Download Liver associated enzymes

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
•
•
Liver associated enzymes
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.
800
Scleral icterus
MEDICAL HISTORY
SOCIAL HISTORY
FAMILY HISTORY
ADDITIONAL
MEDICATIONS
PHYSICAL EXAM
WBC
DIFFERENTIAL
PLATELETS
INR
LDH
OTHER LABS
Total bilirubin
Direct bilirubin
AST
ALT
Alkaline
phosphatase
Acute hepatitis
panel
Chronic hepatitis
panel
Throat culture
CT
RUQUS
ALT
0
1
5
7
9
Alkaline
phosphatase
Day
CHARACTERISTICS
PRESENTATION
400
200
CASE
AGE
RACE
SEX
EXPOSURES
AST
600
U/L
•
20
Caucasian
Male
One protected sexual encounter with a female partner. Swam
in a waterfall in Puerto Rico.
10 days after Spring break vacation, he developed drenching
night sweats, lymphadenopathy, odynophagia, scleral icterus,
fatigue.
None
Nonsmoker, beer once weekly. No drug use.
DISCUSSION
•
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.
Exudative tonsillar adenopathy
•
No history of lymphoma
None
Scleral icterus, exudative tonsillar adenopathy, anterior and
posterior chain lymphadenopathy, tenderness to palpation of
the right upper quadrant and splenomegaly.
21,000/ mcL
•
21% atypical lymphocytes
119/mcL
1.6
777 U/L
Positive heterophile antibody
7.2 mg/dL
6.5 mg/dL
478 U/L
755 U/L
501 U/L
CONCLUSION
•
•
•
Negative
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.
Negative
Negative for alpha hemolytic streptococcus
Enlarged palatine tonsils, extensive palatine tonsils, extensive
adenopathy of the cervical, axillary, supraclavicular, inguinal,
mesenteric lymph nodes. Splenomegaly. Diffusely thickened
gall bladder.
Circumferential gallbladder wall thickening with pericholecystic
fluid.
RESOURCES
CT demonstrates splenomegaly
1) Agergaard, J., and C.s. Larsen. "Acute Acalculous Cholecystitis in a Patient with PrimaryEpstein-Barr Virus Infection: A Case
Report and Literature Review." International Journal ofInfectious Diseases 35 (2015): 67-72.
2) Busch, Daniel, Sarah Hilswicht, Dominik S. Schöb, Klaus T Von Trotha, Karsten Junge,Nikolaus Gassler, Son Truong, Ulf P.
Neumann, and Marcel Binnebösel. "Fulminant Epstein-Barr Virus - Infectious Mononucleosis in an Adult with Liver Failure,
SplenicRupture, and Spontaneous Esophageal Bleeding with Ensuing Esophageal Necrosis: A
Case Report." J Med Case Rep Journal of Medical Case Reports 8.1 (2014): 35.
3) Salva, I., I. V. Silva, and F. Cunha. "Epstein-Barr Virus-associated Cholestatic Hepatitis."Case Reports 2013.Dec16 1 (2013).
4) Tan, Zh, Kb Phua, C. Ong, and A. Kader. "Prolonged Hepatitis and Jaundice: A Rare Complication of Paediatric Epstein-Barr Virus
Infection." Singapore Medical Journal Smedj 56.07 (2015).
“The views expressed in this presentation are those of the authors and do not reflect the official policy or position of the Department of the Army, the Department of the Navy, the Department of Defense, nor the US Government.”