Pancreatitis and cholecystitis in primary acute symptomatic Epstein-Barr virus infection - Systematic review of the literature

Marked gallbladder wall thickening caused by Epstein-Barr virus-induced infectious mononucleosis

Key Clinical Message

In patients with symptoms of viral infection and marked thickening of the gallbladder wall, it is important to suspect acalculous cholecystitis due to Epstein-Barr virus-induced infectious mononucleosis.

Abstract

A 35-year-old Japanese man presented with fever, abdominal right upper quadrant pain, and liver dysfunction. Positive immunoglobulin M and -G antibodies and negative nuclear antigen for Epstein-Barr virus were observed. Abdominal ultrasonography revealed a markedly thickened gallbladder wall. Acalculous cholecystitis due to Epstein-Barr virus-induced infectious mononucleosis was diagnosed.

The role of Ca2+ signalling in the pathology of exocrine pancreas

Exocrine pancreas has been the field of many successful studies in pancreatic physiology and pathology. However, related disease - acute pancreatitis (AP) is still takes it toll with more than 100,000 related deaths worldwide per year. In spite of significant scientific progress and several human trials currently running for AP, there is still no specific treatment in the clinic. Studies of the mechanism of initiation of AP have identified two crucial conditions: sustained elevations of cytoplasmic calcium concentration (Ca2+ plateau) and significantly reduced intracellular energy (ATP depletion). These hallmarks are interdependent, i.e., Ca2+ plateau increase energy demand for its clearance while energy production is greatly affected by the pathology. Result of long standing Ca2+ plateau is destabilisation of the secretory granules and premature activation of the digestive enzymes leading to necrotic cell death. Main attempts so far to break the vicious circle of cell death have been concentrated on reduction of Ca2+ overload or reduction of ATP depletion. This review will summarise these approaches, including recent developments of potential therapies for AP.

Kidney tubular injury induced by valproic acid: systematic literature review

BACKGROUND

Valproic acid is prescribed for epilepsy and as prophylaxis for bipolar disorder and migraine headaches. It has also been implicated as a cause of a kidney tubular injury.

METHODS

We undertook a review of the literature to characterize the biochemical and histopathological features of the overt kidney tubular injury and to evaluate the possible existence of a pauci-symptomatic injury. The pre-registered review (CRD42022360357) was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. Searches were conducted in Excerpta Medica, the National Library of Medicine, and Web of Science. The gray literature was also considered.

RESULTS

For the final analysis, we retained 36 articles: 28 case reports documented 48 individuals with epilepsy on valproic acid for 7 months or more and presenting with features consistent with an overt kidney tubular injury. The following disturbances were noted: hypophosphatemia (N = 46), normoglycemic glycosuria (N = 46), total proteinuria (N = 45), metabolic acidosis (N = 36), hypouricemia (N = 27), tubular proteinuria (N = 27), hypokalemia (N = 23), and hypocalcemia (N = 8). A biopsy, obtained in six cases, disclosed altered proximal tubular cells with giant and dysmorphic mitochondria. Eight case series addressed the existence of a pauci- or even asymptomatic kidney injury. In the reported 285 subjects on valproic acid for 7 months or more, an isolated tubular proteinuria, mostly N-acetyl-β-glucosaminidase, was often noted.

CONCLUSIONS

Valproic acid may induce an overt kidney tubular injury, which is associated with a proximal tubular mitochondrial toxicity. Treatment for 7 months or more is often associated with a pauci- or oligosymptomatic kidney tubular injury. A higher resolution version of the Graphical abstract is available as Supplementary information.

Acute Pancreatitis and Disseminated Intravascular Coagulopathy in COVID-19 Infection: A Case Report

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and can be a plausible trigger for both disseminated intravascular coagulopathy (DIC) and acute pancreatitis. We present an 85-year-old male patient who presented with altered mental status and tested positive for COVID-19 infection. He was hypoxic with an incremental need for oxygen. He had clinical as well as imaging evidence of acute pancreatitis. Clinical evidence of bleeding was noted and lab findings were suggestive of DIC. Despite aggressive initial management, his clinical status continued to deteriorate and comfort care was sought eventually. This case highlights COVID-19 infection as a possible trigger for acute pancreatitis as well as DIC. It also highlights some of the differences in COVID-19-induced DIC, which fulfills the diagnostic criteria of DIC but has atypical findings.

