S2737 When the Student Becomes the Patient: A Case of Epstein-Barr Virus-Induced Acute Liver Injury

Abstract

INTRODUCTION: Viral hepatitis is a diagnosis that can lead to acute liver injury and commonly occurs following an acute Hepatitis A or B infection. Epstein-Barr virus (EBV) is a rare cause of acute viral hepatitis. We present a case of acute liver injury secondary to acute EBV infection. CASE DESCRIPTION/METHODS: A 25-year-old female medical student with no significant past medical history presented with five days of fever, sore throat, nausea, and left upper quadrant abdominal pain while on her Pediatric rotation. She was afebrile, tachycardic to 106 beats/min, and demonstrated tender cervical lymphadenopathy, exudative tonsillar enlargement, and splenomegaly on physical exam. Heterophile antibody was negative three days prior to presentation. Initial studies revealed a leukocytosis of 12,600/mm3 and elevated liver enzymes (AST 421 U/L, ALT 788 U/L, alkaline phosphatase 404 U/L, total bilirubin 1.4 mg/dL, and INR 1.3). CT abdomen revealed hepatosplenomegaly. Hepatic vasculature was patent on doppler ultrasound with an unremarkable gallbladder and biliary tree. Subsequent studies were pertinent for an undetectable serum acetaminophen level, negative Hepatitis A-C serologies, and negative cytomegalovirus PCR. EBV serologies were positive for acute infection including an elevated viral capsid antibody, IgM, IgG, and negative nuclear antigen antibody. The patient was discharged with supportive treatment and followed ten days later in clinic with liver enzymes improved to near normal levels. DISCUSSION: Infectious mononucleosis from EBV infection is associated with development of acute hepatitis in 80% of cases. Diagnosis may be delayed due to high rate of false negative heterophile antibodies early in the disease course. Most cases are subclinical with hepatomegaly occurring in only 14% of cases. The pattern of liver injury is typically hepatocellular. Serum aminotransferases exhibit a transitory rise to three-fold the upper limit of normal, peak in the second or third week of illness, and normalize within thirty days. Treatment is typically supportive, though steroids and antivirals have been used in severe cases. Viral hepatitis is a common cause of acute liver injury, second to drug-induced liver injury, and accounts for 10% of acute liver failure. This case highlights the importance of including uncommon causes of viral hepatitis in the differential for acute liver injury, particularly in patients without traditional risk factors for hepatitis.