P1004 - A Rare Case of Isolated EBV Hepatitis Without Mononucleosis

Rohan Umrani, DO¹, Rahul Patel, DO¹, Charles Yang, DO¹, Trinava Roy, 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) is a commonly encountered virus that is typically associated with infectious mononucleosis. While it is known that EBV can have other disease manifestations, these are less commonly encountered. We present a rare case of EBV hepatitis with severe hyperbilirubinemia.

Case Description/Methods: A 26-year-old female presented with one week of vomiting, fevers, and jaundice. One day prior to illness onset, she consumed shellfish. She also consumed ashwagandha for one month prior to symptom onset. Admission vitals were significant for HR 130 BPM. Physical exam demonstrated jaundice, and scleral icterus without cervical lymphadenopathy, tonsillar erythema or hepatosplenomegaly. Initial labs were significant for, total bilirubin 24.9 mg/dL, direct bilirubin 15.8 mg/dL, alkaline phosphatase 363 IU/L, AST 624 IU/L, ALT 823 IU/L, GGT 373 IU/L, LDH 1,103 IU/L, WBC 17.2 B/L, Hb 11.7 g/dL, Plt 301 B/L, INR 1.09, and negative acetaminophen level. Blood smear demonstrated atypical lymphocytes. Due to the unclear etiology of the liver injury and possible toxic interaction with ashwagandha, she was empirically treated with N-acetylcysteine (NAC) for three days. Abdominal ultrasound and MRCP demonstrated hepatic steatosis. Hepatitis panel, CMV, antimitochondrial antibody, anti-smooth muscle antibody were negative. Serum copper, ceruloplasmin, and phosphatidylethanol were unremarkable. The patient had a positive ANA titer (1:160), and positive EBV IgM and IgG, suggesting acute EBV hepatitis without mononucleosis. After 3 days of NAC, the patient’s liver function tests and symptoms improved and was discharged.

Discussion: This case demonstrates an unusual presentation of EBV hepatitis without mononucleosis in an immunocompetent patient. The patient’s marked hyperbilirubinemia and cholestatic hepatitis prompted an investigation that included evaluation for structural, infectious, autoimmune and toxin related etiologies. EBV leads to mild elevation of aminotransferases less than five-fold normal levels. Prior case reports have demonstrated hepatitis with concomitant mononucleosis, however, the severity of hyperbilirubinemia seen in this case is rare. This may be related to the patient’s concurrent use of ashwagandha, which has rarely been implicated in drug induced liver injury. Our patient was managed with NAC, although data for its utility outside of acetaminophen toxicity is limited. NAC may be beneficial, but more research is needed to assess its efficacy in this patient population.


Disclosures:


Rohan Umrani, DO¹, Rahul Patel, DO¹, Charles Yang, DO¹, Trinava Roy, DO¹, Neethi Dasu, DO², C. Jonathan Foster, DO³. P1004 - A Rare Case of Isolated EBV Hepatitis Without Mononucleosis, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.