma. Lab Med 48(2):137\\u0026ndash;147. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1093/labmed/lmx002\\u003c/span\\u003e\\u003cspan address=\\\"10.1093/labmed/lmx002\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eJerez J, Ernst DM (2020) High percentage of smudge cells in a patient with COVID19: Rediscovering their utility. eJHaem 1(1):374\\u0026ndash;375. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1002/jha2.52\\u003c/span\\u003e\\u003cspan address=\\\"10.1002/jha2.52\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eNowakowski GS, Hoyer JD, Shanafelt TD, Geyer SM, LaPlant BR, Call TG et al (2007) Using smudge cells on routine blood smears to predict clinical outcome in chronic lymphocytic leukemia: A universally available prognostic test. \\u003cem\\u003eMayo Clinic Proceedings.\\u003c/em\\u003e ;82(4):449\\u0026ndash;453. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.4065/82.4.449\\u003c/span\\u003e\\u003cspan address=\\\"10.4065/82.4.449\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eNowakowski GS, Hoyer JD, Shanafelt TD, Zent CS, Call TG, Bone ND et al (2009) Percentage of smudge cells on routine blood smear predicts survival in chronic lymphocytic leukemia. J Clin Oncol 27(11):1844\\u0026ndash;1849. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1200/jco.2008.17.0795\\u003c/span\\u003e\\u003cspan address=\\\"10.1200/jco.2008.17.0795\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSall A, Seck M, Fall S, Sall FB, Faye BF, Ndiaye FS et al (2022) Smudge cells percentage on blood smear is a reliable prognostic marker in chronic lymphocytic leukemia. Hematol Transfus Cell Therapy 44(1):63\\u0026ndash;69. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1016/j.htct.2021.04.002\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.htct.2021.04.002\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":true,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"Orange Diagnostics Clinics and Research Centre, Kolhapur, Maharashtra India\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Infectious mononucleosis, EBV, herpes virus, EBV, smudge cells, monospot-test\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-5487813/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-5487813/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003eInfectious mononucleosis is a very common infection. It is caused mostly by Epstein‒Barr virus (EBV), which belongs to herpesviridae or sometimes by the other member, Cytomegalovirus (CMV). It spreads through saliva. It has typical symptoms such as fever, extreme fatigue, sore throat and tonsillitis, enlarged lymph nodes in the neck, armpit, skin rashes, bodyache, and obstruction in the upper respiratory tract, and enlarged spleen and liver. It can lead to other complications such as anemia, encephalitis, meningitis, inflammation of the kidney, heart muscles, and rupture of the spleen. Laboratory diagnosis is costly. The physician may order heterophile antibody tests (monospot-test), EBV- or CMV- specific antibody tests, and viral DNA load. Patients with lower financial means do not want to go for such tests. This research indicates that a close examination of a blood sample for unusual lymphocytes and smudge cells (Downey cells) could also be the least expensive way to address this problem, although it is not a confirmatory test.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Case Report: Smudge Cells as a Valuable Prognostic Marker in Infectious Mononucleosis\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2024-11-25 15:27:17\",\"doi\":\"10.21203/rs.3.rs-5487813/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"7003836d-cab1-4b8c-ac2b-864952460ce3\",\"owner\":[],\"postedDate\":\"November 25th, 2024\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[{\"id\":40501071,\"name\":\"Immunology\"},{\"id\":40501072,\"name\":\"Laboratory Diagnostics\"},{\"id\":40501073,\"name\":\"Applied \\u0026 Industrial Microbiology\"},{\"id\":40501074,\"name\":\"Virology\"},{\"id\":40501075,\"name\":\"Pathology\"}],\"tags\":[],\"updatedAt\":\"2024-11-25T15:27:17+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2024-11-25 15:27:17\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-5487813\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-5487813\",\"identity\":\"rs-5487813\",\"version\":[\"v1\"]},\"buildId\":\"qtupq5eGEP_6zYnWcrvyt\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}