S5901 Hemolytic Anemia and Hepatitis in the Setting of Acute Epstein-Barr Virus Infection

Introduction: Epstein Barr virus (EBV) infection, common in adult population, presents as viral prodrome of fever, fatigue, lethargy, sore throat, and tender cervical lymphadenopathy (LAD). Acute infection can induce hepatitis. Rarely, hemolytic anemia is reported. We describe case of a young man presenting with hemolytic anemia and hepatitis in the setting of acute EBV infection. Case Description/Methods: A 21-year-old White man without notable past medical history presented with jaundice, fever, joint pain, rash, dark urine. Physical examination was significant for scleral icterus, jaundice, pharyngeal erythema, tender cervical LAD, patches of petechial rash on right upper limb. Elevated total bilirubin with indirect bilirubinemia and transaminitis were noted. High lactate dehydrogenase, low haptoglobin, mildly increased reticulocyte count (2.7%) with immature retic fraction at 19.2% indicated hemolysis. Epstein-Barr virus DNA PCR was 867 IU/ml. Immunoglobulin (Ig) M antibodies against viral capsid antigen (VCA) were positive, IgG was negative. Infectious etiologies like babesia, rickettsia, histoplasma, blastomycoses, viruses like varicella, cytomegalovirus, herpes simplex virus, parvovirus, hepatitis B/C, HIV were ruled out. Antibodies for autoimmune disease, acute toxicology panel, and blood culture were normal. Peripheral smear showed reactive lymphocytes. Abdominal ultrasound revealed splenomegaly, normal liver. Over hospital course, arthralgia, rash, tender LAD resolved. Bilirubin trended down but aspartate aminotransferase/alanine aminotransferase increased. Albumin, international normalized ratio, prothrombin time were normal, indicative of intact synthetic liver function. Ultrasound-guided liver biopsy (bx) showed lymphocytic infiltrates in sinusoids and portal tracts, consistent with EBV hepatitis. Lobular architecture was preserved with evidence of lobular inflammation, focal acidophil bodies (hepatocyte apoptosis), scattered mitotic figures. Labs, liver bx with clinical picture suggested acute EBV infection with hepatocellular pattern of liver injury and hemolytic anemia, managed with supportive treatment/monitoring. Discussion: Hemolytic anemia in acute EBV is rare and mostly immune-mediated. Hepatitis is self-limiting, rarely results in liver failure. Uncommonly, splenic rupture occurs. A viral prodrome of non-specific symptoms with jaundice and lab findings suggestive of hemolysis in young patients should warrant testing for EBV to avoid complications. Early EBV determination, initiation of supportive care carry favorable prognosis.