{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,8]],"date-time":"2026-10-08T16:48:04Z","timestamp":1791478084814,"version":"4.3.4"},"reference-count":32,"publisher":"MDPI AG","issue":"7","license":[{"start":{"date-parts":[[2026,3,25]],"date-time":"2026-03-25T00:00:00Z","timestamp":1774396800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Ricerca Corrente grant from the Italian Ministry of health","award":["2026"],"award-info":[{"award-number":["2026"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background: Epstein-Barr virus-related acute pharyngotonsillitis is common in children and adolescents and is generally managed successfully with positive outcomes by both ENT specialists and pediatricians. However, a variety of acute, life-threatening complications can occur, including upper airway obstruction and infectious or immune-mediated sequelae. Methods: This paper describes our recent experience with four pediatric patients presenting with severe ENT manifestations of infectious mononucleosis (IM) that led to life-threatening complications, all of whom were hospitalized and managed at our tertiary pediatric hospital between January 2022 and April 2025. Results: We report four cases (two boys and two girls) aged 5 to 16 years, hospitalized with complicated EBV-related pharyngotonsillitis. Presentations included respiratory distress (cases 1 and 2), hemophagocytic lymphohistiocytosis resulting in death (case 3), and a retropharyngeal abscess (case 4). Conclusions: The prognosis of IM in the pediatric population is generally favourable. However, acute, life-threatening complications may arise. In such cases, timely and coordinated multidisciplinary management involving ENT specialists, pediatricians, and anesthesiologists is crucial.<\/jats:p>","DOI":"10.3390\/jcm15072516","type":"journal-article","created":{"date-parts":[[2026,3,25]],"date-time":"2026-03-25T15:34:27Z","timestamp":1774452867000},"page":"2516","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Catastrophic ENT Complications of Pediatric Infectious Mononucleosis: Recent Experience at a Tertiary Pediatric Hospital"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0882-8892","authenticated-orcid":false,"given":"Lorenzo","family":"Gaini","sequence":"first","affiliation":[{"name":"Fondazione IRCCS C\u00e0 Granda Ospedale Maggiore Policlinico di Milano, 20122 Milano, Italy"},{"name":"Department of Clinical Sciences and Community Health, University of Milan, 20122 Milano, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-4055-5843","authenticated-orcid":false,"given":"Anna","family":"Cozzi","sequence":"additional","affiliation":[{"name":"Fondazione IRCCS C\u00e0 Granda Ospedale Maggiore Policlinico di Milano, 20122 Milano, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5986-7117","authenticated-orcid":false,"given":"Gioia","family":"Piatti","sequence":"additional","affiliation":[{"name":"Department of Clinical Sciences and Community Health, University of Milan, 20122 Milano, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5435-685X","authenticated-orcid":false,"given":"Michele","family":"Gaffuri","sequence":"additional","affiliation":[{"name":"Fondazione IRCCS C\u00e0 Granda Ospedale Maggiore Policlinico di Milano, 20122 Milano, Italy"},{"name":"Department of Clinical Sciences and Community Health, University of Milan, 20122 Milano, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Samantha","family":"Bosis","sequence":"additional","affiliation":[{"name":"Fondazione IRCCS C\u00e0 Granda Ospedale Maggiore Policlinico di Milano, 20122 Milano, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5691-3920","authenticated-orcid":false,"given":"Paola","family":"Marchisio","sequence":"additional","affiliation":[{"name":"Fondazione IRCCS C\u00e0 Granda Ospedale Maggiore Policlinico di Milano, 20122 Milano, Italy"},{"name":"Department of Clinical Sciences and Community Health, University of Milan, 20122 Milano, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giovanna","family":"Ghidini","sequence":"additional","affiliation":[{"name":"Fondazione IRCCS C\u00e0 Granda Ospedale Maggiore Policlinico di Milano, 20122 Milano, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5979-7841","authenticated-orcid":false,"given":"Giorgio","family":"Croci","sequence":"additional","affiliation":[{"name":"Fondazione IRCCS C\u00e0 Granda Ospedale Maggiore Policlinico di Milano, 20122 Milano, Italy"},{"name":"Department of Clinical Sciences and Community Health, University of Milan, 20122 Milano, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Antonio","family":"Carpino","sequence":"additional","affiliation":[{"name":"Fondazione IRCCS C\u00e0 Granda Ospedale