Epstein-Barr virus-associated cholestatic hepatitis

Atypical Presentation of Epstein-Barr Virus Infectious Mononucleosis With Cholestatic Hepatitis and Hyperbilirubinemia in a Young Adult: A Case Report

This case report details the presentation of a 24-year-old male of South Asian descent with an atypical manifestation of Epstein-Barr virus (EBV) infectious mononucleosis, characterized by cholestatic hepatitis and hyperbilirubinemia. The patient initially presented with common symptoms of sore throat, intermittent fever, and general malaise, which subsequently progressed to include nausea and vomiting. Laboratory investigations revealed significantly elevated liver enzymes and bilirubin levels. Comprehensive serological testing confirmed an EBV infection. Despite the absence of typical risk factors, this case underscores the importance of considering EBV in the differential diagnosis for young adults presenting with both infectious symptoms and abnormal liver function tests. Early recognition of such atypical presentations is crucial for guiding appropriate management and avoiding unnecessary diagnostic procedures.

Epstein-Barr in a Patient Presenting with Right Upper Quadrant Pain: A Case Report from the Emergency Department

BACKGROUND

Right upper quadrant abdominal pain and elevated cholestasis blood tests are usually associated with bacterial calculous cholecystitis. However, viral infections, such as Epstein-Barr virus (EBV) can also manifest with a similar clinical picture and is an important differential diagnosis.

CASE REPORT

This case report discusses a young woman presenting to the emergency department with acute right upper quadrant abdominal pain. The initial assessment revealed a positive Murphy's sign, elevated white blood count, and a cholestatic pattern on liver function tests, leading one to suspect bacterial calculous cholecystitis and initiating antibiotic therapy. However, clinical examination also revealed tonsillar exudates and differential white blood cell count revealed monocytosis and lymphocytosis rather than a high neutrophil count. The patient tested positive for EBV. Furthermore, ultrasound and magnetic resonance imaging revealed gallbladder wall edema with no gallstones, leading one to conclude that the clinical manifestation and laboratory results were due to an EBV infection. Antibiotic therapy was ceased and the patient did not require surgical intervention. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Calculous bacterial cholecystitis usually entails antibiotic therapy and cholecystectomy. It is important to be aware of the differential diagnosis of EBV, as it usually does not require either of these and resolves spontaneously.

The influence of steroid therapy of complications of infectious mononucleosis on the course of Epstein-Barr virus hepatitis

Aim of the study

The purpose of the study was to characterize the differences in the course of Epstein-Barr virus (EBV) primary infection-induced hepatitis between patients treated with steroids due to complications of infectious mononucleosis (IM) and those not receiving such therapy.

Material and methods

We analyzed the changes in the activity of liver enzymes and differences in abdominal ultrasound results. The study was based on reviewing the medical records of children hospitalized for primary EBV infection at the Department of Children's Infectious Diseases, Medical University of Warsaw, Regional Hospital of Infectious Diseases in Warsaw, between August 2017 and March 2023. The study population was divided into two groups: patients treated with steroids (Group 1) and children not receiving steroids (Group 2).

Results

Significant differences were obtained for alanine aminotransferase activity only in the first week of IM (205.34 ±115.40 vs. 288.82 ±170.16 IU/l for Group 1 and 2, respectively; p = 0.024), and for aspartate aminotransferase in the first (170.63 ±159.47 vs. 218.85 ±128.22 IU/l for Group 1 and 2, respectively; p = 0.009) and the third week (151.09 ±138.57 vs. 235.50 ±170.27 IU/l for Group 1 and 2, respectively; p = 0.016). The analysis of the results of laboratory tests for the diagnosis of cholestasis (γ-glutamyl transferase and total serum bilirubin concentrations with fractions) did not show significant differences between the groups.

Conclusions

Our results indicated that the two cohorts of patients may differ in the course of hepatitis associated with primary EBV infection, especially at the beginning of the disease, when the laboratory features of hepatitis were less pronounced in children treated with steroids.

Epstein-Barr virus induced acute hepatitis with hyperferritinemia: A rare presentation

Elevated aminotransaminases and hyperbilirubinemia are common in primary Epstein-Barr Virus (EBV) infection in the adult and pediatric population and the disease course is usually subclinical and self-limited. However, EBV-induced hepatitis is an uncommon diagnosis, accounting for less than 1% of acute hepatitis causes. Acute EBV-hepatitis usually affects immunocompromised and older populations, with nearly half of patients being aged greater than 60 years. Significantly elevated ferritin levels correlate with severe infection and have been associated with EBV complications such as infectious mononucleosis, autoimmune hemolytic anemia, and hemophagocytic lymphohistiocytosis. We present a case of isolated acute cholestatic EBV-hepatitis and hyperferritinemia in an adult immunocompetent patient.

