S2803 An Uncommon Presentation of a Common Illness: Epstein-Barr Virus Resulting in Splenic Infarction

Abstract

Introduction: When a patient presents with fever, malaise, sore throat a viral etiology may come to mind. Findings of splenomegaly, elevated liver enzymes and lymphadenopathy may even point towards Infectious Mononucleosis, especially in a patient in their teens and early twenties. However, when a patient in their fifties presents with fever, transaminitis and imaging revealing splenic infarction, does Infectious Mononucleosis come to mind? Here is why it should. Case Description/Methods: Our patient is a fifty-seven year old female with a past medical history of monoclonal gammopathy of undetermined significance (MGUS) who presented to the emergency department for evaluation of abnormal liver enzymes noted by her hematologist/oncologist on routine outpatient blood work. Her aspartate transaminase (AST) was 1241 and alanine transaminase (ALT) was 1372 on presentation. She complained of fever, malaise and left upper quadrant abdominal pain. Imaging of her abdomen revealed a liver without focal abnormality and a small wedge shaped hypodensity in the spleen likely representing a small splenic infarct. The gastroenterology service was consulted for further evaluation of her transaminitis. A chronic liver disease workup was negative for viral hepatitides, autoimmune hepatitis and several rheumatological conditions. A urine toxicology screen, tylenol level and alcohol level were unremarkable. Other etiologies including drug induced liver injury and shock liver were also ruled out. Given her sore throat, Epstein-Barr Virus (EBV) test was ordered and results confirmed Infectious Mononucleosis as the etiology of her presenting symptoms. Our patient was managed conservatively and her liver function tests continued to downtrend with AST and ALT in the 200s on day of discharge. Patient was seen by hematology who recommended three months of anticoagulation for splenic infarction due to Infectious Mononucleosis, a rare complication with only a few reported cases. Discussion: Although Infectious Mononucleosis is often considered a benign, self-limiting viral illness, it is important to rule out splenic infarction which can result in serious and even life threatening complications. With early diagnosis and management of EBV complicated by splenic infarction our patient was followed outpatient with notable improvement in her presenting symptoms and normalization of her liver enzymes.Figure 1.: Computed Tomography (CT) imaging of our patient's abdomen and pelvis revealing a small hypodensity in the spleen likely representing splenic infarction.