Maggiore Policlinico di Milano, 20122 Milano, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8461-6042","authenticated-orcid":false,"given":"Sara","family":"Torretta","sequence":"additional","affiliation":[{"name":"Fondazione IRCCS C\u00e0 Granda Ospedale Maggiore Policlinico di Milano, 20122 Milano, Italy"},{"name":"Department of Clinical Sciences and Community Health, University of Milan, 20122 Milano, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,3,25]]},"reference":[{"key":"ref_1","first-page":"71","article-title":"Infectious mononucleosis: Rapid evidence review","volume":"107","author":"Sylvester","year":"2023","journal-title":"Am. Fam. Physician"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"911.e1","DOI":"10.1016\/j.amjmed.2006.12.011","article-title":"Diagnostic evaluation of mononucleosis-like illnesses","volume":"120","author":"Hurt","year":"2007","journal-title":"Am. J. Med."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"305","DOI":"10.2174\/1573396320666230801091558","article-title":"Infectious Mononucleosis: An Updated Review","volume":"20","author":"Leung","year":"2024","journal-title":"Curr. Pediatr. Rev."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"397","DOI":"10.1016\/S0196-0709(96)90073-3","article-title":"Otolaryngologic clinical patterns in pediatric infectious mononucleosis","volume":"17","author":"Ganzel","year":"1996","journal-title":"Am. J. Otolaryngol."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"263","DOI":"10.1097\/00008480-200006000-00016","article-title":"Acute complications of Epstein-Barr virus infectious mononucleosis","volume":"12","author":"Jenson","year":"2000","journal-title":"Curr. Opin. Pediatr."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"989","DOI":"10.1007\/s00405-016-3904-x","article-title":"Clinical practice guideline: Tonsillitis II. Surgical management","volume":"273","author":"Windfuhr","year":"2016","journal-title":"Eur. Arch. Otorhinolaryngol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"28","DOI":"10.4103\/jgid.jgid_38_22","article-title":"Infectious Mononucleosis Presenting as Near-Fatal Tracheal Obstruction","volume":"15","author":"Kumar","year":"2022","journal-title":"J. Glob. Infect. Dis."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"848","DOI":"10.1258\/0022215001904149","article-title":"Bacterial penetration into tonsillar surface epithelium during infectious mononucleosis","volume":"114","year":"2000","journal-title":"J. Laryngol. Otol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"S3","DOI":"10.1097\/PGP.0000000000000899","article-title":"The International Collaboration on Cancer Reporting (ICCR): 10 Years Progress in the Development of Cancer Pathology Datasets","volume":"41","author":"Helliwell","year":"2022","journal-title":"Int. J. Gynecol. Pathol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"642","DOI":"10.1111\/ped.14143","article-title":"Nasopharyngeal airway for upper airway obstruction in infectious mononucleosis","volume":"62","author":"Fukumasa","year":"2020","journal-title":"Pediatr. Int."},{"key":"ref_11","first-page":"584","article-title":"Airway obstruction in infectious mononucleosis\u2014A case report","volume":"17","author":"Woolf","year":"1989","journal-title":"S. Afr. Med. J."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"999","DOI":"10.1017\/S0022215100147875","article-title":"Otolaryngological complications in infectious mononucleosis","volume":"98","author":"Johnsen","year":"1984","journal-title":"J. Laryngol. Otol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"e242500","DOI":"10.1136\/bcr-2021-242500","article-title":"Acute upper airway obstruction due to tonsillitis necessitating emergency cricothyroidotomy","volume":"14","author":"Ravindran","year":"2021","journal-title":"BMJ Case Rep."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"958S","DOI":"10.1177\/0145561320930046","article-title":"Infectious Mononucleosis and Upper Airway Obstruction: Intracapsular Tonsillectomy and Adenoidectomy with Microdebrider for Prompt Relief","volume":"100","author":"Lloyd","year":"2020","journal-title":"Ear Nose Throat J."},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Esposito, S., De Guido, C., and Pappalardo, M. (2022). Retropharyngeal, Parapharyngeal and Peritonsillar Abscesses. Children, 26.","DOI":"10.3390\/children9050618"},{"key":"ref_16","first-page":"826","article-title":"Tonsillectomy for the acute anginous type of infectious mononucleosis","volume":"53","author":"Mann","year":"1974","journal-title":"Laryngol. Rhinol. Otol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"989","DOI":"10.1017\/S0022215100121541","article-title":"Acute tonsillectomy in the management of infectious mononucleosis","volume":"106","author":"Stevenson","year":"1992","journal-title":"J. Laryngol. Otol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"729","DOI":"10.1016\/j.otohns.2005.07.013","article-title":"Haemorrhage risk after quinsy tonsillectomy","volume":"133","author":"Giger","year":"2005","journal-title":"Otolaryngol. Head Neck Surg."