Acute pancreatitis as an adverse effect of COVID-19 vaccination

While vaccination against COVID-19 has significantly improved the morbidity and mortality of the disease, with the increase in the administration of COVID-19 vaccines, it is more likely to observe their rare side effects in the clinical settings. Herein, we report a case of an 82-year-old man with history of coronary artery disease, prostate cancer in remission, gastroesophageal reflux disease, and hypothyroidism, who presented with acute pancreatitis few hours after receiving the third dose of Pfizer-BioNTech BNT162b2 mRNA COVID-19 vaccine, without other identified etiology. His symptoms were mild and he was discharged in a stable condition after improvement in his condition with supportive care.

The Pancreas and Known Factors of Acute Pancreatitis

Pancreatitis is regarded by clinicians as one of the most complicated and clinically challenging of all disorders affecting the abdomen. It is classified on the basis of clinical, morphological, and histological criteria. Causes of acute pancreatitis can easily be identified in 75–85% of patients. The main causes of acute, recurrent acute, and chronic pancreatitis are gallstone migration and alcohol abuse. Other causes are uncommon, controversial, or unexplained. For instance, cofactors of all forms of pancreatitis are pancreas divisum and hypertriglyceridemia. Another factor that should be considered is a complication of endoscopic retrograde cholangiopancreatography: post-endoscopic retrograde cholangiopancreatography acute pancreatitis. The aim of this study is to present the known risk factors for acute pancreatitis, beginning with an account of the morphology, physiology, and development of the pancreas.

Acute Pancreatitis in Individuals with COVID-19: A Case Report and Critical Review of Literature

Involvement of gastrointestinal tract has been reported in individuals diagnosed with COVID-19. Herein, we report a case of 65-year-old woman with type 2 diabetes mellitus, hypertension, and end-stage renal disease undergoing hemodialysis who was initially diagnosed with COVID-19 on a screening test. During the course of the disease, her respiratory symptoms remained mild; however, she developed acute pancreatitis leading to severe hypertension and hyperosmolar hyperglycemic state. During the hospitalization and treatment of acute pancreatitis, hyperglycemia, and hypertension, her condition improved and she was discharged in stable condition.

Association between Severe SARS-CoV-2 Infection and Severe Acute Pancreatitis in Pregnancy and Postpartum

INTRODUCTION

SARS-CoV-2 infection (COVID-19) affects the respiratory system but is not limited to it. The gastrointestinal symptoms are polymorphic, including diarrhea, vomiting, abdominal pain, and even acute pancreatitis (AP). Pregnant women are more vulnerable to SARS-CoV-2 infection and have a higher risk of severe outcomes of COVID-19.

CASE REPORT

We present a case report of a 31-year-old primigravid patient at 30 weeks of gestation, unvaccinated, with a medical history of thrombophilia, chronic nephropathy of unknown origin, hypertension, and optic neuropathy with left eye hemianopsia. She was diagnosed with moderate-to-severe COVID-19 and respiratory failure, with indication for cesarean section. Postpartum, she developed severe acute pancreatitis, complicated by peripancreatic and supradiaphragmatic abscesses. After 3 months of hospitalization and eight surgical interventions, the patient was discharged. A short mini-review of the literature is introduced.

CONCLUSION

Pregnant women with cardiovascular comorbidities are prone to severe complications of SARS-CoV-2 infection. Clinicians should be aware of the association of SARS-CoV-2 and AP in pregnant women.

Epstein-Barr virus-associated infectious mononucleosis with acute epididymitis: a case report

Background

Infectious mononucleosis due to the Epstein–Barr virus is an infectious disease that causes the appearance of atypical lymphocytes in the peripheral blood; it mainly presents with fever, tonsillar pharyngitis, and lymphadenopathy. In addition to hepatitis, splenomegaly, and rashes, it can involve different organs. Here, a case of epididymitis as a rare complication in a patient with Epstein–Barr virus-associated infectious mononucleosis was reported.

