Epstein-Barr Virus Infection with Acute Acalculous Cholecystitis
A 10-year-old female was admitted to Seoul National University Bundang Hospital, Korea, with a 3-day history of nausea, right upper quadrant (RUQ) abdominal pain, and a 1-day history of high fever. Before visiting our hospital, she had visited a local clinic, and abdominal ultrasonography revealed diffuse edematous wall thickening of the gallbladder. She was transferred to Seoul National University Bundang Hospital with a provisional diagnosis of acute cholecystitis and acute hepatitis. She had no history of abdominal trauma or surgery. She did not report any familial history of hepatitis or cholecystitis. On physical examination, she appeared ill. Scleral icterus was not present. The pharynx was not injected and both tonsils were not hypertrophic. The right cervical lymph node was palpable and measured approximately 2×3 cm in diameter. The abdomen was soft, not distended. Bowel sounds were normoactive. The right side of the abdomen was tender with painful fullness in the right hypochondrium, indicating a positive Murphy's sign. A 8×3 cm mass-like lesion was palpable on the RUQ of the abdomen with reddish discoloration in this area. No hepatosplenomegaly or evidence of free fluid in the abdomen was noted.\nLaboratory investigations revealed a hemoglobin level of 13.7 g/dL, hematocrit value of 39.7%, platelet count of 234,000/mm3, and white blood cell count of 8,280/mm3 (neutrophils 30%, monocytes 12%, lymphocytes 56%). Atypical lymphocytes were present (1%) on peripheral blood smear. Blood chemistry revealed aspartate aminotransferase of 311 U/L, alanine aminotransferase of 489 U/L, and total/direct bilirubin level of 1.0/0.6 mg/dL. The gamma-glutamyltransferase level was raised to 308 U/L (). Other laboratory data showed a prothrombin time/international normalized ratio of 1.19, serum total protein level of 6.9 g/dL, serum albumin level of 4.5 g/dL, blood urea nitrogen level of 7 mg/dL, creatinine level of 0.54 mg/dL, and C-reactive protein level of 0.40 mg/dL.\nPlain radiographys of the abdomen revealed no abnormality. Abdominal ultrasonography showed diffuse edematous wall thickening of the gallbladder (6 mm thickness) with increased vascularity. Sonographic Murphy's sign was positive. Definite echogenic calculi was not visible. Biliary ductal dilatation was not present ().\nThe following EBV panel results were indicative of acute primary infection; IgM of the viral capsid antigen (VCA) was positive (1.59, negative≤0.90, positive≥1.10). And the VCA-IgG was equivocal (0.92); the early antigen (EA) IgM was negative (5.26); and EBV EA IgG was negative (1.15). EBV EBNA IgG was negative (4.89). Other tests were performed to exclude other infectious causes of acalculous cholecystitis, the results of viral hepatitis profiles, including HBsAg, anti-hepatitis A virus IgM, anti-hepatitis C virus, and cytomegalovirus IgM were all negative.\nOnce the diagnosis of primary EBV infection had been confirmed, the patient was treated with empirical antibiotics, and conservative management with fasting and total parenteral nutrition. Gastrointestinal symptoms such as abdominal pain and nausea then began to improve, thus she started a regular diet on the third day of admission. She continued to have episodes of fever for approximately 5 days, but her appetite gradually improved. She eventually became afebrile for 48 hours and was discharged on the seventh day of admission. During the 2-month follow-up examination at the outpatient clinic, she was in good condition without any sign of relapse of cholecystitis.