Chronic active Epstein-Barr exacerbated by COVID-19 co-infection

Abstract

A 60-year-old Hispanic female was admitted with recurrent fevers, altered mental status, lymphadenopathy, hepatosplenomegaly, and pancytopenia. Initially, sepsis was presumed because of recurrent urinary tract infection with extended-spectrum beta-lactamase Escherichia coli. Despite appropriate therapy, her clinical condition continued to decline. An extensive workup was obtained to determine the source of her ailments. Bone marrow biopsy was negative for leukemia, lymphoma, and myelodysplastic syndrome; fluorescence in situ hybridization and a cytogenetic panel were normal; a lumbar puncture was negative. However, peripheral blood was remarkable for elevated titers for Epstein-Barr virus (EBV) consistent with chronic active EBV. Treatment with valganciclovir showed early positive results, but the patient became co-infected with COVID-19, and her EBV titer increased again, resulting in a precipitous health decline and death.

Keywords: COVID-19; Chronic active Epstein-Barr; Co-infection; Epstein-Barr virus; SARS-CoV-2.

Figure 1

(A) Top left: coronal section CT abdomen and pelvis with contrast grossly observed hepatosplenomegaly with the liver measuring 21.7 cm in length and the spleen measuring 14.6 cm in length. Mild to moderate ascites was noted with fluid surrounding the liver and spleen and layering dependently within the pelvis. (B) Top right: coronal section CT abdomen and pelvis with contrast bilateral enlarged inguinal lymphadenopathy that continued inferiorly and extensively from chains of the para-aortic and iliac lymph nodes that were infectious in origin. (C) Bottom left: MRI brain/head bilateral medial temporal lobe hyperintensity with associated atrophy has been previously described in EBV encephalitis as a source of seizures. Mild medial temporal lobe atrophy likely from chronic microvascular ischemic change. (D) Bottom right: MRI brain/head microvascular ischemic change in the right frontal lobe that abuts the cortex, increasing the likelihood of seizure focus because of the involvement of the cortex. CT = computed tomography; EBV = Epstein-Barr virus; MRI = magnetic resonance imaging.