Epstein-Barr Virus (EBV) Infection as a Cause of Myopericarditis

Introduction: Myopericarditis is a rare complication of Epstein-Barr infection, with nonspecific symptoms.

Case description: A 9-year-old boy, with no relevant past medical history, was admitted to ER with a two week history of intermittent pleuritic chest pain, vomiting, nausea, anorexia and periumbilical pain. In the last ten days he also had productive cough and unilateral knee pain, but no inflammatory signs and in the last month he had high fever and nasal symptons for eight days.

At the admission he was afebrile, with a normal physical examination. Blood tests revealed elevated biochemical markers of liver injury (AST 361U/L, ALT 604U/L, FA 214U/L and GGT 105U/L) with normal liver function, elevated serum creatine kinase (998U/L) and cardiac biomarkers (troponin I 19.1ng/mL, CK-MB 122U/L). Chest radiography was normal. The electrocardiogram showed ST-elevation in leads II, III, aVF, V5 and V6. Myopericarditis was the initial diagnosis and after Pediatric Cardiology evaluation AINE therapy was initiated. Transthoracic echocardiogram was normal. Investigation revealed no active infection for hepatitis A, B and C, cytomegalovirus, herpes I and II and adenovirus. IgM and IgG antibodies to viral capsid Epstein Barr Virus (EBV) antigen and to nuclear EBV antigen were positive. Early antigen antibodies to EBV were negative. The positive EBV DNA pointed out a recent EBV infection with hepatitis and myopericarditis.

Chest pain resolution was observed on day three and improvement in transaminases and cardiac biomarkers on day five; electrocardiogram showed flattened T waves on aVF, V5 and V6.

He was discharged to Pediatric Cardiology follow-up consultation and he remains asymptomatic with normal ECG.

Discussion: Myopericarditis is a rare disease, often caused by viral infections but exact etiology remains undetermined in most patients. This report highlights the importance of considering this diagnosis as a rare presentation of a common infection.