P1072 - Lymphoproliferative-Disorder-Like Liver Injury in an Elderly Patient With Acute Epstein-Barr Virus

Lovepreet Singh, MD¹, Ramanpreet Bajwa, DO², Kristelle Imperio-Lagabon, MD¹, William Carey, MD^1
1Cleveland Clinic Foundation, Cleveland, OH; ²Cleveland Clinic Foundation, Shaker Heights, OH

Introduction: Acute Epstein-Barr Virus (EBV) infection is typically a self-limiting infectious mononucleosis (IM) in young people. Symptoms involve pharyngitis, lymphadenopathy, hepatitis and splenomegaly. EBV is also associated with lymphoproliferative disorders primarily in immunocompromised patients. We present a case of acute EBV infection in an immunocompetent patient in whom the biopsy was concerning for lymphoproliferative disorder (LPD).

Case Description/Methods: An 80-year-old female with past medical history of colon cancer and type 2 diabetes mellitus presented for evaluation of abdominal pain and elevated liver enzymes. Two weeks prior, she began experiencing fatigue, acholic stools and dark urine. Labs showed alkaline phosphatase of 547, AST 137, ALT 235, and total bilirubin 1.1. She had worsening symptoms and up trending liver enzymes prompting hospital admission. Magnetic resonance cholangiopancreatography (MRCP) was obtained which was negative for biliary obstruction but did show hepatosplenomegaly with spleen measuring 14.5 cm. Liver serology was positive for EBV IgM along with positive monospot test with negative remaining workup. EBV DNA was 12,000 and repeat 11 days after was 1,550. Liver biopsy showed EBV positive LPD with differential including underlying T cell lymphoma or polymorphic proliferation. LPD could not be confirmed as she had no cytopenia, lymphadenopathy or masses noted on positron emission tomography (PET) scan. Bone marrow biopsy and flow cytometry concluded no immunophenotypic evidence of involvement by a lymphoproliferative disorder. Her symptoms improved and liver enzymes stabilized with EBV PCR down trending.

Discussion: In acute EBV infections, the most characteristic finding on biopsy of EBV is diffuse lymphocytic sinusoidal infiltrate in a “string of beads” pattern. Sinusoidal infiltration of atypical T cells in EBV hepatitis can mimic lymphoproliferative disorders which can be associated with EBV in the context of immunosuppressive therapy after transplant. Thus, diagnosis and differentiation between acute EBV hepatitis and EBV positive LPD solely based on histologic grounds is difficult. Our patient was immunocompetent yet biopsy was typical for EBV+LPD prompting further evaluation that yielded she indeed had acute EBV infection which resolved. Infectious mononucleosis and EBV positive LPD can overlap and must be differentiated through further testing to ensure appropriate treatment. In elderly patients with acute liver injury, EBV testing should be explored.



Disclosures:


Lovepreet Singh, MD¹, Ramanpreet Bajwa, DO², Kristelle Imperio-Lagabon, MD¹, William Carey, MD¹. P1072 - Lymphoproliferative-Disorder-Like Liver Injury in an Elderly Patient With Acute Epstein-Barr Virus, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.