Introduction
Epstein-Barr virus (EBV) is a common virus affecting around 95% of the world’s population1. The presentation of EBV is variable and often includes fever, exudative pharyngitis, and lymphadenopathy. Often, patients have transient, asymptomatic elevations in liver enzymes during acute infection. Rarely, patients can have clinically significant cholestatic hepatitis2.

Case Presentation
A previously healthy 33-year-old female presented to the primary care clinic with intractable itching. The itching started acutely over two days with no associated rash. She reported mild cervical lymphadenopathy, but denied any pharyngitis, fevers, or fatigue. She described a self-limited episode the week prior to presentation including vomiting, fever, and rigors, which resolved within 24 hours. Medications include cetirizine and as needed ibuprofen and acetaminophen. Physical exam revealed a well-appearing female with no apparent jaundice, mild submandibular lymphadenopathy, and no pharyngeal erythema or tonsillar exudates. Her abdomen was non-tender with no hepatosplenomegaly. Due to intractable itching, the differential included a cholestatic pattern of hepatitis (both infectious and autoimmune), drug reaction, or malignancy. Labs revealed a mild leukocytosis with lymphocytic predominance, mild anemia, and elevated transaminases: AST 145 [7-34 U/L], ALT 250 [16-62 U/L], ALP 681 [50-136 U/L], GGT 343 [5-55 U/L]) with a normal total bilirubin level. Hepatitis panel was negative for acute hepatitis A, B, or C. Right upper quadrant ultrasound revealed a normal caliber common bile duct, normal gallbladder, and mild splenomegaly. Given the ultrasound findings, EBV serologies were ordered and confirmed an acute infection with positive immunoglobulin M antibody against the EBV capsid antigen (VCA).

Final/Working Diagnosis
Acute cholestatic hepatitis secondary to EBV Infection

Management and Outcome
The patient received symptomatic treatment with doxepin for itching. After three days, patient clinically improved. Of note, patient began showing signs of classic acute EBV infection with pharyngitis and fatigue one week after initial presentation. She showed a complete clinical recovery along with normalization of lab abnormalities. This case represents an uncommon presentation of acute EBV infection and should remind the primary care physician to keep EBV in the differential during a presentation of pruritus secondary to cholestatic hepatitis. Early ordering of EBV serologies can lead to a quicker diagnosis and less unnecessary testing for patients.

References and Resources

1. Womack J, Jimenez M. Common questions about infectious mononucleosis. Am Fam Physician. 2015;91(6):372-376.
2. Kofteridis DP, Koulentaki M, Valachis A, et al. Epstein Barr virus hepatitis. Eur J Intern Med. 2011;22(1):73-76.