At Goldstein morning report, PGY3 Katherine Loomis presented a case of a 41 year old female with no significant past medical history who presented with 7 day history of subjective fevers (Tmax to 102F at home) and 5 days of worsening RUQ and epigastric abdominal pain, nausea and emesis. She also noted yellowing of her eyes 1 day prior to admission. Ancillary history was insignificant. Exam was significant for mild bilateral scleral icterus, mild lower eyelid and sublingual icterus, and tenderness to palpation in RUQ, epigastric and RLQ with the livers enlarged 4cm below the costal margin, no palpable splenomegaly.
CBC: WBC 10.3 > Hb 13/ Hct 39.3 <Plt 183
Na 139/K 4.1/Cl 104/HCO3 22/BUN 2/Cr 0.56 <Glucose 108
ALP 217>T.protein 7/Albumin 4.1/AST 98/ALT 147/Tbili 2.8/DBili 2.4
*of note, hepatic function on the patient was normal 1 month prior to admission
Hepatitis viral serologies (A, B, C and E) were negative along with negative autoimmune workup.
Abd US showed concerns of gallbladder wall thickening measuring up to 9mm but no evidence of acute cholecystitis:
CT A/P w/ contrast and MRCP also confirmed presence of a markedly thickened and edematous gallbladder wall but no intra or extrahepatic duct dilatation.
Further viral studies returned:
- EBV IgG: 59.4 U/mL (<18.9 negative)
- EBV IgM: >160 U/mL (<36.0 negative)
- EBV nuclear Ag Ab IgG: <18.9 U/mL (<18.0 negative)
- CMV IgG: 9.2 U/mL (>0.7 positive)
- CMV IgM: <30.9 AU/mL (<30.0 no Ab detected)
Treatment: Patient improved with symptomatic treatment and was discharged with 1 month hepatology clinic follow-up which showed near normalization of labs.
Take home points:
- EBV most commonly manifests as infective mononucleosis but there are less common complications of which one is hepatitis.
- Treatment is supportive but there are rare cases of severe or fatal hepatitis.
- Severe or fatal hepatitis, although rare may be seen in immunocompromised or in rare cases immunocompetent individuals and treatment can include steroids and antivirals
Epstein-Barr Virus Infection