A rare presentation of infectious mononucleosis: cholestatic hepatitis with hyperbilirubinemia

Introduction

Epstein-Barr virus infection with mononucleosis is the most common presentation in young adults. Most infections are self-limited, although in a few cases complications can include serious conditions such as lymphoproliferative disorders or in less severe cases, mild hepatitis.

Case report

We present an unusual case of a young male with no liver disease, who presented with markedly elevated cholestatic pattern hyperbilirubinemia, as well as hepatitis. The patient responded well to symptomatic treatments, with spontaneous improvement of the hyperbilirubinemia and transaminitis.

Conclusions

Epstein-Barr virus mononucleosis can frequently present with mild elevation of transaminases, but very rarely can have marked elevation of bilirubin, which may make clinicians doubt that the infection is the sole culprit of the process.

Jaundice in relation to immune activation during Epstein-Barr virus-induced infectious mononucleosis

BACKGROUND

Liver involvement during infectious mononucleosis is common, but jaundice is considered rare. This study aimed to investigate serum bilirubin concentrations in patients with infectious mononucleosis and immune abnormalities associated with jaundice.

METHODS

We report on an adult patient with monoclonal B lymphocytosis and IgM-lambda gammopathy who developed a severe icteric hepatitis during infectious mononucleosis. We then reviewed the clinical records of 389 patients admitted to the hospital with infectious mononucleosis between 1995 and 2018 (51.7% male patients; median age, 19 years; range, 15-87 years) with focus on liver abnormalities and associated factors.

RESULTS

Fifty-nine patients (15.1%) had serum bilirubin concentrations between 1.5 and 3 mg/dL, and 47 patients (12.0%) had serum bilirubin >3 mg/dL. Patients with increased bilirubin concentrations had a distinct clinical presentation, with more frequent abdominal pain, nausea and vomiting, and less frequent sore throat than patients with normal bilirubin. Age and sex were not significantly different for the patients with increased and normal serum bilirubin concentrations. The patients with increased serum bilirubin concentrations showed higher levels of immune activation markers than the patients with normal bilirubin, including blood lymphocyte counts, serum IgM, and β₂-microglobulin concentrations. Heterophile antibody-positive patients (88.6%) showed similar bilirubin concentrations but higher aspartate aminotransferase and alkaline phosphatase levels than their heterophile-negative counterparts. Serum bilirubin elevations normalized quickly during follow-up.

CONCLUSIONS

Transient hyperbilirubinemia is common during severe (in-hospital) infectious mononucleosis in adult patients. Patients with hyperbilirubinemia have less frequent pharyngitis symptoms and more frequent abdominal symptoms. Hyperbilirubinemia during infectious mononucleosis is associated with immune activation markers.

The value of bile acid spectrum in the evaluation of hepatic injury in children with infectious mononucleosis caused by Epstein Barr virus infection

Background

Infectious mononucleosis (IM) is an acute infectious disease, caused by Epstein-Barr virus (EBV) infection, which can invade various systemic systems, among which hepatic injury is the most common. In this study, ultra performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) was used to detect serum bile acid spectrum in IM children quantitatively, and to investigate its role in the early assessment of hepatic injury.

Methods

This case-control study was conducted at Yuhuan People's Hospital. A total of 60 IM children and 30 healthy children were included in the study. Among 60 children with IM, 30 had hepatic injury, and 30 without hepatic injury. The clinical and laboratory data were analyzed, and the serum bile acid spectrum and lymphocyte subsets were evaluated in the three groups.

Results

There were statistically significant differences in cholic acid (CA), chenodeoxycholic acid (CDCA), deoxycholic acid (DCA), lithocholic acid (LCA), glycochenodeoxycholic acid (GCDCA), glycodeoxycholic acid(GDCA), glycolithocholic acid (GLCA), taurocholic acid (TCA), taurochenodeoxycholic acid (TCDCA), taurodeoxycholic acid (TDCA), ursodeoxycholic acid (UDCA), glycoursodeoxycholic acid (GUDCA), tauroursodeoxycholic acid(TUDCA), percentage of NK cells, CD4+ and CD8+ in IM hepatic injury group, without hepatic injury group, and the healthy control group (P < 0.05). The percentage of NK cells was positively correlated with TCA (P < 0.05); it was negatively correlated with CDCA, DCA, LCA, GCDCA, GDCA, GLCA, TDCA, UDCA, GUDCA, TUDCA (P < 0.05). CD4+ was positively correlated with CA, TCA and TCDCA (P < 0.05); it was negatively correlated with CDCA, DCA, LCA, GCDCA, GDCA, GLCA, TDCA, UDCA, GUDCA and TUDCA (P < 0.05). CD8+ was positively correlated with CDCA, DCA, LCA, GCDCA, GDCA, GLCA, TDCA, UDCA, GUDCA and TUDCA (P < 0.05); it was negatively correlated with CA, TCA and TCDCA (P < 0.05). ROC curve analysis showed that CD8+, GDCA and GLCA had high predictive value for hepatic injury in IM patients.

