S2582 Acute Hepatitis Secondary to Asymptomatic Epstein-Barr Virus (EBV) Infection

Abstract

INTRODUCTION: Symptomatic EBV infection usually presents with fever, sore throat, lymphadenopathy, termed as infectious mononucleosis syndrome. Marginal elevation of liver enzymes may be seen however, acute symptomatic hepatitis without mononucleosis syndrome is rare. We present a case of a female with acute cholestatic hepatitis with laboratory-confirmed EBV infection without mononucleosis syndrome. CASE DESCRIPTION/METHODS: A 36-year-old female, underweight, with past history of alcohol use (sober for 60+ days), seizure disorder, sub-clinical hypothyroidism presented with intermittent nausea followed by non-bloody, non-bilious vomiting for 5 days without melena or blood in the stool. She didn’t report any fever, chills, night sweats, sick contacts, recent travel history. On clinical exam, her vital signs were blood pressure 112/78 mm Hg, pulse 104/min, oral temperature of 36.7 deg C and breathing comfortably on room air. Inspection notable scleral icterus without periorbital skin involvement, no buccal mucosa changes, enlarged tonsil, no spider nevi, or scratch mark on inspection, no lymphadenopathy on palpation. The abdomen was soft and protuberant on the exam with liver just palpable below costal margin but non-tender to palpation. Her home medicine includes oral vitamin B12, folic acid, zonisamide (no changes to regimen in 2 years). Initial laboratory evaluation revealed a normal white cell count with an elevated liver enzymes, bilirubin, and alkaline phosphatase (R factor: 1.2). An ultrasonography of abdomen showed a common bile duct diameter of 3 mm without any dilation of extra or intrahepatic ducts, visualized portion of the portal vein was patent and showed hepatopetal flow. Unremarkable pancreas with cholelithiasis without cholecystitis. To rule in/out additional causes of cholestatic jaundice, viral, and antibody panel were sent which were positive for EBV infection. Additionally, ANA was positive reflecting cross-reactivity between EBV proteins and autoantigens. Her symptoms improved with conservative management which included hydration and low-fat diet. DISCUSSION: EBV is an important cause of cholestatic hepatitis resulting in elevated liver enzymes and bilirubin, however, the presentation is usually associated with mononucleosis syndrome. EBV hepatitis as a differential in patients with cholestatic hepatitis but without demonstrable biliary obstruction, prompt identification would avoid costly and/or invasive diagnostic procedures. No effective treatment is available for EBV hepatitis.Table 1.: Laboratory profile on admission and 8 weeks later