Case presentation

A healthy 23-year-old man visited an outpatient clinic with fever and pharyngitis. Tonsillar pharyngitis, lymphadenopathy, atypical lymphocytes in the peripheral blood, liver dysfunction, and splenomegaly were observed. The patient was diagnosed with infectious mononucleosis based on clinical signs. The next day, the patient developed left testicular pain and was immediately transferred to the emergency outpatient ward. Pain, redness, and swelling were observed in the left scrotum. Ultrasonography revealed swelling of the epididymis and increased blood flow, and the patient was hospitalized with a diagnosis of left epididymitis. The patient’s symptoms improved with symptomatic treatment and was discharged on day 16 after admission. Changes in antibody titers established a definitive diagnosis of infectious mononucleosis caused by the Epstein–Barr virus. Based on the disease course, the patient was also diagnosed with infectious mononucleosis associated with unilateral epididymitis.

Conclusions

This is the first case report of Epstein–Barr virus-associated infectious mononucleosis complicated with acute epididymitis. Infectious mononucleosis can cause numerous organ-related complications; thus, physicians and healthcare workers should remain cognizant of Epstein–Barr virus-associated complications throughout the body and not just in the primary organs affected by infectious mononucleosis.

COVID-19 associated pancreatitis: A mini case-series

INTRODUCTION

One of the recognized causes of acute pancreatitis is viral-induced pancreatitis. The SARS-COV-2 virus has been linked to pancreatic injury and hence the causation of acute pancreatitis. This paper reports three cases of acute pancreatitis linked to COVID-19 infection adding to serving to further consolidate evidence.

CASE PRESENTATION

Three patients aged between 63 and 87 years were diagnosed with acute pancreatitis and concomitant or previous COVID-19 infection. Criteria for diagnosis of pancreatitis were according to the revised Atlanta criteria. None of the patients had had previous episodes of pancreatitis and other aetiologies were not suggestive. The patients were not vaccinated against SARS-CoV-2. Supportive treatment was instituted for the three patients, and all made an uneventful recovery. Mean hospital stay was 4 days.

DISCUSSION

The diagnosis of acute pancreatitis in the presented cases is being linked to COVID-19 infection, as other causes were not evident. There is however a confounding factor, as the patient in case 2 had slightly elevated triglyceride levels and had been on long-term low dose atorvastatin, both of which are associated with a low risk of acute pancreatitis. However, she had never had pancreatitis prior to this presentation.

CONCLUSION

The novel virus SARS-COV-2 has also been linked to pancreatic damage and thus a possible causative factor in acute pancreatitis. This mini-case series presents three cases of acute pancreatitis in COVID-19 positive patients, in the absence of other risk factors. This phenomenon linking COVID-19 and pancreatitis has been expounded by other case reports and cohort studies from around the world. It is reasonable to acknowledge that, like other viruses, SARS CoV-2 may cause acute pancreatitis, although sounder evidence from the international community needs to be compiled.

Acute pancreatitis associated with severe acute respiratory syndrome coronavirus-2 infection: a case report and review of the literature

Introduction

We report a case of Severe acute respiratory syndrome coronavirus-2 infection with acute pancreatitis as the only presenting symptom. To the best of our knowledge, there are few case reports of the same presentation.

Case presentation

An otherwise healthy 44-year-old white male from Egypt presented to the hospital with severe epigastric pain and over ten attacks of nonprojectile vomiting (first, gastric content, then bilious). Acute pancreatitis was suspected and confirmed by serum amylase, serum lipase, and computed tomography scan that showed mild diffuse enlargement of the pancreas. The patient did not have any risk factor for acute pancreatitis, and extensive investigations did not reveal a clear etiology. Given a potential occupational exposure, a nasopharyngeal swab for polymerase chain reaction testing for severe acute respiratory syndrome coronavirus 2 was done, which was positive despite the absence of the typical symptoms of severe acute respiratory syndrome coronavirus 2 such as fever and respiratory symptoms. The patient was managed conservatively. For pancreatitis, he was kept nil per os for 2 days and received intravenous lactated Ringer’s (10 ml per kg per hour), nalbuphine, alpha chymotrypsin, omeprazole, and cyclizine lactate. For severe acute respiratory syndrome coronavirus 2, he received a 5-day course of intravenous azithromycin (500 mg per day). He improved quickly and was discharged by the fifth day. We know that abdominal pain is not a rare symptom of severe acute respiratory syndrome coronavirus 2, and we also know that elevated levels of serum amylase and lipase were reported in severe acute respiratory syndrome coronavirus-2 patients, especially those with severe symptoms. However, the association between severe acute respiratory syndrome coronavirus-2 infection and idiopathic acute pancreatitis is rare and has been reported only a few times.

