S1438 Epstein-Barr Virus Infection Masquerading as Cholestasis in a Patient With Gallstone Disease

Abstract

INTRODUCTION: Epstein-Barr virus (EBV) induced infectious mononucleosis (IMN) is primarily a disease of adolescents and young adults. Hepatobiliary manifestations like acalculous cholecystitis, cholestasis and acute hepatitis are uncommon, and EBV infection will be of low suspicion when there is concomitant cholecystolithiasis. We report a case of EBV infection in an adult who presented with possible gallstone disease and cholestasis. CASE DESCRIPTION/METHODS: A 57-year-old woman with past medical history of migraine presented with fever, diffuse abdominal pain, nausea and vomiting of 6 days duration. She denied any sore throat. On examination she had scleral icterus, bilateral tender cervical and axillary lymphadenopathy and diffuse abdominal tenderness on palpation. Lab abnormalities noted were total bilirubin 4.7 mg/dl, direct bilirubin 2.6 mg/dl, AST 173 U/L, ALT 355 U/L, ALP 535 IU/L, GGT 349 U/L. Computed tomography (CT) of abdomen showed cholelithiasis with features of acute cholecystitis. She underwent Endoscopic ultrasound (EUS) and Endoscopic retrograde cholangiopancreatography (ERCP) with biliary sphincterotomy, balloon sweep with removal of sludge, and placement of a biliary stent, due to clinical suspicion of ascending cholangitis. Esophagogastroduodenoscopy showed erosive gastritis (Figure 1) and was biopsied. Liver chemistry remained unchanged despite this. Meanwhile peripheral smear showed polymorphous lymphocytes including a few atypical forms (Figure 2). Monospot test was positive, while HIV and acute hepatitis panel were negative. EBV early D Antibody and IgM antibodies to Viral capsid antigen were positive. The gastric biopsy demonstrated expansion of the lamina propria by atypical lymphoid infiltrates, and positive immunohistochemical studies for EBV (Figure 3). She was treated with antibiotics for her cholecystitis. She had significant clinical improvement at the time of her discharge at 7 days and laboratory improvement on follow up. An elective cholecystectomy has been arranged as an outpatient procedure. DISCUSSION: EBV can have gastrointestinal and hepatobiliary manifestations, but rarely the primary presentation. Superimposed cholecystolithiasis can sometimes necessitate invasive evaluation. EBV should be in the differential diagnosis in patients with generalized lymphadenopathy who have cholestasis, hepatitis or mixed pattern of liver injury, especially when the liver chemistry remains unchanged despite biliary decompression.Figure 1.: EGD showing erosive gastritis.Figure 2.: Peripheral smear demonstrated atypical lymphocytes.Figure 3.: Gastric biopsy showed lymphoid infiltrates in lamina propria and had positive immunohistochemical studies for EBV.