Serum ALP after transplantation was initially increased but decreased immediately Fig. The patient is presently doing well 6 months after liver transplantation with no evidence of clinical EBV infection or lymphoproliferative disease. Liver biopsy performed 5 days before the liver transplant.
We describe a case of ALF-associated with EBV infection in a previously healthy elderly woman that underwent successful emergent liver transplantation. The clinical manifestation usually includes loss of hepatic function, coagulopathy, hepatic encephalopathy and in many cases, progressive multi-organ failure [ 1 , 2 ].
Despite recent advances in intensive care management, mortality rates remain high [ 6 ]. The only therapy of proven benefit is emergent liver transplantation [ 7 ]. The etiologies of ALF vary greatly by country and have evolved over time.
Thirteen percent of cases are of indeterminate etiology. These cases often follow a relatively insidious presentation before patients quickly develop liver failure, and rates of survival are poor without transplantation. Proposed potential causes include novel viruses and exposure to toxin.
Recent studies showed that the cause may be related to EBV infection [ 9 ]. In our case, the cause of ALF was initially thought to be diclofenac, because the patient had been taking diclofenac for about 5 months prior to admission, and other causes such as acetaminophen, infectious agents and metabolic diseases were excluded through serological tests; however, the biopsy and blood EBV DNA PCR results confirmed that EBV is the major cause of ALF, and diclofenac may have played no or a minor role in this process.
It usually occurs in adults younger than 40 years of age, which is consistent with the fact that young adult patients tend to have symptomatic infectious mononucleosis [ 10 , 11 ]. In adult aged 60 years or older, there were only two cases of EBV-associated ALF in the literature; however, both of them had impaired immune system: one had just started steroids and the other had recent heart surgery [ ].
In our case, the patient does not have any of the above mentioned problems and did not take any immunosuppressant medications. Her immune system appears normal although her lymphocyte counts were low. This indicates that in older immunocompetent patients presenting with ALF, a primary EBV infection or EBV reactivation should be considered when other causes have been excluded. Early diagnosis of EBV-associated hepatitis was difficult as reliable diagnostic criteria are not clearly defined [ 11 ].
Steroids started after liver transplantation may accelerate the rapid replication. Moreover, the liver enzyme showed cholestatic enzyme changes after transplantation with continuously increased ALP.
Interestingly, ALP rapidly decreased after we started acyclovir. Treatment with acyclovir should be strongly considered after liver transplantation for ALF from EBV to prevent infection of the liver graft during the period of high level immunosuppression. There are some limitations in our case. First, we were not able to diagnose EBV hepatitis until after evaluation of the explanted liver. Liver transplantation could be potentially avoided if an early diagnosis of EBV hepatitis could have been made.
Third, the serological test was done 10 days after we started acyclovir, which may not show the initial changes of EBV infection. In addition, the use of diclofenac in this patient since a few months ago might have caused some initial injury to the liver. Diclofenac is reported to cause liver injuries by two main mechanisms, hypersensitivity and metabolic aberration [ 19 , 20 ]. Acute liver injury caused by diclofenac is thought to be due to hypersensitivity and usually presents within days to a few weeks after starting diclofenac, which can result in fatal liver failure.
Metabolic aberration can cause persistent mild liver injury and once diclofenac is stopped, the liver can recover quickly [ 20 ]. In our patient, diclofenac might have caused mild liver injury initially; however, the reactivation of EBV plays a major role in developing ALF. Early recognition and diagnosis is extremely important, however difficult.
Liver biopsy should be strongly considered in patients with unexplained ALF with hepatitis pattern and EBV RNA by in situ hybridization should be mandatory if sinusoidal lymphocytosis is present. Emergent liver transplantation is the only definitive treatment option, with very favorable prognosis for such patients. National Center for Biotechnology Information , U.
Journal List Gastroenterology Res v. Gastroenterology Res. Published online Sep Befeler , b Adrian M. Alex S. Adrian M. Di Bisceglie. Author information Article notes Copyright and License information Disclaimer. Difficulty breathing Sudden and sharp pain on the upper left side of your abdomen a sign that you may be experiencing a rupture in your spleen High fever Editorial Sources and Fact-Checking.
October 1, Mononucleosis: Symptoms and Causes. Mayo Clinic. September 8, Balfour Jr. HH, Dunmire S, et al. Infectious Mononucleosis. February The Mono Project. University of Minnesota Medical School. July 3, Mononucleosis Mono. October 24, September Infectious Diseases and the Liver. Clinical Liver Disease. Centers for Disease Control and Prevention.
May 8, Genetic and Rare Diseases Information Center. Current Topics in Microbiology and Immunology. Epstein-Barr Virus and Autoimmune Diseases.
J Infect Chemother. Children ages , PLoS One. Acute Epstein - Barr virus hepatitis without mononucleosis syndrome: a case report. Gastroenterol Hepatol Bed Bench.
Characteristics of Epstein-Barr virus hepatitis among patients with jaundice or acute hepatitis. Aliment Pharmacol Ther. Epstein-Barr virus as a trigger of autoimmune liver diseases. Adv Virol. Infectious mononucleosis. Curr Top Microbiol Immunol. Characteristics of Epstein—Barr viraemia in adult liver transplant patients: a retrospective cohort study.
Transplant Int. Antiviral drugs for EBV. Cancers Basel. Severe EBV hepatitis treated with valganciclovir. Antiviral medication for the treatment of infectious mononucleosis glandular fever. Cochrane Database Syst Rev.
Epstein-Barr virus-positive posttransplant lymphoproliferative disease after solid organ transplantation: pathogenesis, clinical manifestations, diagnosis, and management.
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I Accept Show Purposes. Table of Contents View All. Table of Contents. Causes and Risk Factors of Mononucleosis. How Mononucleosis Is Diagnosed.
Antiviral Drugs for Mononucleosis Antiviral drugs like Zovirax acyclovir have not proven to have any significant impact on EBV infection. How Mononucleosis Is Treated. Was this page helpful? Thanks for your feedback! Sign Up. What are your concerns? Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles.
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