S2462 A Patient Presenting With Acute Hepatitis and Retroperitoneal Lymphadenopathy Due to Cytomegalovirus and Epstein-Barr Virus Co-Infection: A Rare Complication in an Immunocompetent Patient

Abstract

INTRODUCTION: Acute hepatitis refers to an acute inflammation of a liver and hepatic cell necrosis. Viral infection accounts for 95% of cases. Acute viral hepatitis due to cytomegalovirus (CMV) and Epstein-Barr virus (EBV) co-infection in an immunocompetent individual is very rare. We report a patient who presented with fatigue, fever, and retroperitoneal lymphadenopathy due to EBV and CMV infection. CASE DESCRIPTION/METHODS: A 26-year-old man presented with intermittent high-grade fever, nausea, fatigue and generalized body weakness of 1-week duration. The patient noticed a pinkish rash on his abdomen and legs while he was febrile. Otherwise patient denied vomiting, hematemesis, melena, jaundice, or contact with a patient with similar illness. He was not immunocompromised and had no personal history of hematological disorders or autoimmune disease. On examination, the patient was sick looking; blood pressure was 120/68 mmHg, heart rate 110 beats/min, temperature 102 F. He had pink conjunctiva and non-icteric sclera. No palpable lymphadenopathy was felt in accessible areas. The abdomen was nontender, no organomegaly, and no sign of ascites. Laboratory tests revealed a white blood cell count 7.6K, hemoglobin 13.8gm/dl, platelet 163K. Peripheral blood smear revealed lymphocytosis (59%). Alanine transferase 279units/L, aspartate transaminases 217units/L, alkaline phosphatase 121units/L, and total bilirubin of 0.4 mg/dl. Both CMV IgM and IgG were positive, both EBV IgM and IgG were positive. Hepatitis viral panel A, B, C, human immunodeficiency virus, ANA and rheumatoid factor were all negative. Computed tomography of chest/abdomen/pelvis revealed multiple enlarged axillary and retroperitoneal lymph nodes, normal liver and spleen size. DISCUSSION: CMV and EBV are a family of herpes virus commonly encountered during childhood. CMV transmission is either congenital or contact with body secretions or blood transfusion. EBV is transmitted by close contact during child hood or by kissing in adults. Hepatitis as a manifestation of CMV/EBV is rare in an immune-competent patient, but both can present with infectious mononucleosis. Although acute hepatitis can happen in both cases, it is more likely due to CMV. This patient did not have typical symptoms of infectious mononucleosis on presentation, and lymphoma and other causes were considered. A high degree of suspicion helped us to do serology that confirmed the diagnosis. Treatment is supportive in an immune-competent patient.