P1848 - A Rare Case of EBV Reactivation in an Immunocompetent Patient

Teresa Da Cunha, MD, Sheena Mago, DO, Roopjeet K. Bath, MBBS
University of Connecticut Health Center, Farmington, CT

Introduction: Hepatic involvement during an active primary Epstein-Barr virus (EBV) infection often results in mild, self-resolving elevation of transaminases and is associated with infectious mononucleosis (IM). EBV rarely reactivates, and most cases occur in immunocompromised individuals. We present a rare case of EBV reactivation in an immunocompetent patient only presenting with cholestatic liver injury.

Case Description/Methods: A 19-year-old female with a history of resolved EBV IM one year prior presented with dark urine and jaundice. She had no fever, abdominal pain, nausea, vomiting, weight changes or night sweats. She had no history of illicit drug, tobacco or alcohol use, recent travel, or sick contacts. Her medications were loratadine and an OCP; she denied use of acetaminophen or herbal supplements. Family history was unrevealing. On exam she was jaundiced but otherwise normal. Initial laboratory tests showed AST 97 U/L, ALT 75 U/L, ALP 165 U/L, T-BILI 8.1 mg/dL, D-BILI 5.7 mg/dL. CT abdomen revealed splenomegaly. Work up revealed ASMA titer (1:40), but otherwise negative/ normal ANA, IgG, AMA, HCV Ab, HBV serologies, HAV IgM, CMV PCR, iron studies, tick borne serologies, SARS CoV-2 PCR, A1AT and ceruloplasmin. On the second day, the T-BILI peaked to 12.4 mg/dL, AST 151 U/L, ALT 131 U/L, ALP 237 U/L. (Fig.1) EBV serologies were positive (EBV VCA IgG >750.0 U/ml, EBV VCA IgM >160.0 U/ml), EBV viral load of 23,500 copy/ml and negative monospot test. On day four, the LFTs improved and she was discharged. One month later LFTs had normalized, and she was asymptomatic.

Discussion: EBV reactivation causing cholestatic liver injury is extremely rare in immunocompetent individuals. Furthermore, EBV-induced hepatitis is usually associated with IM but our patient’s sole complaint was jaundice and dark urine. Interestingly, she had mononucleosis due to EBV one year prior with unremarkable LFTs. The fact that the hepatitis was caused by the reactivation of the virus instead of a primary infection may be the reason for lack of other symptoms. It is unclear whether EBV reactivation increases the risk of hepatitis. The diagnosis can be made without a liver biopsy if thorough work up for hepatitis is negative and the EBV serologies are positive. The disease is often self-limited and the use of antivirals is controversial and thus there is no clear indication. Our case demonstrates that EBV reactivation presenting without the ‘classic’ IM symptoms may be under-recognized as a cause of cholestatic liver injury.


Figure: Fig. 1 Bilirubin and transaminases levels throughout the course of admission

Study	Age	Sex	Symptoms	Physical Exam	AST U/L	ALT U/L	ALP U/L	T BILI mg/dL	D BILI mg/dL	Treatment	Outcome
Salva et al.	6	M	Fever, vomiting, fatigue, choluria	Jaundice Hepatomegaly	97	166	NA	3.2	2.89	Supportive	Resolved
Hinedi et al.	29	F	Fever, chills, jaundice, cold like symptoms, jaundice	Jaundice Hepatosplenomegaly	277	251	976	7.5	5.5	Supportive	Resolved
Pisapia et al.	18	M	Fever, sore throat, arthromyalgias	Jaundice Pharyngotonsillitis Lymphadenopathy Hepatosplenomegaly	349	465	NA	8	NA	Valganciclovir	Resolved
Cauldwell et al.	21	M	Fever, headache, dry cough, myalgia, anorexia	Jaundice Fever	236	253	286	3.5	NA	Valganciclovir	Resolved
Sanchez et al.	24	F	Fever, myalgia, headache, odynophagia, cough	Fever Jaundice	723	647	708	9.6	NA	Supportive	Resolved
Edoute et al.	60	M	Fever, chills, malaise, anorexia	Fever Jaundice Hepatomegaly	95	102	118	5.4	4.7	Supportive	Resolved
Herold et al.	23	M	Jaundice, dark urine, fever, fatigue	Fever Jaundice Lymphadenopathy	692	753	198	7.9	6.9	Supportive	Improved

Table: Table 1 – Overview of the signs/symptoms, laboratory values, treatment and outcome for reported cases of EBV associated significant cholestatic hepatitis in immunocompetent individuals.


Disclosures:
Teresa Da Cunha indicated no relevant financial relationships.
Sheena Mago indicated no relevant financial relationships.
Roopjeet Bath indicated no relevant financial relationships.


Teresa Da Cunha, MD, Sheena Mago, DO, Roopjeet K. Bath, MBBS. P1848 - A Rare Case of EBV Reactivation in an Immunocompetent Patient, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.