2412 A Unique Case of Acute Liver Injury Due to Severe Epstein-Barr Virus Infection

Abstract

INTRODUCTION: The liver is often affected by EBV infection, but involvement is commonly subclinical and self-limited. Infrequently, severe and potentially fatal EBV hepatitis has been reported in immunocompromised patients and, more rarely, in immunocompetent individuals. CASE DESCRIPTION/METHODS: A 25 y/o reasonably healthy man was transferred to a tertiary care hospital for advanced liver care due to increasing liver enzymes and concern for acute liver failure. Prior to presentation, he had experienced dry mouth, fatigue, and dark urine for six days. Of note, he worked in the police academy and regularly engaged in rigorous training. He used multiple OTC supplements, including clomiphene, creatine, ligandrol, and ibutamoren. Also, he would ingest 1600-2400 mg of ibuprofen in a day, for about 12 days per month, for general soreness from his workouts. Upon admission, his physical exam was notable for scleral icterus and generalized jaundice. He was A+Ox3 with no mental status changes. His labs were significant for AST 1,611, ALT 3,529, ALP 114, and total bilirubin 15.2 (direct 12.3). He had strongly positive EBV IgM titers, and was found to have a positive EBV PCR (52,000 copies/mL). During the admission, he had two episodes of seizure-like activity, the second of which was recorded on EEG without epileptiform activity. The episodes were attributed to syncope/presyncope in the setting of symptomatic anemia. He received a total of three units of packed RBCs due to anemia, but his hemoglobin did not initially improve. However, the last transfusion was warmed and there was adequate improvement in the hemoglobin, supporting a diagnosis of cold-agglutinin disease. Liver biopsy showed severe acute hepatitis, a mixed portal and lobular inflammatory infiltrate, and marked cholestasis. The overall picture was consistent with an EBV-driven hepatitis, along with a severe hemolytic anemia due to cold-agglutinin disease induced by EBV, in conjunction with likely predisposition to liver injury from taking various supplements. Ultimately, his liver enzymes improved and he was discharged in stable condition. DISCUSSION: EBV is associated with a variety of clinical manifestations and can present as cholestatic hepatitis with or without features of infectious mononucleosis (IM). Conversely, although rare in the immunocompetent, there is a need to test for EBV in cryptogenic hepatitis even if it remains difficult to prove its causative role. The mainstay of treatment for IM and other primary EBV diseases is supportive care.