Conclusion

We believe further studies should be conducted to determine the extent of pancreatic involvement in severe acute respiratory syndrome coronavirus-2 patients and the possible causality between severe acute respiratory syndrome coronavirus 2 and acute pancreatitis. We reviewed the literature regarding the association between severe acute respiratory syndrome coronavirus 2 and acute pancreatitis patients. Published data suggest that severe acute respiratory syndrome coronavirus 2 possibly could be a risk factor for acute pancreatitis.

Acute Pancreatitis in a Patient With COVID-19 After the Resolution of Respiratory Symptoms

The gastrointestinal (GI) involvement, including acute pancreatitis (AP) from the novel coronavirus disease-2019 (COVID-19), is increasingly being reported. Recent evidence suggests that the pathogenesis of COVID-19 is mediated by the angiotensin-converting enzyme 2 (ACE-2) receptors and transmembrane protease serine 2 (TMPRSS2) for “priming,” which is highly expressed in the pancreas. To our knowledge, there is no other reported case of AP associated with COVID-19 after the respiratory symptoms are resolved. In this article, we present a patient with COVID-19, who came with intractable epigastric pain and resolved respiratory symptoms. A diagnosis of AP complicated with COVID-19 was made after laboratory and imaging workup, which was successfully managed conservatively.

Severe fever with thrombocytopenia syndrome in Hefei: Clinical features, risk factors, and ribavirin therapeutic efficacy

OBJECTIVES

This study described the clinical features, risk factors, factors affecting the outcome of this disease, and ribavirin therapeutic efficacy for severe fever with thrombocytopenia syndrome (SFTS) patients in Hefei.

METHODS

Between April 2020 and July 2020, 62 cases admitted to the First Affiliated Hospital of Anhui Medical University were included in this study. Serum samples were collected from all patients, after which diagnosis was made via reverse transcription-polymerase chain reaction and via the use of a colloidal gold immunochromatography assay approach.

RESULTS

In multivariate analysis, the following factors were determined as risk factors for SFTS: Being a farmer (odds ratio [OR], 3.033), working in areas with weeds and shrubs (OR, 2.807), and being bitten by a tick (OR, 6.64). The rates of confusion, neck stiffness, viral encephalopathy, and the presence of liver damage were higher in the patients who died than that in the surviving ones. Additionally, the median of alanine aminotransferase, aspartate aminotransferase, lactate dehydrogenase, creatine phosphokinase, activated partial thromboplastin time, D-dimer, fibrinogen degradation products, creatinine, and urea was also higher in the patients who died. One of the 15 patients treated with ribavirin in the early stage could not survive (6.7%), whereas 11 of the 35 patients treated with ribavirin in the late stage could not survive (31.4%); this difference was statistically significant. However, there was no significant difference in mortality between the untreated group and the other two groups (i.e., patients who started antiviral treatment <5 days from the onset and those who started antiviral treatment ≥5 days from the onset). Moreover, there was no positive effect determined on clinical or laboratory parameters in SFTS patients treated with ribavirin. Also, it was observed that leukocyte levels and platelet levels took longer to return to normal.

CONCLUSIONS

In Hefei, clinical features, prognostic factors, and risk factors associated with SFTS are similar to those in other areas. Patients who were given ribavirin did not have better survival rates than patients who were not given ribavirin.

Pancreatic Injury after COVID-19 Vaccine-A Case Report

The COVID-19 pandemic has caused more than 3 million deaths worldwide. Recently developed genetically engineered vaccines are the most critical solution for controlling the pandemic. Clinical trials on a large number of participants confirmed their safety and efficacy. However, with the growing number of vaccinated people, new infrequent adverse effects have been reported, not described in the medicinal product characteristics. We would like to report a case of acute pancreatic injury that occurred shortly after administering Pfizer BioNTech COVID-19 mRNA vaccine (Comirnaty). The report points out the potential need for close monitoring of patients reporting abdominal pain after vaccination (unresponsive to standard oral painkillers) because such symptom can be associated with acute pancreatitis.

