A Case of Acute Hepatitis With Co—Infections: Co—Existent Hepatitis E With a Positive Serology for Double Mono

Abstract

Epstein—Barr virus (EBV), Cytomegalovirus (CMV) and Hepatitis E virus (HEV) are all known to cause mild and usually self—limiting acute viral hepatitis. Acute hepatitis caused by simultaneous presence of two viruses has been reported in literature. However, patients with positive serology for three acute viral infections causing acute hepatitis is very rare. A 23—year—old Caucasian female with an unremarkable past medical history presented with one—week duration of nausea, vomiting, generalized abdominal pain, fever and one day duration of scleral icterus and jaundice. The patient had stable vital signs but elevated liver enzymes on admission with AST 385 IU/L, ALT 290 IU/L, Alkaline phosphatase 461 IU/L, Total bilirubin 9 mg/dL and Direct bilirubin of 5.1 mg/dL. White blood cell (WBC) count was 13500/uL. Work up was unremarkable for acute hepatitis A, B & C viruses, Influenza A & B and infectious mono—spot test along with a negative pregnancy test. When Ultrasound and Computed tomography scan of the abdomen was unrevealing a magnetic resonance cholangiopancreatography was obtained and was unremarkable. Anti—mitochondrial antibody, anti—smooth muscle antibody, anti—nuclear antibody, Alpha—1 antitrypsin level and ceruloplasmin level were all un—remarkable. Infectious disease was consulted when the patient became febrile to 102.0 F despite negative work up. Serologic work up for acute EBV, CMV and HEV infections turned out to be positive; with positive PCR for EBV (Table. 1). The patient was subsequently managed conservatively per infectious disease recommendations and improved. She was discharged on her fourth hospital day with a 6 week follow up showing normalization of liver enzymes. The above patient was diagnosed with Infectious mononucleosis with associated acute hepatitis due to EBV infection. Positive CMV serology was thought to be false positive as the patient's CMV PCR titers were low. HEV PCR wasn't obtained but given the significantly elevated bilirubin in combination with positive serology, it was thought to be a true infection. The patient improved only with conservative management. This lead to two important conclusions: (1) If the patient has positive serology concerning for co—infection of EBV, CMV and/or HEV; it should be confirmed via PCR and (2) if the patient truly is co—infected supportive treatment is one management option in immunocompetent patients.3047.tif Figure 1: No Caption available.