Abstract
Epstein–Barr virus infection usually presents as infectious mononucleosis with fever, pharyngitis, and lymphadenopathy, while cholestatic jaundice is a rare manifestation. We report a 36-year-old man who presented with progressive jaundice, pruritus, and dark-coloured urine with deranged liver function tests showing a cholestatic pattern. Evaluation revealed atypical lymphocytosis and positive EBV IgM serology after exclusion of biliary obstruction and other common causes of hepatitis. The patient improved with supportive treatment alone. This case highlights the importance of considering EBV infection in the differential diagnosis of cholestatic jaundice.
Introduction
Epstein-Barr virus (EBV) causes infectious mononucleosis, also known as glandular fever or the ‘kissing disease’. 1 This common infection may be asymptomatic and may appear weeks later. It typically has an incubation period of up to eight weeks. 2 Symptoms include fever, sore throat, lymphadenopathy, fatigue, muscle aches, chills, sweats, loss of appetite, headaches, or a general rash. 2
EBV spreads mainly through saliva by kissing or sharing food and drinks. During the acute phase, 90% of patients have elevated liver enzyme levels. 3 Although these may rise temporarily, severe jaundice and cholestasis are rare, affecting <5%. 3
Case report
A 36-year old male, working as an office accountant, presented with dark coloured urine, jaundice, and pruritus for the previous week. His jaundice had progressively increased in severity. He was tired and had a mild fever for the past month. He had no gastro-intestinal nor respiratory symptoms. He had jaundice at the age of 15 years from which he made a complete recovery, but proffered no diagnosis. He had no other medical co-morbidiy. On examination, he was icteric with bilateral cervical lymphadenopathy and rashes over limbs and trunk due to scratching. His pharynx was not congested, the chest was clear with equal air entry, and the abdomen was soft, non-tender, with no organomegaly.
Initial investigations showed a leucocytosis (17.4 × 109/L) with 30% neutrophils, 13% lymphocytes with >50% atypical. His liver function test was deranged: aspartate transaminase 70 IU/L, alanine transferase 180 IU/L, alkaline phosphatase 340 IU/L, and bilirubin (99 mmol/L). All other parameters were within normal limits including haemoglobin, platelet count, C reactive protein, PT INR, and renal function tests. IgM anti-hepatitis A, B, and C were all negative. An ultrasound abdominal scan showed no signs of dilated bile ducts. With the presence atypical lymphocytes, an EBV IgM was performed, being strongly positive (2.29). On supportive therapy, the liver function improved and discharge was possible.
Discussion
The exact cause of cholestasis during an EBV primary infection is unclear. An increase in cytokines may cause inflammation and disruption of canalicular function, or direct liver cell damage through auto-antibody mediated oxidative damage.4,5,6 Cholestyramine might be useful for severe pruritis.7–9
Footnotes
Acknowledgment
None.
Ethical approval
Written consent was obtained from the patient for publication of this report.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.