herpes group virus

1. MIXED PATTERN HEPATITIS: A RARE CONSEQUENCE OF INFECTIOUS MONONUCELOSIS
Cynthia Philip MD, Christie Joya DO, Roseanne Ressner DO
Department of Internal Medicine; Walter Reed National Military Medical Center, Bethesda, MD
INTRODUCTION
RESOURCES
CONCLUSION
DISCUSSION
“The views expressedin this presentationare thoseof the authorsand do notreflectthe official policy or position of the Departmentof the Army, the Departmentof the Navy, the Departmentof Defense, nor the USGovernment.”
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4) Tan, Zh, Kb Phua, C. Ong, and A. Kader. "Prolonged Hepatitis and Jaundice: A Rare Complication of Paediatric Epstein-Barr Virus
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• It is important to consider EBV in the differential for
cholestatic hepatitis to avoid unnecessary testing
• Close monitoring during the clinical course is
important because a few patients may develop acute
liver failure
• In the absence of immunodeficiency, we recommend
supportive treatment.
CASE
0
200
400
600
800
1 5 7 9
U/L
Day
Liver associated enzymes
AST
ALT
Alkaline
phosphatase
• Epstein Barr virus (EBV) infections can present
with fever, pharyngtonsillitis, lymphadenopathy,
fatigue and a self limited increase in
transaminase values.
• Transaminase levels are typically less than five
times the upper limit of normal levels.
• Cholestatic hepatitis is rare and is seen in 5% of
cases.
• Jaundice in mononucleosis syndrome may be due
to autoimmune hemolytic anemia, cholestasis due
to acalculous cholecystitis, biliary duct obstruction,
cholestatic hepatitis but the mechanism is
unknown.
• Our patient had thrombocytopenia and
coagulopathy which were further evidence of liver
dysfunction.
• There have been rare cases reported of acalculous
cholecystitis and fulminant hepatic failure.
CHARACTERISTICS
AGE 20
RACE Caucasian
SEX Male
EXPOSURES One protected sexual encounter with a female partner. Swam
in a waterfall in Puerto Rico.
PRESENTATION 10 days after Spring break vacation, he developed drenching
night sweats, lymphadenopathy, odynophagia, scleral icterus,
fatigue.
MEDICAL HISTORY None
SOCIAL HISTORY Nonsmoker, beer once weekly. No drug use.
FAMILY HISTORY No history of lymphoma
ADDITIONAL
MEDICATIONS
None
PHYSICAL EXAM Scleral icterus, exudative tonsillar adenopathy, anterior and
posterior chain lymphadenopathy, tenderness to palpation of
the right upper quadrant and splenomegaly.
WBC 21,000/ mcL
DIFFERENTIAL 21% atypical lymphocytes
PLATELETS 119/mcL
INR 1.6
LDH 777 U/L
OTHER LABS Positive heterophile antibody
Total bilirubin 7.2 mg/dL
Direct bilirubin 6.5 mg/dL
AST 478 U/L
ALT 755 U/L
Alkaline
phosphatase
501 U/L
Acute hepatitis
panel
Negative
Chronic hepatitis
panel
Negative
Throat culture Negative for alpha hemolytic streptococcus
CT Enlarged palatine tonsils, extensive palatine tonsils, extensive
adenopathy of the cervical, axillary, supraclavicular, inguinal,
mesenteric lymph nodes. Splenomegaly. Diffusely thickened
gall bladder.
RUQUS Circumferential gallbladder wall thickening with pericholecystic
fluid.
Scleral icterus
Exudative tonsillar adenopathy
CT demonstrates splenomegaly