Introduction: Infectious mononucleosis (IM) is an acute viral infection caused by the Epstein-Barr virus (EBV) and usually occurs with acute tonsillitis, fever, swollen and tender cervical lymph nodes, enlargement of liver and spleen. In our case a 33-year-old man was admitted to our emergency room due to progressive bilateral periorbital edema with an initially suspected allergic reaction. In addition, the patient was suffering from sore throat and was feeling generally unwell for several days though taking NSAR.

Methods: On arrival the patient presented an impressive bilateral periorbital edema, hypertrophic fibrinous tonsils and tongue base. Initial medication of 4mg antihistamines and 500mg prednisolone was without effect. The oxygen saturation was stable at 95% with 2 litres of O2 insufflation. It was decided to monitor the patient at our intermediate care unit due to suspected Quincke edema.

Result: Blood sampling showed increased CRP and WBC, normal levels of C1/C4-inhibitor and positive EBV IgM. Hepatosplenomegaly was diagnosed in abdominal ultrasound. We diagnosed an acute EBV infection. Interdisciplinary co-evaluation was carried out. Clindamycin iv was administered for 10 days. The therapy improved the patient"s symptoms significantly. Convalescence occurred after 4 weeks.

Discussion: Periorbital edema, or Hoagland sign, can be an initial symptom of IM. Still, it is not well known by many clinicians. Otorhinolaryngologists should be aware of this clinical sign of IM to optimize diagnostics and therapy in outpatient and inpatient care. Furthermore, clinicians should not only recognise periorbital edema as a manifestation of IM but also be alerted of its potentially protracted course. The pathophysiology of periorbital involvement by IM is still unknown.

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