S5657 A Rare Case of Acute Liver Failure Caused by Epstein-Barr Virus

Introduction: Acute liver failure (ALF) is a rare syndrome that is associated with a high mortality rate. With increase in early clinical recognition, advances in intensive care, and access to liver transplantation, outcomes continue to improve. In developed countries, acetaminophen toxicity remains the leading cause of ALF, followed by drug induced, hepatitis A and B, alcoholic hepatitis, and acute fatty liver injury. ALF from Epstein-Barr Virus (EBV) accounts for <1% of all cases of ALF. Here we present a rare case of ALF from EBV. Case Description/Methods: A 68-year-old man presented after being found down. He was noted with encephalopathy, with slurred speech and urinary incontinence. Initial lab work was notable for an acute kidney injury, and he was mildly hypoxic. With supportive care, his mentation improved to baseline. Overall, his work up for acute encephalopathy was unrevealing. However, MRI was notable for hepatomegaly with patchy/nodular areas of enhancement. Labs demonstrated an acute liver injury in a cholestatic pattern – alkaline phosphatase in the 400’s, total bilirubin 10.1 and mild elevation of alanine aminotransferase/aspartate aminotransferase. He denied prior or ongoing alcohol abuse. An acute viral hepatitis panel and HIV test were nonreactive. There were no known episodes of hypotension to suggest ischemic hepatopathy. A broad work up for acute liver injury was pursued including autoimmune, genetic, and more extensive viral testing. He also was scheduled to undergo endoscopic ultrasound-guided liver biopsy. His liver function tests and international normalized ratio continued to uptrend. Following this, his mental status again declined, and he required intubation, thus giving him the diagnosis of acute liver failure. His biopsy eventually revealed chronic portal inflammation, healing necrosis, and was positive for EBV without evidence of cirrhosis or fibrosis. n-Acetyl Cysteine was initiated along with continued supportive care, and he was accepted at outside facility for transplant. Discussion: This case highlights the unusual etiology of ALF due to EBV infection as diagnosed on biopsy. The patient’s age is also unusual for EBV infection. Given the potential severity of acute liver injury and possible progression to ALF, even uncommon etiologies should be considered. This case also demonstrates the importance of monitoring patients with acute liver injury for progression to liver failure, as timely diagnosis and evaluation by a transplant center is of utmost importance.