A Rare Manifestation of Epstein-Barr Virus

Background: Epstein-Barr virus (EBV) is a highly disseminated herpesvirus, associated with several manifestations, such as infections of the Central Nervous System. The incidence of EBV encephalitis is less than 0.5%, and commonly presents with confusion, decreased level of consciousness, fever and/or epileptic seizures.

Objectives: Herein, we report a case of 14-year-old female adolescent with confirmed EBV encephalitis being successfully treated with acyclovir.

Methods and Results: Case Report: A 14-year-old female adolescent is brought to the Pediatric Emergency Service with 8 days evolution symptoms, started with general malaise and fatigue, followed by fever and bilateral eyelid edema. On the last day she presented with vomiting, followed by dysarthria, deviation of the labial commissure, sialorrhoea, ocular revulsion and generalized tonic-clonic seizure. Her physical examination showed bilateral palpebral edema (Hoagland Sign), mental confusion and psychomotor agitation. Initial laboratory testing showed 36% activated lymphocytes and positive Paul-Bunnell test. MRI was performed showing T2 FLAIR hypersignal at the posterior border of the left putamen and laterally of the right putamen, and at the caudates heads bilaterally. Lumbar puncture was done and cerebrospinal fluid was positive for EBV PCR, she started acyclovir therapy, for 14 days (7 days IV). Electroencephalogram was performed at the fourth day of hospitalization, showing generalized background slowing, without paroxysmal activity. She presented gradual clinical improvement being discharged after 10 days, with levetiracetam 500mg twice daily. Patient was followed in pediatric neurology consultation, and after 6 months, was asymptomatic with EEG normalization, starting levetiracetam tapering.

Conclusion: Among infectious causes of encephalitis, viruses are the most frequently identified etiology. A wide variety of viruses can cause encephalitis. Encephalitis caused by EBV does not typically follow an infectious mononucleosis-like illness, so we should be alert for this condition that can be a life-threatening emergency, requiring prompt intervention.