P3902 - Atypical Presentation of Epistein-Barr Virus Infection With Cholestatic Hepatitis Without Pharyngitis in a 19-Year-Old Woman: A Case Report

Joane Titus, MD, Roger Crouse, MD, Takuma Iwai,
UCF College of Medicine/HCA Osceola, Orlando, FL

Introduction: Epstein-Barr virus (EBV) typically infects young adults causing a syndrome known as mononucleosis characterized by fever, pharyngitis, and lymphadenopathy. EBV causing hepatitis with a mixed hepatic and cholestatic picture, including jaundice and pruritus without pharyngitis is exceedingly rare (about 5% of cases). We report a case of EBV hepatitis in a 19-year old woman who not only had a mixed hepatic/cholestatic picture, but was also unassociated with the usual pharyngeal presentation of disease.

Case Description/Methods: A 19-year-old woman presented with a 2-week history of non-bilious vomiting, anorexia, and chills associated with fatigue and malaise for one month. Physical exam confirmed jaundice, absence of lymphadenopathy, pharyngitis or tonsillar exudates. She had right upper quadrant tenderness with hepatosplenomegaly. Laboratory testing included mild leukocytosis (10,900 mm3) with 69% atypical lymphocytes, total bilirubin of 2.9mg/dL (direct 2.2mg/dL), AST-273 units/L, ALT-521 units/L and Alkaline Phosphatase of 296 units/L, negative hepatitis panel, negative HIV, negative CMV, and negative anti-smooth muscle antibodies. Abdominal ultrasound was negative for gallstones. Heterophile antibody test (Monospot) was positive, the EBV panel showed a positive early antigen greater than 8.0 AI (normal range 0.0-0.8 AI). EBV DNA (PCR) results showed 251 copies/mL. Peripheral blood smear showed atypical lymphocytosis with the presence of Downey type II lymphocytes. Treatment included supportive therapies with fluid resuscitation, and anti-nausea medications. On the fifth day the patient reported pruritus. Bile acids were 173.4 umol/L (normal range 0-10 umol/L). A bile acid sequestrant was administered and a diagnosis of cholestatic hepatitis was made. Two weeks after discharge she still endorsed fatigue, and had complete resolution of her pruritus.

Discussion: This atypical presentation of EBV infection causing cholestatic hepatitis is rare. To our knowledge this is first case which describes liver involvement without pharyngitis in a young individual. By detailing this atypical presentation of viral hepatitis due to EBV, the authors want to emphasize the need to consider EBV as a cause of cholestatic or non-cholestatic hepatitis, with or without pharyngitis, when evaluating a patient with acute hepatitis.



Disclosures:


Joane Titus, MD, Roger Crouse, MD, Takuma Iwai, . P3902 - Atypical Presentation of Epistein-Barr Virus Infection With Cholestatic Hepatitis Without Pharyngitis in a 19-Year-Old Woman: A Case Report, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.