P2907 - Blame It on the Virus: An Interesting Case of Epstein-Barr Virus-Induced Autoimmune Hepatitis

Chad Kaplan, MD, Jeremy Polman, DO, MS, MBA, Maheswar Rao, MD
Baton Rouge General Medical Center, Baton Rouge, LA

Introduction: The Epstein-Barr virus (EBV) has been cited as one of many potential triggers of autoimmune related diseases. Although rare, there have been documented cases of acute EBV infection related to autoimmune hepatitis (AIH). Here, we present one such case.

Case Description/Methods: A 19-year-old Caucasian female with a past medical history of assumed infectious mononucleosis presents to the emergency department with nausea, loss of appetite, and muscle cramps for the past week. She denied sore throat, rash, or weight loss. Physical exam revealed scleral icterus and splenomegaly without lymphadenopathy. Laboratory studies revealed AST 1014 U/L, ALT 1027 U/L, ALP 243 U/L, and total bilirubin 2.3 mg/dL. CT scan of the abdomen revealed an enlarged spleen (21.5cm) with a normal appearing liver. Upon admission to the hospital, the patient underwent an extensive hepatic evaluation seen in table 1, all of which were negative. Given history of mononucleosis per patient memory, EBV IgM and IgG were evaluated. IgM was found to be slightly detectable at 43.8 U/ml while IgG was undetectable. After receiving supportive care 5 days, liver enzymes gradually improved and the patient was discharged to home. Two weeks later, the patient presented with similar symptoms and elevated liver enzymes with ALT 1005 U/L, AST 1242 U/L, ALP 211 U/L, and total bilirubin 4.0 mg/dL. Repeat EBV IgM was 87.8 U/mL and EBV IgG was now detectable at 23.2 U/mL. A liver biopsy was obtained which showed severe active interface and lobular hepatitis with bridging necrosis and abundant plasma cells suggestive of autoimmune hepatitis. EBV was notably absent from biopsy. Prednisone 40mg daily was started empirically. After initiation of therapy, patient’s LFTs gradually improved, prompting discharge home with Prednisone 40mg to be taken once a day. The patient was evaluated one month after discharge, at which point liver enzymes had returned to normal. Azathioprine 50mg twice daily was started with concomitant Prednisone taper.

Discussion: As demonstrated by this case, the history of EBV was a major consideration, prompting serial testing. Although the patient states she had a clinical history of mononucleosis, initial serological evaluation for EBV IgG was undetectable. Ultimately, the patient seroconverted from acute infection with EBV IgM positivity followed by EBV IgG positivity two weeks later. The pathology findings on liver biopsy were consistent with AIH, and it is suspected that acute EBV infection triggered AIH in this patient.

Hepatitis A Virus IgM	Non-Reactive
Hepatitis B Virus Surface Antigen	Non-Reactive
Hepatitis B Virus Core IgM Antibody	Non-Reactive
Hepatitis C Virus	Non-Reactive
Ferritin	9.1 ng/mL
Ceruloplasmin	23.3 mg/dL
Alpha 1 Antitrypsin	102 mg/dL
Anti-Smooth Muscle Antibody	Negative
Mitochondrial M2 Antibody	Negative
HSV 1, 2	Negative
C-ANCA	Negative
P-ANCA	Negative
Atypical P-ANCA	Negative
HIV	Negative
Parvo IgG, IgM	Negative
Liver Kidney Microsomal Antibody Type 1	Negative
Direct Coombs Test	Negative
ANA	Negative
TTG IgA, IgG	Negative
Antigliadin IgA, IgG Antibody	Negative

Table: Table demonstrating extensive hepatitis workup with negative results.


Disclosures:
Chad Kaplan indicated no relevant financial relationships.
Jeremy Polman indicated no relevant financial relationships.
Maheswar Rao indicated no relevant financial relationships.


Chad Kaplan, MD, Jeremy Polman, DO, MS, MBA, Maheswar Rao, MD. P2907 - Blame It on the Virus: An Interesting Case of Epstein-Barr Virus-Induced Autoimmune Hepatitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.