Primary Epstein-Barr Virus Infection Presenting as Cholestatic Hepatitis Without Infectious Mononucleosis in an Immunocompetent Middle-Aged Adult: A Case Report

Epstein-Barr virus (EBV) infections commonly present with a subclinical hepatitis, often in the context of infectious mononucleosis (IM). A 56-year-old male presented with fever, alongside signs of jaundice and right upper quadrant tenderness. Initial investigations revealed marked cholestatic hepatic dysfunction, but imaging showed no evidence of biliary tree pathology. Serological and molecular testing confirmed primary EBV infection, whilst excluding other viral and autoimmune causes of hepatitis. The patient was managed conservatively, with rapid normalisation of liver function during outpatient follow-up. The rare occurrence of cholestatic hepatitis secondary to primary EBV infection in an immunocompetent middle-aged adult, and the lack of typical IM symptoms - including rash, pharyngitis, and lymphadenopathy - makes diagnosis challenging and complex. Given the rare but potentially fatal risk of progression to acute liver failure, and the atypical presentation, EBV should be high on the list of differentials in cases of acute cholestatic hepatitis in the absence of other IM features, particularly in middle-aged and older adults. Once common aetiologies have been excluded, early targeted EBV serological and molecular tests are key to avoiding unnecessary invasive investigations and inappropriate management.