Conclusions

UPLC-MS/MS method can sensitively detect the changes in serum bile acid spectrum before hepatic injury in children with IM, which is helpful for early assessment of hepatic injury in children with IM. The changes in lymphocyte subsets in IM children are related to some bile acid subfractions, which may be related to IM hepatic injury.

Epstein-Barr Virus Hepatitis Masquerading as Painless Jaundice

Epstein-Barr virus (EBV) infection typically presents with pharyngeal symptoms and subclinical transaminitis. We present a case of a 27-year-old woman with no known past medical history who presented with painless jaundice and dark-colored urine for three days. Her review of systems was negative for fever, sore throat, nausea, vomiting, pruritus, or rash. Her last sexual contact was six months ago with a male partner, and she only drank alcohol socially. Family and surgical history were non-significant. Physical examination revealed 3+ bilateral conjunctival icterus without abdominal tenderness or organomegaly. She had elevated transaminases: alanine transaminase (ALT) of 1287U/L and aspartate aminotransferase of (AST) 1057U/L but her alkaline phosphatase (ALP) was only slightly above normal at 109U/L (normal range 35-104U/L), with a direct hyperbilirubinemia - total bilirubin 9.5mg/dl, direct bilirubin 6.8mg/dl; the abdominal ultrasound revealed non-dilated bile ducts. Hepatitis A, B, and C serology was negative, but her EBV serology showed an infection. She had incidental thalassemia minor without splenomegaly or asterixis. She was managed conservatively, and her liver enzymes trended down with supportive management. Although EBV is an uncommon cause of painless jaundice, this diagnosis should be considered, especially when other more common causes of jaundice have been ruled out. A high index of suspicion should be maintained to detect EBV hepatitis as it can easily be diagnosed through serological testing.

Cholestatic Hepatitis Secondary to Epstein–Barr Virus Infection in Children: Case Series and Review of the Literature

Objective Cholestatic hepatitis (CH) secondary to Epstein–Barr virus (EBV) infection is a rare clinical condition in children and adolescents, which was reported in 5% of patients. Herein, we aimed to present our pediatric cases of EBV-induced CH with a comprehensive review of previously reported patients.

Methods Three cases of EBV-induced CH diagnosed in our department were included in the study. EBV diagnosis was established with positive viral capsid antigen immunoglobulin M and immunoglobulin G. A search of English literature on pediatric cases with EBV-induced CH was conducted on common search engines (PubMed and GoogleScholar).

Results We report three novel cases (aged 6, 15, and 16 years) presented with infectious mononucleosis and jaundice. The physical examination revealed mild hepatomegaly in all of them. In our cases, a total of 21 pediatric patients with EBV-induced CH were reported until now (52.4% male), with a median age of 15 (1–18) years. Regarding all patients, the most common symptoms were fever (94.1%) and jaundice (84.6%). In laboratory results, aspartate aminotransferase [308 (62–2,148) IU/L], alanine aminotransferase [312 (79–899) IU/L], and γ-glutamyl transpeptidase [328.9 ± 198.6 IU/L] levels were elevated. Hyperbilirubinaemia was observed in all cases with a median direct bilirubin level of 3.9 (1.9–21.8) mg/dL. A thickened gallbladder wall was the most common (50%) finding in the abdominal ultrasonography of the cases. Most of the reported patients recovered under supportive treatment without any further morbidity.

Conclusions Although EBV-induced CH is an atypical presentation for children, it should be considered in the differential diagnosis of cholestasis. Supportive therapies are the mainstay of treatment in most of these cases.

