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A 19-year-old adolescent was hospitalized with lymphadenopathy, pharyngotonsillitis and palatal petechiae (left). As an incidental finding, the left arm had a positive Rumpel–Leede sign, i.e. multiple petechiae where the patient’s blood pressure had been taken the day before (centre and right).

Blood tests showed a platelet count of 38 × 109/l, a haemoglobin concentration of 154 g/l and a white cell count of 16 × 109/l with 49·5% lymphocytes and 13% atypical mononuclear cells. The platelet count reached a nadir of 36 × 109/l on the second day of hospitalization and then recovered spontaneously. Seroconversion 2 weeks later confirmed the suspected Epstein–Barr virus (EBV) infection.

Mild EBV-associated thrombocytopenia is found in about 30% of mononucleosis patients. However, petechiae are uncommon.

A Rumpel–Leede sign denotes the development of cutaneous petechiae after tourniquet application. Initially reported in 1909 by Rumpel and in 1911 by Leede as a clinical sign of scarlet fever it soon became associated with leukaemia, liver disease and infantile scurvy. Current interpretation considers the phenomenon as nonspecific, related either to a vasculopathy or to a reduced number or function of the platelets. In our patient it may be explained by thrombocytopenia and possibly mild vasculitis.

EBV infection may present with petechiae formation and a positive Rumpel–Leede test adding to the occasionally puzzling clinical presentations of this disease.