The general symptoms had subsided and the child had regained his normal function. phase. Introduction The Epstein-Barr virus (EBV) is a double-stranded DNA human herpes virus type 4 (HHV-4) . It is transmitted mainly through oral secretions and establishes latency by invading memory B-cells, resulting in a high prevalence throughout the world (about 90?% of adults are lifelong carriers) [2, 3]. Primary EBV infection generally occurs asymptomatically in the early years of life but in adolescence its hallmark is infectious mononucleosis (IM) [4, 5]. Viral proliferation induces both cellular and humoral immunologic responses and there is an increase in the overall number of mononuclear lymphoid cells. Thus, the condition usually presents with malaise, sweats, lymphadenopathy, fever and pharyngitis . Blood results often demonstrate marked leucocytosis with a high differential lymphocyte cell count and atypical enlarged lymphoid cells. In ophthalmology, EBV has been implicated as a causative agent in various ocular malignancies and infections which affect mostly the anterior segment (as a whole EBV-related ocular diseases have been on the rise in the past decade) [7C9]. The virus has a preference for mucosa-associated lymphoid tissues (MALT), which are rich in B lymphocytes, such as the conjunctiva or the lacrimal glands [9C11]. In this article we present a case of an EBV-related follicular conjunctivitis with an unusual unilateral bulbar Tiagabine and subtarsal mass in a paediatric patient, which was diagnostically challenging due Tiagabine to the atypical blood picture. Case report A 13-year old boy presented to the accident and emergency with a large painless conjunctival mass under the right upper eyelid. It had been first noticed two weeks previously in the right supranasal quadrant and had gradually increased in size since then. No itching or excessive lacrimation were reported. The child had had a febrile illness and had been complaining of malaise, intermittent chills and sore-throat in the past 4?days. Otherwise, no significant past medical or ophthalmic history was reported and he was not on any medication. In addition, there were no known allergies. On examination, there was no pain during extraocular movements (EOM), no proptosis or diplopia. Vision was normal (Snellen acuity of 6/9) in both eyes. The intraocular pressure (IOP) was 18?mmHg bilaterally. Conjunctival follicles were present on the upper and lower eyelids in both eyes. The mass was obvious on lid retraction involving both the bulbar and subtarsal conjunctiva. It was salmon-pink, non-tender and spread across the entire conjunctiva superior to the limbus with no corneal involvement, as seen on Fig.?1a. It had well delineated borders. Pupils CALCR were equal and reactive to light. The anterior chamber was deep and clear and no abnormalities were detected in the posterior segment. Open in a separate window Fig. 1 Pre-operative extend of lesion (a) and post-operative outcomes (b) The boys temperature was 37.9?C. One lymph node was palpable on the left and two on the rightCall in the upper Tiagabine cervical chain. They were mobile and non-tender. There was no organomegaly on palpation. Blood tests indicated that serum alanine transaminase (ALT) was elevated at 60?IU/L (normal range: 0C41?IU/L) and haemoglobin was slightly low at 131?g/L (normal range: 135C180?g/L). The overall and differential white blood cell counts (WBC) were normal, as illustrated on Table?1. Table 1 Total leucocyte and differential cell counts WBC: 5.9??109/L (normal range: 4.0C11.0)Differential:Neutrophils 2.0??109/L (normal range: 2.0C7.5) 34.1?%Lymphocytes 3.2??109 (normal range: 1.3C3.5) 54.5?%Monocytes 0.6??109 (normal range: 0.2C0.8) 9.9?%Eosinophils 0.0??109 (normal range: 0.0C0.4) 0.5?%Basophils 0.1??109 (normal range: 0.0C0.1) 1?% Tiagabine Open in a separate window A successful excision was performed under general anaesthetic and the mass was sent for a biopsy. Post-operative results at 7?days were excellent (Fig.?1a and ?andb).b). The general symptoms had subsided and the child had regained his normal function. There was a small residual lymph node palpable on the left in the upper cervical chain. Discussion Diagnosing the lesion was challenging and initially two types of malignancies were considered: rhabdomyosarcoma and lymphoma. Conjunctival.