S5174 Cholestatic Jaundice in a Healthy Young Woman: An Unusual Manifestation of Epstein-Barr Virus

Introduction: Epstein-Barr virus (EBV), a common cause of infectious mononucleosis, frequently leads to transient hepatic enzyme elevations in up to 90% of cases. However, cholestasis with overt jaundice is rare, especially in immunocompetent individuals, occurring in fewer than 5% of cases. This atypical presentation may resemble obstructive or autoimmune hepatitis, creating diagnostic uncertainty. We report a rare instance of EBV-induced cholestatic hepatitis in a healthy young woman. Case Description/Methods: A 25-year-old woman presented with 1 week of nausea, vomiting, fatigue, pruritus, jaundice, and right upper quadrant (RUQ) discomfort. She denied alcohol or medication use. Examination revealed icterus and RUQ tenderness without pharyngitis, lymphadenopathy, or splenomegaly. Labs showed alanine aminotransferase 301 U/L, aspartate aminotransferase 228 U/L, alkaline phosphatase 321 U/L, total bilirubin 5.2 mg/dL, direct bilirubin 4.4 mg/dL, and lymphocytosis (absolute count 4.3 bil/L). Viral hepatitis, cytomegalovirus serologies, and Monospot were negative. Abdominal ultrasound showed hepatomegaly and a normal biliary tree without obstruction. Liver doppler ruled out thrombosis. Despite supportive care, liver enzymes initially worsened. Further testing revealed positive EBV VCA IgM and detectable EBV DNA, confirming EBV-induced cholestatic hepatitis. She improved with conservative management, including intravenous fluids and symptomatic treatment, and was discharged with outpatient follow-up. Discussion: Cholestatic hepatitis due to EBV is rare in immunocompetent adults but should be considered in patients with acute hepatitis, hyperbilirubinemia, and cholestatic patterns. The liver injury is thought to be immune-mediated, involving lymphocytic infiltration and Kupffer cell activation rather than direct viral cytotoxicity. This causes intrahepatic inflammation and cholestasis. Diagnosis can be challenging. Heterophile antibody (Monospot) tests have limited sensitivity, particularly early in disease. EBV-specific serologies and DNA polymerase chain reaction are essential for accurate diagnosis. Management is mainly supportive. Antiviral agents are not routinely recommended due to lack of proven benefit. Steroids are reserved for complications such as fulminant hepatitis or airway compromise. Recognition of EBV as a cause of cholestatic hepatitis can prevent unnecessary procedures like endoscopic retrograde cholangiopancreatography or liver biopsy. Clinicians should maintain a high index of suspicion, particularly in young adults with systemic symptoms and an unrevealing initial workup.