2325 Severe Cholestatic Hepatitis: An Atypical Presentation of Epstein-Barr Virus Infection

Abstract

INTRODUCTION: Infectious mononucleosis (IM) is a benign lymphoproliferative disease caused by Epstein-Barr Virus (EBV). In adults, EBV infection can cause an acute hepatitis with elevation of transaminases, usually resolving spontaneously. We report a rare case of a severe cholestatic hepatitis following an acute EBV infection. CASE DESCRIPTION/METHODS: A 24-year-old previously healthy Caucasian woman presented with fever, body aches, headache, odynophagia and dry cough for 5 days. Initially CBC was normal but she had significant liver test abnormalities: aspartate transaminase (AST) 723 IU/L, alanine transaminase (ALT) 647 IU/L, alkaline phosphatase (ALP) 708 IU/L, and normal total bilirubin (TB) 1.2 mg/dl (Figure 1). Patient took acetaminophen (<2 g/day) at home for fever for 5 days. She had no prior history of hepatitis, blood transfusions, intravenous drug use, high-risk sexual activity, or significant alcohol use. Monospot test was positive. Chest x-ray showed left lower lobe pneumonia, azithromycin was prescribed for 5 days. The fever subsided, but she became jaundiced (TB 9.2 mg/dl) on day 11 and the patient was admitted. RUQ ultrasound showed no evidence of biliary obstruction, masses or gallstones. CBC showed profound lymphocytosis. Hepatitis A, B, C and E serologies were negative. EBV VCA IgM Ab was positive, CMV and EBV PCR were negative. Autoimmune markers revealed mildly elevated ANA (1:160). Liver biopsy was done revealing sinusoidal lymphocytic infiltration typical of EBV hepatitis (Figure 2). Cholestasis worsened after admission with peak TB of 9.6 mg/dl and ALP 2080 IU/L. Follow-up lab work a month later showed a normal TB with mild elevation of ALP, GGT, AST and ALT. At 4-month follow up, all liver tests normalized with positive EBV serology (VCA IgG and EBNA), which confirmed the patient’s recent EBV infection. DISCUSSION: Acute cholestatic hepatitis is an extremely rare presentation of EBV infection, with few cases reported in the medical literature. To the best of our knowledge, our patient had the highest ALP elevation reported in association with EBV infection. It is essential for physicians to recognize this unusual EBV infection presentation in patients with fever and progressive cholestasis in the absence of biliary obstruction, to avoid prolonged hospitalization and invasive procedures.