Complicated EBV infection in a healthy child
- Hugo Teles ,
- Teresa Brito ,
- Joana Cachão and
- Susana Parente
- Pediatrics Department, Centro Hospitalar de Setubal EPE, Setubal, Portugal
- Correspondence to Dr Joana Cachão; joanacbc@hotmail.com
Abstract
The Epstein-Barr virus (EBV) is highly prevalent throughout the population. Although in most cases, the infection has a good prognosis, it can cause severe complications. We report a case of a healthy child with a primary EBV infection that evolved with two rare complications. She first presented in the emergency room with fever and sore throat, and was diagnosed with tonsillitis and medicated with antibiotic. She returned 7 days later for fatigue, vomiting and abdominal pain. The examination revealed tonsillitis, swollen cervical lymph nodes and pain in the right hypochondrium. An abdominal ultrasound was performed, compatible with acute acalculous cholecystitis. She was admitted in the paediatric nursery and medicated with intravenous antibiotics. The EBV serology revealed primary infection. Two days later, she developed cardiogenic shock and had to be transferred to an intensive care unit under mechanical ventilation and inotropics. She was discharged 12 days later, keeping a moderate left ventricular dysfunction.
Background
The Epstein-Barr virus (EBV), a human herpes virus, is one of the most common human viruses in the world. It is highly contagious and worldwide, it is estimated that approximately 90% of the population will get infected with EBV in their lifetime. The clinical course of an EBV infection is highly variable. Most EBV infections are asymptomatic, mainly those affecting small children. In adolescents and young adults, it can lead to a clinical syndrome known as infectious mononucleosis, which is usually characterised by extreme fatigue, fever, sore throat, swollen lymph nodes in the neck, and swollen liver and/or spleen. More rarely, EBV infection can lead to other illnesses and complications, which are sometimes fatal. This case reports two known rare complications of an EBV infection in a previous healthy 10-year-old girl that every clinic should always be aware of.
Case presentation
A previous healthy 10-year-old girl, with no history of recurrent infections or relevant disease in family, was admitted in the emergency room (ER) for fever and sore throat for 4 days. No relevant findings on the examination, except bilateral tonsillar exudate. No complementary diagnostic examinations were required. She was diagnosed with bacterial tonsillitis and treated with oral amoxicillin at a dose of 50 mg/kg/day for 7 days. She returned to the ER 1 week later for persisting fever in association with fatigue, vomiting and abdominal pain in the right hypochondrium. Physical examination reported bilateral tonsillitis, swollen cervical lymph nodes and pain in the right hypochondrium on abdominal examination.
Investigations
The blood analysis revealed a whole blood count of 13,7 ×109/L leucocytes (with 68% neutrophils), C-reactive protein (CRP) of 5,3 mg/dL, alanine aminotransferase (ALT) of 31 U/L and aspartate aminotransferase (AST) of 240 U/L. The serology test for EBV revealed a positive antiviral capsid antigen IgM antibody, compatible with primary infection. Serology tests for cytomegalovirus and hepatitis A virus were both negative. The blood culture was sterile. An abdominal ultrasound was performed, showing a diffuse gallbladder wall thickening of approximately 7 mm, and suspected for acute acalculous cholecystitis. She was then admitted in the paediatric nursery with the diagnosis of acalculous cholecystitis, and medicated with intravenous cefuroxime and metronidazole. Two days after the admission, the patient began to feel chest pain in association with haemoptysis and respiratory distress. Clinical examination revealed hypoxemia (78% oxygen saturation), hypotension (88/55 mm Hg), pulmonary crackles and hepatomegaly.
The biochemistry evaluation revealed a whole blood count of 16,9 x 109 leucocytes (with 78,4% neutrophils), CRP of 18,38 mg/dL, ALT of 79 U/L and AST of 224 U/L, creatine kinase (CK) of 1361 U/L, CK-MB of 211 U/L, D-dimer of 6536 ng/mL, troponin of 8184 ng/L, N-terminal pro-B-type natriuretic peptide of 33 530 pg/mL. A thoracic CT was then performed, and revealed acute respiratory distress syndrome and right pleural effusion. A 12-lead ECG showed sinus tachycardia (102 beats/min). Then an echocardiogram was performed and showed diffuse hypokinesia with biventricular dysfunction with low cardiac output (ejection fraction of approximately 15%) and a small pericardial effusion, compatible with cardiogenic shock.
