A CASE OF EPSTEIN-BARR VIRUS MYOCARDITIS

Abstract

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Numerous viruses can cause myocarditis with Enteroviruses being a common cause and Epstein-Barr Virus (EBV) being a rare cause. This virus has also been described in the pathophysiology of hepatitis and cholangiopathy. CASE PRESENTATION: A 22-year-old woman with no significant past medical history presented with a 3-day history of generalized abdominal pain, diarrhea, vomiting, fever, and chest pain. She also endorsed 1 week of myalgias, sore throat, and fatigue. Physical examination showed fever, abdominal tenderness, and scleral icterus. Initial laboratory data demonstrated mildly elevated transaminases, alkaline phosphatase, and bilirubin. ERCP demonstrated mild intrahepatic ductal dilation, 1 cm narrowing of the common bile duct, and non-obstructing gall stones necessitating cholecystectomy and biliary duct stent placement. However, her symptoms persisted, and she became more tachycardic and dyspneic, with worsening chest pain. Laboratory data showed an elevated N-terminal pro-brain natriuretic peptide > 6500 pg/ml with leukocytosis up to 35,000 WBC/microliter. She was transferred to the intensive care unit and clinical evaluation commenced. Empiric antimicrobial therapy was instituted and computed tomography angiography (CTA) was performed which was negative for pulmonary embolus but did demonstrate bilateral large pleural effusions and diffuse airspace infiltrates. Impending respiratory failure was averted with Bi-PAP and transthoracic echocardiogram revealed ejection fraction of 35% confirming suspected cardiomyopathy. Infectious diseases evaluation was extensive and negative except for Epstein-Barr Virus (EBV) polymerase chain reaction (PCR) 472 copies/mL, markedly elevated EBV IgM and IgG to viral capsid antigen, EBV D antigen IgG, and EBV antibody to nuclear antigen. Other etiologies were excluded by PCRs, serologies, cultures, autoimmune evaluation, bone marrow biopsy, imaging, and bronchoscopy. Antimicrobial agents were discontinued, and glucocorticoids were initiated resulting in gradual improvement of symptoms and laboratory abnormalities. The patient was diagnosed with EBV myocarditis with associated hepatitis/cholangiopathy. DISCUSSION: The differential diagnosis of patients with dyspnea, fever, abdominal pain, chest pain and leukocytosis can be broad. This case demonstrates that unusual symptoms of a relatively common viral infection (infectious mononucleosis) must be considered in order to not delay diagnosis and proper treatment. Myocarditis can be the first symptom of EBV infection with manifestations ranging from asymptomatic electrocardiographic changes to fulminant heart failure, cardiac arrhythmias, or even sudden death. CONCLUSIONS: Manifestations of EBV infection can cross multiple organ systems and must be considered by clinicians in the differential diagnosis of acute cardiomyopathy with fever, leukocytosis and signs of hepatitis/cholangiopathy. Reference #1: Muneuchi, J., Ohga, S., Ishimura, M. et al. Cardiovascular Complications Associated with Chronic Active Epstein–Barr Virus Infection. Pediatr Cardiol (2009) 30: 274. Reference #2: Lawee D. Mild infectious mononucleosis presenting with transient mixed liver disease: case report with a literature review. Can Fam Physician. 2007;53(8):1314-6. Reference #3: Fauci, A., Hauser, S., Jameson, J., Kasper, D., Longo, D. and Loscalzo, J. (2016). Harrison's Manual of Medicine, 19e. New York, N.Y.: McGraw-Hill Education LLC. DISCLOSURES: No relevant relationships by Christopher Farmakis, source=Web Response No relevant relationships by Leigh Hunter, source=Web Response