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"422","DOI":"10.1002\/ajh.21811","article-title":"EBV-associated hemophagocytic syndrome","volume":"86","author":"Liapis","year":"2011","journal-title":"Am. J. Hematol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"93","DOI":"10.1002\/rmv.638","article-title":"Viral infections associated with hemophagocytic syndrome","volume":"20","author":"Maakaroun","year":"2010","journal-title":"Rev. Med. Virol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"4","DOI":"10.1046\/j.1365-2141.2003.04726.x","article-title":"Modern management of children with haemophagocytic lymphohistiocytosis","volume":"124","author":"Janka","year":"2004","journal-title":"Br. J. Haematol."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"e30772","DOI":"10.1002\/pbc.30772","article-title":"Prognostic scoring system for pediatric Epstein-Barr virus-associated hemophagocytic lymphohistiocytosis based on baseline characteristics: A multicenter retrospective study","volume":"71","author":"Kong","year":"2024","journal-title":"Pediatr. Blood Cancer"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"208","DOI":"10.12701\/yujm.2020.00591","article-title":"A retrospective analysis of etiology and outcomes of hemophagocytic lymphohistiocytosis in children and adults","volume":"38","author":"Kwak","year":"2021","journal-title":"Yeungnam Univ. J. Med."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"2728","DOI":"10.1182\/blood-2017-06-788349","article-title":"Confirmed efficacy of etoposide and dexamethasone in HLH treatment: Long-term results of the cooperative HLH-2004 study","volume":"130","author":"Bergsten","year":"2017","journal-title":"Blood"},{"key":"ref_25","first-page":"e7563","article-title":"Epstein-Barr Virus Infection-associated Hemophagocytic Lymphohistiocytosis","volume":"12","author":"Gaznabi","year":"2020","journal-title":"Cureus"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"58","DOI":"10.1532\/IJH97.07012","article-title":"Nationwide survey of Hemophagocytic lymphohistiocytosis in Japan","volume":"86","author":"Ishii","year":"2007","journal-title":"Int. J. Hematol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"810","DOI":"10.1080\/10245332.2018.1491093","article-title":"Epstein-Barr virus-associated hemophagocytic lymphohistiocytosis in adults and adolescents\u2014A life-threatening disease: Analysis of 133 cases from a single center","volume":"23","author":"Lai","year":"2018","journal-title":"Hematology"},{"key":"ref_28","first-page":"001829","article-title":"Infectious Mononucleosis Resulting in Acute Necrotizing Mediastinitis: A Case Report and Literature Review","volume":"7","author":"Markowicz","year":"2020","journal-title":"Eur. J. Case Rep. Intern. Med."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"32","DOI":"10.1186\/s12941-020-00375-x","article-title":"Complications of peritonsillar abscess","volume":"19","author":"Klug","year":"2020","journal-title":"Ann. Clin. Microbiol. Antimicrob."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1781","DOI":"10.1128\/JCM.03578-14","article-title":"Descending mediastinitis in Epstein-Barr virus infection","volume":"53","author":"Geerts","year":"2015","journal-title":"J. Clin. Microbiol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"663","DOI":"10.1007\/s00134-002-1270-1","article-title":"Life-threatening bilateral empyema and mediastinitis complicating infectious mononucleosis","volume":"28","author":"Andrianakis","year":"2022","journal-title":"Intensive Care Med."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"55","DOI":"10.3349\/ymj.2007.48.1.55","article-title":"Predisposing Factors of Complicated Deep Neck Infection: An Analysis of 158 Cases","volume":"48","author":"Lee","year":"2007","journal-title":"Yonsei Med. J."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/7\/2516\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,26]],"date-time":"2026-03-26T14:20:52Z","timestamp":1774534852000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/7\/2516"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,3,25]]},"references-count":32,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2026,4]]}},"alternative-id":["jcm15072516"],"URL":"https:\/\/doi.org\/10.3390\/jcm15072516","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,3,25]]}}}