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

Abstract

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.

Keywords: cholestasis; epstein–barr virus; hepatitis; infectious mononucleosis; jaundice.

Figure 1. Abdominal ultrasonography

A: Enlarged liver, 191mm, without focal lesions. B: Common biliary duct dilatation, 6mm, without cholelithiasis. C: Splenomegaly, 154mm. Structures marked between the yellow crosses.

Figure 2. Liver histopathologic findings

A: Liver parenchyma with mild steatosis, histiocytic aggregates outlining epithelioid granulomas and sinusoidal lymphocytosis. No hepatocellular necrosis was found. B: Immunohistochemical staining for Epstein-Barr virus (EBV) by EBV encoding region (EBER) revealed positivity of few hepatocytes (arrow).