P1003 - A Rare Case of Clinical EBV Hepatitis in a 44-Year-Old Male With Mononucleosis

Rahul Patel, DO¹, Rohan Umrani, DO¹, Charles Yang, DO¹, Neethi Dasu, DO², C. Jonathan Foster, DO^3
1Jefferson Health, Stratford, NJ; ²Jefferson Health, New Jersey, NJ; ³Jefferson Health, Cherry Hill, NJ

Introduction: Epstein-Barr Virus (EBV) associated mononucleosis is an illness typically prevalent and symptomatic in 15–24-year-old individuals. While transaminitis is a common finding in these patients, it is often less than five-fold normal levels. We present a rare case of EBV hepatitis with severe cholestatic hyperbilirubinemia.

Case Description/Methods: A 44-year-old male presented with one week of nausea, jaundice and fevers. Patient is chronically on atomoxetine for ADHD but had not been taking it due to his symptoms. He consumed alcohol one to two times per month and was not taking any supplements. Admission vitals were significant for a HR of 102 BPM. Physical exam demonstrated jaundice, scleral icterus, shotty posterior cervical lymph nodes, tender supraclavicular left lymph node, palpable splenomegaly with left upper quadrant tenderness to palpation and no purulent tonsils. Initial labs were significant for total bilirubin 7.9 mg/dL, direct bilirubin 5.1 mg/dL, alkaline phosphatase 408 IU/L, AST 453 IU/L, ALT 620 IU/L, ferritin of 1340 nG/mL, WBC 13.2 B/L, INR 1.01, reactive mono screen and negative acetaminophen level. Blood smear demonstrated lymphocytosis. Abdominal ultrasound showed mild gallbladder wall thickening. CT of the abdomen and pelvis demonstrated hepatosplenomegaly, gallbladder with mild pericholecystic edema. HIDA scan was done which was negative. The etiology of liver injury was unknown and NAC was started but shortly discontinued after patient had flushing and dyspnea. Two days later, patient had an eruption of a diffuse maculopapular rash on chest and back with spreading to lower extremities likely related to mono. Hepatitis panel, CMV, anti-smooth muscle antibody were negative. The patient had a positive ANA titer (1:80), and positive EBV IgM. Following conservative management, liver function tests down trended and was discharged.

Discussion: This case demonstrates an unusual presentation of EBV hepatitis with mononucleosis in a 44-year-old male. The patient had severely marked hyperbilirubinemia with a cholestatic pattern. During the acute phase of EBV infection, transaminitis is found in 80% of cases, and jaundice in 5-10%. EBV typically leads to mild elevation of aminotransferases less than five-fold normal levels. Our patient was initially managed with NAC but aborted shortly thereafter due to an allergic reaction. Although data for its utility outside of acetaminophen toxicity is limited. NAC may be beneficial, but more research is needed to assess its efficacy.


Disclosures:


Rahul Patel, DO¹, Rohan Umrani, DO¹, Charles Yang, DO¹, Neethi Dasu, DO², C. Jonathan Foster, DO³. P1003 - A Rare Case of Clinical EBV Hepatitis in a 44-Year-Old Male With Mononucleosis, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.