North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Position Paper on the Diagnosis and Management of Pediatric Acute Liver Failure

ABSTRACT

Pediatric acute liver failure (PALF) is a rare, rapidly progressive clinical syndrome with significant morbidity and mortality. The phenotype of PALF manifests as abrupt onset liver dysfunction, which can be brought via disparate etiology. Management is reliant upon intensive clinical care and support, often provided by the collaborative efforts of hepatologists, critical care specialists, and liver transplant surgeons. The construction of an age-based diagnostic approach, the identification of a potential underlying cause, and the prompt implementation of appropriate therapy can be lifesaving; however, the dynamic and rapidly progressive nature of PALF also demands that diagnostic inquiries be paired with monitoring strategies for the recognition and treatment of common complications of PALF. Although liver transplantation can provide a potential life-saving therapeutic option, the ability to confidently determine the certainness that liver transplant is needed for an individual child has been hampered by a lack of adequately tested clinical decision support tools and accurate predictive models. Given the accelerated progress in understanding PALF, we will provide clinical guidance to pediatric gastroenterologists and other pediatric providers caring for children with PALF by presenting the most recent advances in diagnosis, management, pathophysiology, and associated outcomes.

Hepatocellular-Cholestatic Pattern of Liver Injury in a Patient With Infectious Mononucleosis

Hepatic dysfunction in the setting of infectious mononucleosis has been documented in the literature. However, clinically significant jaundice and direct hyperbilirubinemia are rarely associated with this infection. In the instance of undetermined underlying diagnosis and hepatic enzyme derangement, this may pose a diagnostic challenge. Furthermore, several diagnostic tests may be indicated, which could potentially increase resource consumption in any hospital setting. This case report aims to remind physicians that infectious mononucleosis may be a cause of hyperbilirubinemia, which does not usually require further complex testing other than monitoring and supportive therapy.

Unusual Presentation of Epstein-Barr Virus-Associated Cholestatic Hepatitis in an Infant

Epstein-Barr virus (EBV) infections are prevalent in the pediatric population but are subclinical in the majority of cases. Elevated transaminases in the acute setting rarely increase beyond 5 times the normal upper limit. We present a girl aged 1 y with fever, vomiting, and diarrhea. Although initial physical examination was unremarkable, she developed jaundice, hepatomegaly, abdominal distension, and a maculopapular rash during admission. Laboratory investigations revealed marked increase in transaminases (alanine aminotransferase 7,664.5 IU/L, aspartate aminotransferase 12,266 IU/L), elevated γ-glutamyl transferase (224 IU/L), and hyperbilirubinemia (total 130.7 µmol/L, direct 104.9 µmol/L). Abdominal ultrasound reported hepatomegaly with mild ascites. Serology revealed that both Monospot test and EBV immunoglobulin G were positive. With supportive therapy, improvement was noted within a week of symptom onset. We hereby elucidate the importance of considering EBV as a cause of acute cholestatic hepatitis in a very young pediatric patient who develops a rapid elevation of liver enzymes.

Jaundice as a Rare Manifestation of Epstein-Barr Virus Primary Infection

Epstein-Barr virus (EBV) primary infection usually presents with classic symptoms of infectious mononucleosis (IM) like fever, lymphadenopathies and tonsillopharyngitis. Liver damage is frequently mild and self-limited and there are only a few cases of severe EBV-induced cholestatic hepatitis and jaundice reported in the literature. The authors present the case of a 22-year-old woman who was admitted with acute fever and jaundice. Physical examination revealed posterior cervical lymphadenopathies and painful hepatosplenomegaly. Laboratorial findings suggested an obstructive cause for jaundice but ultrasound and magnetic resonance cholangiopancreatography excluded biliary duct pathology. Heterophile antibodies were negative but EBV-specific antibodies revealed isolated positive viral capsid antigen (VCA) immunoglobin (Ig) M suggesting the diagnosis of early phase of EBV primary infection. The diagnosis of EBV-induced cholestatic hepatitis was confirmed after identification of EBV deoxyribonucleic acid (DNA) in blood and by liver biopsy. Supportive management was provided and, despite an initial clinical deterioration, the patient had a favorable outcome. EBV is a virus with a high prevalence worldwide, mainly subclinical, and jaundice is a rare manifestation of the infection. Although the majority of the patients recover without sequelae, progression to liver failure has been described and a careful assessment for complications is mandatory. Therefore, EBV infection should be included in the comprehensive differential diagnosis of jaundice in all age groups.

