Are Gilbert's syndrome and liver involvement genetically linked in infectious mononucleosis?

Recurrence of infectious mononucleosis in adults after remission for 3 years: A case report

BACKGROUND

Infectious mononucleosis (IM) is a disease caused by Epstein–Barr virus (EBV). EBV infection is common in children; however, it can cause IM in adults. Studies on recurrence of IM in adults after remission are limited.

CASE SUMMARY

We report a 28-year-old man who presented with IM-like symptoms with mild liver damage after initial remission of IM for 3 years. He was first diagnosed with IM and treated in 2015. Follow-up tests in 2016 and 2017 did not show any abnormalities. In November 2018, he presented with swelling of the tonsils. He was misdiagnosed with acute suppurative tonsillitis and treated for 5 d. No signs of improvement were observed. He was readmitted with recurrent fever, pharyngalgia, fatigue, and systemic muscle pain. Examinations revealed enlargement of the tonsils and cervical lymph nodes. Blood tests revealed elevated transaminase levels. Anti-EBV test was positive, indicating virus reactivation. IM recurrence was confirmed on the basis of laboratory tests and clinical manifestations. He was treated with antiviral, anti-infective, and hepatoprotective drugs and vitamin supplements. His condition improved and no abnormalities were observed during follow-up.

CONCLUSION

Recurrence of IM after remission is possible in adults; therefore, long-term follow-up and monitoring are essential.

Ultrasonographic Gallbladder Abnormality of Primary Epstein-Barr Virus Infection in Children and Its Influence on Clinical Outcome

The incidence of pediatric acute inflammatory gallbladder (GB) disease without gallstone such as acute acalculous cholecystitis has increased with the development of improved diagnostic modalities. Although Epstein-Barr virus (EBV) infection is common in general population, only few cases of GB diseases caused by EBV infection have been reported. This study analyzed ultrasonographic characteristics of primary EBV infection in children and evaluated the influence of EBV-associated GB disease on clinical course and outcome of EBV infection.Between March 2004 and January 2013, 94 of 287 pediatric patients with EBV infection underwent abdominal ultrasonography (USG); clinical features, laboratory data, and USG findings were collected and analyzed retrospectively.Of 94 children, ultrasonographic thick GB wall was observed in 24 (25.3%). Platelet counts were lower in the thickened GB wall group than in the normal GB wall thickness group (P = 0.004). Direct bilirubin, alanine aminotransferase, and γ-glutamyl transferase levels were higher in the thickened GB wall group (P = 0.000, P = 0.041, and P = 0.001, respectively). The duration of hospitalization was longer in patients with thickened GB wall (P = 0.043).Radiologic findings of acute acalculous inflammatory GB disease such as thickened GB wall caused by primary EBV infection are more common than previously reported. Consideration of EBV infection in the differential diagnosis of children suspected with acute acalculous GB diseases may avoid unnecessary surgical intervention.

Acute acalculous cholecystitis (AAC) in the pediatric population associated with Epstein-Barr Virus (EBV) infection. Case report and review of the literature

BACKGROUND

Epstein Barr Virus (EBV) is a ubiquitous herpes virus that persists lifelong in normal humans by colonizing memory B cells. Infection during childhood is usually asymptomatic. Isolated gallbladder wall thickening or hydrops have been reported in patients with EBV infectious mononucleosis. However, acute acalculous cholecystitis is an atypical clinical presentation of primary EBV infection. We present a teenager with acute cholecystitis associated with EBV acute infection. Acute acalculous cholecystitis accounts for 2-15% of all cases of acute cholecystitis. Few cases of acute cholecystitis have been reported during the course of primary EBV infection.

PRESENTATION OF CASE

A 15-year-old female who came to the JDCH ER complaining of 3 days history of mild diffuse abdominal pain associated with two episodes of emesis. She also reports headache as well as a mild cough and low grade subjective fever. Blood test results showed mild leukocytosis with significant elevation in the lymphocytes (59%), High alkaline phosphatase (221 U/I), AST (191 U/I), ALT(221 U/I) and bilirubin (Total 1.8 and direct 1.5). Abdominal US showed a contracted gallbladder with wall thickness and pericholecystic fluid. During hospital stay number 2-3 laboratory work up show a trending up in the bilirubin levels. MRCP was ordered and no abdnormalities were found. At this point Hospital stay number 3 EBV acute infection was suspected. Serum serological studies were subsequently diagnostic for this viral disease. Management was conservative and the patient was discharged asymptomatic on hospital day number six.

Acalculous cholecystitis or biliary dyskinesia for Epstein-Barr virus gallbladder involvement?

We present two patients with Epstein-Barr virus (EBV) infection related to gallbladder involvement. Such an association is already known as EBV induced acalculous cholecystitis, diagnosed on the basis of ultrasonographic findings. In our patients, radioisotopic cholescintigraphy was also performed and it showed that gallbladder was visualized in both patients in contrast to that what can be observed in cases of cholecystitis. However, the value of ejection fraction was compatible with biliary dyskinesia. We, therefore, consider that impaired gallbladder contractility in EBV infection cases may actually represent biliary dyskinesia and not acalculous cholecystitis taking into account the radioisotopic findings and the self limited course of the disorder.

Acute acalculous cholecystitis in children with Epstein-Barr virus infection: a role for Gilbert's syndrome?

Acute acalculous cholecystitis (AAC) in association with acute Epstein-Barr virus (EBV) infection has rarely been described in childhood. In the literature, there are only four reported pediatric cases of AAC associated with isolated primary EBV infection. We present two cases (one new, one retrospectively reviewed) of children with Gilbert's syndrome (GS) who presented with AAC during the course of primary EBV infection. Antibiotics were not used and AAC subsided gradually as the infection regressed. The co-occurrence of GS might have played a contributory role in the pathogenesis of AAC during acute EBV infection.