S5839 Double Trouble: EBV and Coronavirus HKU1 Coinfection Leading to Acute Liver Injury

Introduction: Although it has been almost 5 years since we faced the COVID 19 pandemic, it is still surprising to see the effects of Coronavirus on patients and the phenomena associated with it. Case Description/Methods: Nineteen-year-old woman presented for fevers and abnormal liver enzymes. Patient had presented to an urgent care a week before her admission with acute upper respiratory symptoms and at that time all viral etiologies including COVID and Flu were negative, a few days after she went to see her primary care provider (PCP) for persistent fevers. Labs at that time were done and showed white blood cells (WBC) 1.8 k/uL, platelets at 94 K/uL, abnormal liver enzymes with aspartate aminotransferase (AST) 200 IU/L, alanine aminotransferase (ALT) 174 IU/L, Total Bilirubin 3 mg/dL, Direct Bilirubin 1.7 mg/dL, alkaline phosphatase (ALP) 271 IU/L. Right upper quadrant (RUQ) Ultrasound showed normal findings. She presented 2 days later to her PCP with persistent fevers. Repeat Liver enzymes showed worsening values with AST 397 IU/L, ALT 384 IU/L, Total Bilirubin 3.7 mg/dL, Direct Bilirubin 2.2 mg/dL, ALP 390 IU/L, WBC 2.4 k/uL, platelets 86 K/uL, Neutrophils 0.48 K/uL workup including acute viral hepatitis and Epstein-Barr virus (EBV) monospot test were negative. She was admitted thereafter and evaluated by our hepatology team. Her Liver enzymes continued to worsen peaking at AST 656 IU/L, ALT 886 IU/L, Total Bilirubin 3.9 mg/dL, Direct Bilirubin 2.5 mg/dL, ALP 550 IU/L, repeat RUQ Ultrasound showed splenomegaly up to 16 cm. Broad infectious, autoimmune and toxicology labs were ordered and results were positive for Coronavirus HKU1 and EBV PCR with quantitative value of 47,000 copies/mL. The patient was managed supportively. Eventually she improved with a decrease in her liver enzymes and return of normal daily activities while avoiding contact sports. She followed up in clinic with repeat labs every week and normalization of her liver enzymes and undetected EBV PCR 3 weeks after. Discussion: This case outlines 2 underlying etiologies that contributed to the above presentation. Although EBV is a known cause of acute liver injury (ALI) with elevated Liver enzymes and splenomegaly. Coronavirus HKU1 has been reported once as a cause of acute liver injury mainly in the pediatric population as patients present with mild respiratory symptoms and acute liver injury. We wanted to stress the importance of maintaining a high index of clinical suspicion as other uncommon viral etiologies can be the underlying cause of ALI especially in cases where all common viral causes are ruled out.