Abstract
Epstein-Barr virus (EBV) primary infection usually presents with classic symptoms of infectious mononucleosis (IM) like fever, lymphadenopathies and tonsillopharyngitis. Liver damage is frequently mild and self-limited and there are only a few cases of severe EBV-induced cholestatic hepatitis and jaundice reported in the literature. The authors present the case of a 22-year-old woman who was admitted with acute fever and jaundice. Physical examination revealed posterior cervical lymphadenopathies and painful hepatosplenomegaly. Laboratorial findings suggested an obstructive cause for jaundice but ultrasound and magnetic resonance cholangiopancreatography excluded biliary duct pathology. Heterophile antibodies were negative but EBV-specific antibodies revealed isolated positive viral capsid antigen (VCA) immunoglobin (Ig) M suggesting the diagnosis of early phase of EBV primary infection. The diagnosis of EBV-induced cholestatic hepatitis was confirmed after identification of EBV deoxyribonucleic acid (DNA) in blood and by liver biopsy. Supportive management was provided and, despite an initial clinical deterioration, the patient had a favorable outcome. EBV is a virus with a high prevalence worldwide, mainly subclinical, and jaundice is a rare manifestation of the infection. Although the majority of the patients recover without sequelae, progression to liver failure has been described and a careful assessment for complications is mandatory. Therefore, EBV infection should be included in the comprehensive differential diagnosis of jaundice in all age groups.
Highlights
Epstein-Barr virus (EBV) is a common herpesvirus with usually asymptomatic primary infection, occurring between 10 and 30 years old in developed countries [1, 2]
Liver biopsy was performed and histopathological findings were compatible with inflammatory infiltration of the liver by epithelioid granulomas and sinusoidal lymphocytosis (Figure 2) and the diagnosis of cholestatic hepatitis due to EBV primary infection was confirmed
Jaundice is a rare presentation of EBV primary infection
Summary
Epstein-Barr virus (EBV) is a common herpesvirus with usually asymptomatic primary infection, occurring between 10 and 30 years old in developed countries [1, 2]. Abdominal ultrasonography revealed heterogenous enlarged liver, mild common biliary duct dilatation without cholelithiasis and homogeneous splenomegaly (Figure 1). Nonimmune hemolytic anemia (hemoglobin level of 11.2g/dL, reference range (RR) 12-15g/dL; reticulocyte index above 2.5 without significant peripherical blood smear changes, low haptoglobin, negative antiglobulin tests) and coagulopathy have emerged (international normalized ratio of 1.7). Further laboratorial investigation revealed a positive EBV viral capsid antigen (VCA) immunoglobin (Ig) M; VCA and Epstein-Barr nuclear antigen (EBNA) IgG were both negative. Liver biopsy was performed and histopathological findings were compatible with inflammatory infiltration of the liver by epithelioid granulomas and sinusoidal lymphocytosis (Figure 2) and the diagnosis of cholestatic hepatitis due to EBV primary infection was confirmed. Follow-up tests three months after discharge revealed normal liver tests and EBV seroconversion (Table 3)
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