Objective: Epstein-Barr virus (EBV) is a ubiquitous human herpesvirus often causing an acute, self-limited clinical picture referred to as infectious mononucleosis. Asymptomatic hepatitis, involving mild elevations of liver aminotransferase levels, is very common. However, cholestatic hepatitis, manifested by direct hyperbilirubinemia and jaundice, is rare. We present five pediatric cases of EBV induced cholestatic hepatitis and summarize 31 additional cases from the literature.
Methods: A PubMed search was conducted for all reported cases of EBV induced cholestatic hepatitis between January 1996 and September 2013. Thirty-one reported cases were identified. Five additional cases from our institute were added. Clinical characteristics, presenting symptoms, laboratory and imaging findings, treatment and outcome were reviewed.
Results: Our series included 19 male and 17 female patients. Median age was 18 years. 19 patients were children and adolescents. Fever, jaundice, cervical lymphadenopathy and splenomegaly were the most common presenting symptoms. Levels of hepatocellular liver enzymes were higher than in classical infectious mononucleosis. In many cases, serum alkaline phosphatase was elevated as well, accompanied by direct hyperbilirubinemia.
Common ultrasound findings included hepatomegaly or splenomegaly. Gallbladder wall thickening was observed in over 30% of patients. The diagnosis was confirmed by EBV viral capsid antigen IgM in 32 patients (88%). Heterophile antibodies were reported positive in 14 of 19 patients. One adolescent died of fulminant hepatitis. All others made a full recovery.
Conclusion: EBV infection should be included in the differential diagnosis of cholestatic hepatitis in all age groups. In the vast majority, full recovery is expected.
