S5046 Beyond the Hepatitis Panel: The Gastroenterologist’s Role in Diagnosing Atypical Epstein-Barr Virus

Introduction: Epstein-Barr virus (EBV) is a herpesvirus known for causing infectious mononucleosis, which is classically characterized by pharyngitis, lymphadenopathy, and fatigue. Transaminitis is common in EBV infection; however, less than 1% of EBV cases present with isolated transaminitis or splenomegaly without the typical upper respiratory symptoms. In such cases, gastroenterology (GI) is frequently consulted for evaluation of liver injury and guidance on further testing. This case focuses on an EBV infection manifesting as isolated transaminitis and splenomegaly. Case Description/Methods: An 18-year-old woman without previous medical history presents to the Emergency Department with a week of fever, chills, and malaise followed by dark colored urine and abdominal pain. She denied upper respiratory symptoms or sick contacts. On presentation, she was found to have abdominal distention, left-sided tenderness, and splenomegaly. Initial workup revealed elevations in total bilirubin 2.5, alkaline phosphatase 299, aspartate aminotransferase 231, alanine aminotransferase 444, ESR 26 and C-reactive protein 8.4. Acute hepatitis panel, heterophile antibody, and HIV screening were negative, with CBC significant for lymphocytic/monocytic predominance. Computed tomography (CT) abdomen demonstrated splenomegaly and large stool burden. Abdominal ultrasound revealed diffuse gallbladder wall thickening without distention. Due to persistent fevers, further infectious workup revealed positive EBV polymerase chain reaction (PCR) and EBV IgG/IgM. GI and infectious disease were consulted and agreed with supportive measures, which the patient received during the admission with overall improvement in symptoms prior to discharge. She was discharged with close GI follow-up to monitor LFTs and symptom resolution. Discussion: This case highlights an atypical EBV presentation involving isolated transaminitis and splenomegaly without classic systemic symptoms. The initial negative heterophile antibody test emphasizes the limitations of early serologic screening. Whereas EBV-specific serologies and PCR proved essential for the diagnosis. Gastroenterologists are often involved in the evaluation of unexplained transaminitis and should maintain a broad differential that includes EBV, especially in young patients with transaminitis and splenomegaly in the absence of classic infectious symptoms. Most cases are self-limited and management remains supportive, however, early recognition helps avoid unnecessary procedures and ensures appropriate follow-up.