Unusual Presentation of Epstein Barr Virus Hepatitis

Abstract

54 year old male with no medical history and no medications originally evaluated at outside emergency department on several occasions with headaches with minimal improvement with narcotics. On third presentation labs including liver function test were done showing an alkaline phosphatase of 870 U/L, Bilirubin 2.3 mg/dL, AST 114 U/L, ALT 157 U/L. Abdominal ultrasound done at that time was normal. Patient continued to complain of headache, photophobia, night sweats, and anorexia with only mild right upper quadrant discomfort. He was then transferred to our institution with continued elevation of LFTs: Alk Phos 883, AST 134, ALT 209, bilirubin 5.8. A CT abdomen showing complicated acalculus cholecysitis. Repeat ultrasound showed thickened gallbladder wall. LFT's continued to rise over the next few days. ERCP was performed, revealing normal biliary anatomy and without stones or sludge. A laparoscopic cholecystectomy was subsequently performed along with intraoperative liver biopsy. The gallbladder was grossly normal and pathology returned with mild inflammation. Liver biopsy showed dense chronic inflammatory cell infiltrate within the portal tract. Periportal cholestasis noted with rare neutrophils within bile ductules. The conclusion was this was non-specific finding and could be consistent with acute or unresolved viral hepatitis, autoimmune, drug induced, or possibly extrahepatic biliary obstruction with superimposed cholangitis. The patient was seen in GI clinic one week after discharge and continued to complain of anorexia, pruritis, and fatigue. Bilirubin had dramatically improved to 3.4, Alk Phos 893, AST 125, ALT 152. CMV and EBV PCR along with EBV to capsid IgM were sent. Serologies returned positive for EBV PCR and capsid IgM. Pathology was re-reviewed showing atypical lymphocytes in sinusoids and in situ hybridization studies for EBV were positive. The patient made a full recovery with normalization of his LFTs one month later. Epstein-Barr virus (EBV) is known to cause acute hepatitis but is usually seen with elevated transaminases. Cholestasis at presentation is an extremely rare presentation with only a few case reports in the literature. EBV is usually self-limited although cases requiring liver transplantation are reported. Costly diagnostic laboratory tests and invasive procedures may be performed to rule biliary obstruction in patients with EBV. EBV infection should be included in the differential diagnosis of cholestatic jaundice especially in those patients who present with only mild right upper quadrant discomfort.