Pancreatic Damage and Radiological Changes in Patients With COVID-19

Background and objective

The novel coronavirus disease 2019 (COVID-19) primarily affects the lungs. However, others organs are also affected in varying degrees. We aimed to investigate the changes in pancreatic density on CT and its correlation with amylase/lipase values in patients diagnosed with COVID-19.

Materials and methods

Radiological changes using non-contrast CT and amylase/lipase values were evaluated retrospectively in patients admitted to the pandemic clinic. The patients were classified into two groups: [polymerase chain reaction (PCR)-positive and PCR-negative]. The correlation and difference between the data were evaluated statistically.

Results

There was no significant difference with respect to age and gender between the two groups (PCR-positive and PCR-negative). There was a significant difference in the head, neck, trunk, and tail of the pancreas and mean density values, but no statistically significant difference in amylase and lipase values between the two groups. No significant correlation was found using Spearman’s correlation test.

Conclusion

Based on our findings, pancreatic involvement and severe necrotizing pancreatitis can be seen in COVID-19 patients. Pancreatic involvement is more common in patients with severe disease. Patients with gastrointestinal complaints should be evaluated for pancreatitis and their amylase/lipase values should be assessed. We believe that decreased pancreatic density on CT scans can be an early sign of pancreatitis.

"Remdesivir-Associated Pancreatitis"

ABSTRACT

We report a case of acute pancreatitis that developed after four days of remdesivir therapy in a patient being treated for COVID-19. Despite improvement in patient's respiratory status, abdominal pain worsened and clinical signs and symptoms progressed to a diagnosis of acute pancreatitis 4 days after initiation of remdesivir therapy. Withdrawal of remdesivir paired with medical management of acute pancreatitis led to the resolution of pancreatitis within three days. To our knowledge, this is the first case report depicting remdesivir as a possible cause of acute pancreatitis.

Acute Pancreatitis as a Possible Unusual Manifestation of COVID-19 in Children

Coronavirus disease-2019 (COVID-19) which is caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has spread throughout the world causing problems for millions of people. Symptoms of COVID-19 in pediatric patients include both respiratory and gastrointestinal symptoms. The most common symptoms are fever, cough, and fatigue. In this report, we describe a case of a previously well 14-year-old boy, who presented to our emergency department with a complaint of abdominal pain, nausea, and vomiting without fever or respiratory symptoms. He was diagnosed with acute pancreatitis based on an abnormal amylase level and abdomen computed tomography (CT) and later found to be infected by SARS-CoV-2, by a positive reverse transcriptase-polymerase chain reaction (RT-PCR) test.

Emerging Clinical Features of COVID-19 Related Pancreatitis: Case Reports and Review of the Literature

INTRODUCTION

SARS-CoV-2 is fundamentally a respiratory pathogen with a wide spectrum of symptoms. The COVID-19 related pancreatitis is less considered than other clinical features. The purpose is to describe two cases of pancreatitis associated with COVID-19.

METHODOLOGY

Patients' demographics, clinical features, laboratory, and instrumental findings were collected.

RESULTS

Two patients admitted to the hospital were diagnosed with COVID-19 and severe acute pancreatitis, according to the Atlanta criteria. Other causes of acute pancreatitis were excluded. Treatment included broad-spectrum antibiotics, proton pump inhibitors, and low molecular weight heparin. Steroids, oxygen, antifungal treatment, and pain killers were administered when appropriate. Both patients were asymptomatic, with normal vital parameters and blood exams, and were discharged in a good condition.

CONCLUSION

It is recommendable to include lipase and amylase on laboratory routine tests in order to evaluate the need for the abdominal CT-scan and specific therapy before hospital admission of the patients with COVID-19 related life-threatening acute pancreatitis.

