Epstein-Barr Virus Infection with Acute Pancreatitis Associated with Cholestatic Hepatitis
An 11-year-old female was admitted to the emergency center of another hospital with a 1-day history of left upper quadrant abdominal pain, nausea and vomiting. Laboratory data revealed amylase at 1,200 U/L (normal range, 0-220), lipase at 2,000 U/L (normal range, 13.8-110), aspartate aminotransferase (AST) at 724 U/L (normal range, 3-38), and alanine aminotransferase (ALT) at 815 U/L (normal range, 4-44). Computed tomography (CT) finding of the abdomen showed swelling of the pancreas with peripancreatic fluid accumulation compatible with acute pancreatitis. She was transferred to our hospital with a preliminary diagnosis of acute hepatitis and pancreatitis.\nShe had no past history of abdominal trauma, surgery or cholecystitis. She had not received any medications known to cause pancreatitis. She did not report any familial history of pancreatitis or gallstone.\nOn physical examination she appeared sick with icteric sclera. Tenderness on left upper quadrant of abdomen without rebound tenderness was noticed. Exudative pharyngotonsillitis, cervical lymphadenopathy, and hepatosplenomegaly were not present.\nLaboratory investigation revealed hemoglobin of 13.6 g/dL, hematocrit of 39.5%, platelet of 356,000/mm3, white blood cell count of 8,540/mm3 (neutrophil 72%, monocyte 2.7%, lymphocyte 19%). Atypical lymphocyte was absent on peripheral blood smear. Blood chemistry showed AST of 465 U/L, ALT of 657 U/L, total/direct bilirubin of 4.0/1.9 mg/dL (normal range, total bilirubin 0.2-1.2, direct bilirubin 0-0.4). Serum amylase and lipase were elevated to 4,010 U/L and 4,941 U/L respectively (). Alkaline phosphatase was raised to 1,056 U/L (normal range, 104-338) and gamma-glutamyltransferase was raised to 456 U/L (normal range, 16-73). Diagnosis was acute cholestatic hepatitis concurrent with pancreatitis. Other laboratory data showed prothrombin time-international normalized ratio of 1.02, serum total protein of 7.7 g/dL, serum albumin of 4.5 g/dL, blood urea nitrogen of 7 mg/dL, creatinine of 0.7 mg/dL.\nViral hepatitis profiles results including HBsAg, anti-HAV IgM, anti-HCV, anti-HEV IgM/IgG were all negative. Laboratory results for various infectious agent for pancreatitis and hepatitis including anti-mycoplasma IgM, anti-cytomegalovirus IgM, anti-mumps IgM, anti-rubella IgM, anti-measles IgM, leptospira antibody, Clonorchis sinensis antibody were all negative. Serum antinuclear antibody result to evaluate autoimmune disease was negative. Stool smear test for parasites was also negative.\nAlthough the peripheral blood smear did not show atypical lymphocytes, a diagnosis of reactivated EBV infection was made by the positive result of viral capsid antigen (VCA) IgM, VCA IgG and Epstein-Barr nuclear antigen. Heterophile antibody converted from initial negative result to positive in repeated serologic test on 9th day of hospitalization.\nOn radiologic examination, the plain radiographs of abdomen were found unremarkable. Magnetic resonance cholangiopancreatography was performed, which did not show choledochal cyst, pancreatic divisum or a pancreatic duct anomaly.\nThe patient was treated with conservative management with fasting and total parenteral nutrition. On 2nd day of hospitalization, blood chemistry was improved as amylase of 996 U/L, lipase of 516 U/L, AST of 178 U/L, ALT of 440 U/L, total bilirubin of 3.1 mg/dL, direct bilirubin of 1.2 mg/dL. Gastrointestinal symptom such as abdominal pain or vomiting improved also, and she started a regular diet on 4th day when amylase and lipase were normalized (). On 11th day of hospitalization, rapid normalization of biochemical results was observed on follow up laboratory tests. The results were amylase of 223 U/L, lipase of 63 U/L, AST of 31 U/L, ALT of 18 U/L, total bilirubin of 0.4 mg/dL, direct bilirubin of 0.2 mg/dL (). During the 20-month-follow up in the outpatient clinic, she remained in good condition without any sign of relapse of the hepatitis or pancreatitis.