Clinical characteristics of primary and reactivated Epstein-Barr virus infection in children

Epstein-Barr virus (EBV) infection occurs commonly in children and presents as a primary or reactivated infection, which are difficult for clinicians to distinguish. This study investigated the clinical characteristics of the two types of infections. Children with detectable plasma EBV-DNA were retrospectively enrolled and divided into primary and reactivated infection group by EBV-specific antibody. We analyzed the patients' characteristics, clinical manifestations, complications, inflammatory biomarkers, and viral load. A total of 9.3% of children with reactivation were immunocompromised over the long-term. The primary infection mostly appeared as infectious mononucleosis (99.8%), while reactivation occurred as an infectious mononucleosis-like disease (65.0%), hemophagocytic syndrome (22.6%), chronic active EBV infection (5.3%) and lymphoma (3.5%). The incidence of fevers, cervical lymphoditis, periorbital edema, pharyngotonsillitis, hepatomegaly and splenomegaly in primary infection were 93.3%, 93.0%, 51.5%, 66.0%, 76.2% and 63.9%, respectively; the incidence of those symptoms in reactivation was 84.0%, 46.9%, 15.4%, 18.5%, 18.5%, and 43.3%, respectively. The incidence of digestive, respiratory, cardiovascular, neurological, hematological, genitourinary complications and multiple serous effusion in primary infection was 68.8%, 18.1%, 8.0%, 0.8%, 2.9%, 0.0% and 2.3%; whereas the incidence of these complications in reactivation was 56.2%, 22.5%, 14.1%, 8.0%, 38.9%, 0.3% and 19.0%. Patients with reactivation were more prone to multi-systemic damage. B-cells were lower, and CD8+ T-cells were higher in primary infection. Viral load was correlated with the level of different cytokines in primary and reactivated infection. EBV primary infection often presents as infectious mononucleosis. The reactivated infection affects more immunocompromised subjects with diverse and complex manifestations. Various complications are more commonly associated with reactivation as a result of different inflammatory responses to different types of infection.

Epstein-Barr Virus and Cytomegalovirus Infections of the Liver

Epstein-Barr virus (EBV) and cytomegalovirus (CMV) infections are common and are associated with a variety of liver manifestations. EBV and CMV infections, in immunocompetent hosts, commonly manifest as acute hepatitis, with severity varying from asymptomatic, self-limited icteric hepatitis to acute liver failure. Atypical manifestations, such as cholestasis, chronic hepatitis, precipitation of acute-on-chronic liver failure, and autoimmune hepatitis, are reported with EBV infection, whereas cholestasis, portal vein thrombosis, and Budd-Chiari syndrome are reported with CMV infection. In the setting of liver transplantation, CMV is the most common infectious complication and carries significant morbidity; EBV is the major cause of post-transplant lymphoproliferative disorders.

Acute Liver Injury due to Severe Epstein-Barr Virus Infection

Epstein-Barr virus (EBV) is a widely dispersed herpesvirus, transferred through close personal contact between susceptible individuals and asymptomatic shedders of the virus. The liver is often affected, and involvement is usually subclinical and self-limited. However, immunocompromised patients and, more rarely, immunocompetent individuals can develop a severe and potentially fatal acute liver injury. To differentiate EBV hepatitis from other conditions, such as autoimmune hepatitis, lymphoproliferative disorders, and drug-induced liver injury, correlation with clinical history, laboratory findings, and histopathologic features is crucial. We report a unique case of a man who developed acute liver injury from a severe EBV infection.

Epstein-Barr Virus-induced Jaundice

Infectious mononucleosis is primarily caused by Epstein-Barr virus (EBV) and is a common diagnosis made in emergency departments worldwide. Subclinical and transient transaminase elevations are a well-established sequela of EBV. However, acute cholestatic hepatitis is a rare complication. EBV infection should be considered as part of the differential diagnosis in patients with an obstructive pattern on liver function tests without evidence of biliary obstruction demonstrated on advanced imaging.

Acute hepatitis due to infectious mononucleosis

The syndrome of infectious mononucleosis is commonly seen with Epstein-Barr virus (EBV) infection. It may cause acute hepatitis, which is usually self-limiting and characterised by mildly elevated liver enzymes, but rarely jaundice. The patient being reported showcases EBV infection with jaundice, which is an uncommon scenario.

Acute hepatitis due to Epstein-Barr virus with cross-reacting antibodies to cytomegalovirus

Epstein-Barr virus (EBV) is the cause of systemic infection known as infectious mononucleosis with classic presentation of fever, oropharyngitis and lymphadenitis. EBV rarely causes acute hepatitis. In this report, we present a 19-year-old patient presented with nausea, fatigue and jaundice. Her physical examination and laboratory tests revealed the diagnosis as acute hepatitis due to EBV with cross-reacting antibodies to cytomegalovirus.

Acute Epstein - Barr virus hepatitis without mononucleosis syndrome: a case report

Elevated liver enzymes accompanied by Infectious Mononucleosis syndrome are widely seen in primary Epstein-Barr virus infection while acute symptomatic hepatitis without typical presentations of EBV is extremely rare. In the following report, we present a patient with acute isolated hepatitis due to laboratory confirmed Epstein-Barr virus.