S3540 A Youthful Old Man – A Rare Case of EBV Hepatitis Presenting in the Elderly Population

Abstract

INTRODUCTION: Epstein- Barr virus (EBV) is a herpes virus with a majority of its primary presentations being sub-clinical. It is estimated that 90%-95% of adults are positive for infection with studies suggesting that primary infection occurs by the age of 20. EBV presentation of hepatitis accounted for < 1% of the final diagnosis compared to hepatic injury. This rare case presents the uncommon clinical and laboratory manifestations of acute EBV hepatitis. CASE DESCRIPTION/METHODS: An 83-year-old male presented with weakness and loss of appetite with 10 lb weight loss over the last month. He states 3/10 diffuse epigastric pain and nausea for one week prior to admission. He denied exposure to sick contacts, recent travel with last sexual encounter 4 years ago. He denies history of hepatitis or intravenous drug use with occasional use of Tylenol and fish oil supplements. Physical examination revealed a grossly jaundiced male with a normal abdomen without hepatomegaly or splenomegaly. Laboratory findings on admission showed elevated transaminases with ALT 1,028U/L, AST 718U/L, alkaline phosphatase (ALP) 1,185 U/L, total bilirubin 4.2mg/dL, and INR 1.1. During the patient’s hospital stay, the transaminases continued to decrease but ALP rose to 1,378U/L over the next two days before trending down and total bilirubin to 14.7 mg/dL (direct bilirubin >10 mg/dL). Ultrasound revealed a 13.7cm heterogeneous textured liver without biliary or common ductal dilation. Multiple echogenic lesions were seen, likely hemangiomas. All viral panels were negative aside from the EBV panel, which was positive for IgM and IgG. Patient was diagnosed with EBV hepatitis and was provided supportive treatment with NAC therapy. During the patient’s hospital course, his weakness and nausea persisted but pain resolved as LFTs started to trended down. The total bilirubin remained elevated at discharge. INR was stable throughout his stay. AST/ALT had decreased to 190/195 and with improvement, he was discharged home with hepatology clinic follow up. DISCUSSION: EBV hepatitis typically presents with fever, lymphadenopathy, sore throat, lymphocytosis, and splenomegaly with auto resolution over 8 weeks. Our patient did not have the typical symptoms, but presented with jaundice, cholestatic liver injury with significant elevations in liver panels. Treatment is supportive care. Our patient completed NAC therapy and with improvement was discharged home with close with close monitoring but was unfortunately lost to follow up due to the Covid pandemic.