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Hoagland sign
  1. Ryota Inokuchi1,2,
  2. Haruyasu Iida3,
  3. Fumihito Ohta4,
  4. Susumu Nakajima2,
  5. Naoki Yahagi2
  1. 1 Department of Emergency, Shirane Tokushukai Hospital, Minami-Alps, Yamanashi, Japan
  2. 2 Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Bunkyo-ku, Tokyo, Japan
  3. 3 Department of Neurology, Shirane Tokushukai Hospital, Minami-Alps, Yamanashi, Japan
  4. 4 Department of Neurosurgery, Shirane Tokushukai Hospital, Minami-Alps, Yamanashi, Japan
  1. Correspondence to Dr Ryota Inokuchi, Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan; inokuchir-icu{at}

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An otherwise healthy 26-year-old woman was admitted to our hospital for the first time for complaints of fever, fatigue, sore throat and eyelid swelling lasting for 4 days. On examination, tonsillar exudates, bilateral enlarged tender posterior cervical nodes, slight splenomegaly and bilateral upper-lid oedema (figure 1) were noted. Blood tests revealed atypical lymphocytosis and elevated hepatic enzyme and C-reactive protein levels. Results for Epstein-Barr virus-specific antibody tests showed current Epstein-Barr virus infection. The patient was discharged on day 14 without any complications of airway obstruction, neurologic syndromes, or worsened hepatosplenomegaly and was instructed to avoid all sport activities for 2 weeks. The bilateral upper-lid oedema indicated Hoagland sign. Hoagland sign is rare but helpful for distinguishing infectious mononucleosis from other causes of viral pharyngitis or from streptococcal pharyngitis and presents only initially and should not be sought after later in the course of infection.1

Figure 1

Acute dacryoadenitis with oedema and redness of the bilateral upper eyelid.


We would like to acknowledge Takako Sakamaki and Toshiko Ooishi for their assistance.


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  • Contributors RI, HI and FO contributed to patient management. RI drafted the initial manuscript. HI contributed to writing the report. SN and NY critically reviewed the manuscript. All the authors have provided written consent for publication.

  • Competing interests None.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; internally peer reviewed.