An unusual presentation of COVID-19: Acute pancreatitis

Novel COVID-19 infectious disease typically presents with pulmonary symptoms like cough, shortness of breath, and fever. However, gastrointestinal manifestations of COVID-19 are increasingly being recognized and drawn significant attention. We report an atypical case of acute pancreatitis in a patient with SARSCoV2 infection. CT scan of the abdomen showed findings suggestive of acute interstitial edematous pancreatitis with a CT severity index was 3. HRCT chest revealed multifocal ground glass opacities in both lungs with a CORADS score of 5. Later, nasal swab for COVID RT-PCR tested positive. The patient was treated symptomatically with fluid replacement, optimization of electrolyte balance and oxygen supplementation. She had an uneventful recovery with gradual resolution of her abdominal and pulmonary symptoms. COVID-19 pathogenesis is believed to be mediated by the angiotensin converting enzyme 2 (ACE-2) receptor over the cell surface. ACE-2, which acts as a receptor for viral entry into host cells are highly expressed in pancreatic cells. All the reported cases of COVID-19 pancreatitis so far are known cases of COVID 19 pneumonia, developed acute pancreatitis or pancreatic injury in due course or during recovery of the illness. Ours is the first case to present with features of acute pancreatitis without any pulmonary symptoms, who turned out to be positive for COVID 19 during workup. Clinicians involved in the management of acute pancreatitis should be aware of its existence in the context of COVID-19. Further studies are needed to establish the real prevalence and clinical significance of pancreatic injury in COVID-19 patients.

Coronavirus disease-19 (COVID-19) associated with acute necrotising pancreatitis (ANP)

Coronavirus is a severe infectious disease (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and has led to increased mortality worldwide. Multiple reports have been published citing that gastrointestinal symptoms are common in patients with COVID-19 infection. It has also been found that the ACE2 receptor of SARS-CoV-2 is expressed more in the pancreas than the lungs. Despite this, little attention has been paid to the extent and details of pancreatic injury caused by COVID-19. Lack of awareness regarding the COVID-19 status of patients presenting with pancreatitis may expose healthcare workers to SARS-CoV-2 while performing interventions to manage complications of pancreatitis such as necrosis. We report a case of COVID-19-induced acute necrotising pancreatitis in the absence of any known risk factors.

COVID-19 Presenting as Acute Abdominal Pain: A Case Report

As the spread of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) continues across the globe, more details about the disease manifestations and clinical course have been emerging. The main clinical presentation of the ongoing coronavirus disease-19 (COVID-19) pandemic is respiratory symptoms. Along with this, the involvement of the gastrointestinal system and associated symptoms have also been reported. Here we present a case of a 58-year-old patient who presented with acute abdominal pain and was diagnosed with acute pancreatitis. He did not have any respiratory symptoms, but had radiological evidence of lung involvement and was diagnosed to be positive for COVID-19.

COVID-19 presenting as acute pancreatitis

The ongoing pandemic of Coronavirus disease-2019 (COVID-19) has spread over 200 countries worldwide, affecting >2 million people and >120,000 deaths. COVID-19 is caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). The most common symptoms include cough, shortness of breath, and fever. However, gastrointestinal manifestations of COVID-19 are increasingly being recognized. Herein, we report a case of COVID-19 who presented with acute pancreatitis (AP) without any other risk factors.

Acute Acalculous Cholecystitis from Infection with Epstein-Barr Virus in a Previously Healthy Child: A Case Report

Background

Acute cholecystitis is the acute inflammation of the gallbladder. In adults it is most frequently caused by a gallstone(s) obstructing outflow from the cystic duct, leading to gallbladder distention and edema with eventual development of biliary stasis and bacterial overgrowth, often requiring operative management. However, in children acalculous cholecystitis is more common and is often the result of an infectious process.

Case Report

Here we present a case of acute acalculous cholecystitis caused by infection with Epstein-Barr virus in an otherwise healthy three-year-old male.

Conclusion

Acalculous cholecystitis is an uncommon but potentially significant complication of Epstein-Barr virus infection in the pediatric population. Emergency providers should consider this diagnosis in any child being evaluated for EBV with the complaint of abdominal pain.

Infectious mononucleosis complicated by peritonsillar abscess and postural orthostatic tachycardia syndrome: A case report

An unusual case of infectious mononucleosis complicated by both peritonsillar abscess and postural orthostatic tachycardia syndrome is reported. The patient was diagnosed with Epstein-Barr virus infection early in the disease course by her primary care doctor. She subsequently developed a peritonsillar abscess requiring hospitalisation. Recovery was complicated by the development of postural orthostatic tachycardia syndrome. However, resolution was achieved over the course of approximately 1 year, via conservative measures including graded exercise therapy, without resorting to pharmacotherapy.

