B0606 - A Case of EBV Hepatitis Complicated by Hemolytic Anemia

Munraj Singh, MD, Scott R. Piechocki, MD, MS
Louisiana State University Health Sciences Center, New Orleans, LA

Introduction: Epstein-Barr virus (EBV) infection is highly prevalent in the first 2 decades of life and approximately 90% of the US population is seropositive for the infection before the age of 25. EBV infection usually manifests as the clinical syndrome of infectious mononucleosis, which presents as headaches, malaise and low-grade fevers with symptom resolution in 1-2 weeks. Other manifestations of EBV infections include evidence of mild hepatocellular damage and rarely hemolytic anemia. However, jaundice, symptomatic hepatitis and hospital admission is uncommon, specifically in the absence of infectious mononucleosis symptoms.

Case Description/Methods: A 23-year-old woman with no past medical history presented with one week history of generalized malaise, right upper quadrant abdominal pain, jaundice and dark urine. Initial laboratory studies were notable for WBC 16.3 K/uL, Hb 8.8 gm/dL, Haptoglobin < 30 mg/dL, LDH 845 U/L, Reticulocyte count 11.8 %, INR 1.0, AST 127 U/L, ALT 118 U/L, ALP 176 U/L, and Total Bilirubin 9.3 mg/dL (Direct 4.3 mg/dL, Indirect 3.5 mg/dL). CT scan of the abdomen and pelvis showed hepatomegaly with a normal biliary tree. The EBV viral capsid antigen (VCA) IgM was positive at >160 u/ML. Patient underwent a liver biopsy on hospital day 3 which showed sinusoidal patterns of inflammation and an in-situ hybridization study confirmed the diagnosis of EBV hepatitis. She was started on Solumedrol 1 mg/kg with improvement of symptoms and resolution of hepatic and hemolytic anemia lab abnormalities.

Discussion: Hepatic involvement due to Epstein-Barr virus infection can be common but is typically subclinical or mild in presentation with only 5% of patients presenting with jaundice. The pathological manifestations can be extensive, as patients can also present with hemolytic anemia, specifically cold agglutinin autoimmune hemolytic anemia. The pathogenesis is believed to be due to EBV IgM antibodies cross reacting with RBC antigens. The pathogenesis of cholestasis in EBV hepatitis involves direct damage of hepatic cells by autoantibody free radical activation and the inflammation of bile ducts. The majority of cases are self-resolving; however, antivirals such as ganciclovir in conjunction with corticosteroids can provide benefit in severe cases. Due to the high global prevalence of Epstein-Barr virus, healthcare professionals should be aware of the diagnosis, management and complications of hepatic manifestations.



Disclosures:


Munraj Singh, MD, Scott R. Piechocki, MD, MS. B0606 - A Case of EBV Hepatitis Complicated by Hemolytic Anemia, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.