Treatment
The diagnosis of cardiac failure due to complicated EBV disease was made and inotropic therapy was started with epinephrine and dobutamine. The patient was then transferred to a paediatric intensive care unit (PICU), under mechanical ventilation.
Outcome and follow-up
During the admission in the PICU, the patient evolved with good haemodynamic response and could be extubated 4 days after admission. Inotropic therapy had to be maintained for 10 days. She was discharged 21 days after the symptoms began on treatment with carvedilol, linisopril, ivabradine, espironolactone and furosemide, but has ongoing moderate left ventricular dysfunction, with the echocardiography and cardiac MRI revealing a non-dilated or hypertrophied left ventricle with moderately depressed systolic function (ejection fraction of 37%) and no alterations in the coronary arteries, pericardium or in the valvular apparatus.
Discussion
We report a case of a previous healthy girl with manifestation of acalculous cholecystitis and myocarditis due to primary EBV infection. Acute acalculous cholecystitis is an inflammatory disease of the gallbladder in the absence of gallstones. It’s a rare condition in the paediatric age and is mostly caused by severe illness. Rarely, it can be also caused by infectious agents, including EBV. Although the pathophysiology remains uncertain, it is suggested that it can occur due to direct invasion of the gallbladder epithelial cells by EBV.1 In the imaging study, the most common finding is an increase in gallbladder wall thickness, as detected in this case.2 The majority of the cases can be treated without any intervention or with intravenous antibiotics, with no need for surgical intervention.3 Acute myocarditis is an uncommon clinical entity, resulting from inflammation of the myocardium. There are multiple causes, including viral infections, such as EBV. The clinical manifestations of the disease can range from non-specific systemic symptoms to haemodynamic changes and ultimately to congestive heart failure, ventricular dysfunction, cardiogenic shock and ventricular arrhythmias, which can cause sudden death.4 The symptoms that suggest cardiac involvement in EBV disease can include fatigue, palpitations, chest pain, dyspnoea, decreased exercise tolerance and syncope. ECG may be normal, but findings can include sinus tachycardia, ST and/or T wave changes, and atrioventricular or bundle branch block.5 When present, PR depression and diffuse ST elevation can be due to an associated pericarditis. Although EBV infection is considered a benign disease with good prognosis, it is sometimes associated with complications, such as reviewed in this clinical report. In this case, both the clinical and laboratory findings, combined with imaging studies, were the key to diagnosing the disease and its complications, as the clinical presentation was very atypical. Mononucleosis can frequently be associated with a skin rash, particularly when antibiotics, such as penicillin or its derivatives, are taken. In this case, however, although the patient was treated with amoxicillin, that did not occur. Although extremely uncommon, both acalculous cholecystitis and acute myocarditis are known complications of EBV infection in children and adolescents and can occur at the same time, which clinics must be aware of.
Learning points
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The Epstein-Barr virus (EBV) is highly prevalent throughout the population worldwide and its infection can lead to asymptomatic disease, infectious mononucleosis or other rare complications, although it is generally considered a benign disease with good prognosis.
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Acalculous cholecystitis and acute myocarditis are rare complications of EBV infection and can ultimately lead to death.
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Clinics must be aware of rare complications of EBV infection.
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Early recognition of clinical signs can lead to prompt diagnosis and treatment, then affecting the prognosis.
Footnotes
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Contributors HT: Conception of the work, analysis and interpretation of data, drafting the work and final approval of the version published. TB: Revising the work critically for important intellectual content and final approval of the version published. JC: Revising the work critically for important intellectual content and final approval of the version published. SP: Revising the work critically for important intellectual content and final approval of the version published.
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
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Competing interests None declared.
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Patient consent for publication Parental/guardian consent obtained.
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Provenance and peer review Not commissioned; externally peer-reviewed.
- © BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.
References
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