Primary Epstein-Barr Virus Infection in an Adolescent Female Complicated by Acute Acalculous Cholecystitis

Epstein-Barr Virus (EBV) is estimated to infect greater than 98% of adults worldwide and is one of the most common human viruses. EBV infection can lead to acute infectious mononucleosis characterized by fever, fatigue, malaise, sore throat, and lymphadenopathy. Elevated liver function tests (LFTs) and hepatosplenomegaly may also be present. This infection usually lasts over a period of weeks or months and is self-limited. Infected individuals, however, may suffer rare complications. Acute acalculous cholecystitis (AAC) is an atypical complication of infectious mononucleosis. The case of a young healthy adolescent female with primary EBV infection complicated by AAC is reported. Providers should be aware that many pediatric and adult cases of AAC due to EBV resolve with conservative treatment. Surgical intervention has not been described as necessary or indicated in the context of AAC caused by EBV and should only be considered in severe cases that are not responding to conservative therapy.

Learning from tragedy: the Julia Berg story

This is a case report involving diagnostic errors that resulted in the death of a 15-year-old girl, and commentaries on the case from her parents and involved providers. Julia Berg presented with fatigue, fevers, sore throat and right sided flank pain. Based on a computed tomography (CT) scan that identified an abnormal-appearing gall bladder, and markedly elevated bilirubin and "liver function tests", she was hospitalized and ultimately underwent surgery for suspected cholecystitis and/or cholangitis. Julia died of unexplained post-operative complications. Her autopsy, and additional testing, suggested that the correct diagnosis was Epstein-Barr virus infection with acalculous cholecystitis. The correct diagnosis might have been considered had more attention been paid to her presenting symptoms, and a striking degree of lymphocytosis that was repeatedly demonstrated. The case illustrates how cognitive "biases" can contribute to harm from diagnostic error. The case has profoundly impacted the involved healthcare organization, and Julia's parents have become leaders in helping advance awareness and education about diagnostic error and its prevention.

Acute Acalculous Cholecystitis due to primary acute Epstein-Barr virus infection treated with laparoscopic cholecystectomy; a case report

Introduction

Epstein Barr virus (EBV) is a human herpes virus 4, transmitted through intimate contact between susceptible persons and asymptomatic EBV shedders. It usually presents with fever, pharyngitis and lymphadenopathy. Majority of individuals with primary EBV infection recover uneventfully. Acute Acalculous Cholecystitis (AAC) is usually seen in hospitalized and critically ill patients with major trauma, shock, severe sepsis, total parenteral nutrition and mechanical ventilation.

Case presentation

We report a 25-year- old woman presented with acute Epstein-Barr Virus (EBV)infection and hepatobiliary iminodiacetic acid (HIDA) scan confirmed presence of Acute Acalculous Cholecystitis (AAC). Conservative management was advised initially, but she had a laparoscopic cholecystectomy due to intolerable abdominal pain.

Conclusion

AAC is a rare complication of acute EBV infection and it is usually managed conservatively, although our patient had laparoscopic cholecystectomy due to intolerable abdominal pain.

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Acute Acalculous Cholecystitis (AAC) is a rare complication of acute EBV infection.

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AAC should be suspected in patient with acute EBV infection, presenting with abdominal pain.

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Management is usually conservative without surgical intervention.

Infectious mononucleosis - not always a benign condition: a case report of infectious mononucleosis-associated acute acalculous cholecystitis

Infectious mononucleosis is typically a self-limited viral infection of adolescence and early adulthood that resolves in a period of weeks, causing no major sequelae. We describe a case of a healthy 18-year-old female diagnosed with infectious mononucleosis who also presented with right upper quadrant abdominal pain, moderate transaminitis, and cholestatic biochemistry. An ultrasound revealed acute acalculous cholecystitis, generally a condition seen in the context of critical illness. Further investigating emergency department patients with infectious mononucleosis is often not indicated, but may be important for those who present atypically.