Keywords
Case report
Cholestasis
Epstein-Barr virus
Jaundice
Categories
How to Cite
Abstract
Primary Epstein-Barr virus (EBV) infection usually causes mild aminotransferase elevation. Severe jaundiced hepatitis without encephalopathy is uncommon in adults.
We describe a 20-year-old woman with primary EBV-associated acute liver injury and summarize a March 2026 PubMed-only English-language contextual review of selected adult case reports/case series. Severe acute liver injury was defined descriptively as acute hepatic injury with INR ≥1.5 without encephalopathy. Injury pattern was classified with the R-ratio at presentation and peak jaundice.
The patient presented with headache, nausea, and vomiting and had AST 1,942 U/L, ALT 2,032 U/L, total/direct bilirubin 4.0/1.7 mg/dL, alkaline phosphatase 140 U/L, gamma-glutamyltransferase 73 U/L, and INR 1.1, with atypical lymphocytosis and hepatosplenomegaly without biliary obstruction. Heterophile testing, EBV serology, and plasma EBV DNA supported primary infection; alternative infectious, autoimmune, metabolic, and selected toxic causes were not identified. The R-ratio was 54.7 at presentation and 27.2 at peak jaundice, indicating a hepatocellular pattern at both time points despite evolving cholestatic features. INR peaked at 1.6, but no encephalopathy developed. With supportive care alone, jaundice resolved clinically by 1 month and liver tests and INR normalized by 2 months.
Primary EBV infection should be considered in young adults with marked acute liver injury and jaundice even without classic mononucleosis features. This case illustrates severe hepatocellular liver injury with evolving cholestatic features, transient coagulopathy without acute liver failure, and biochemical normalization by 2 months.
References
1. Dunmire SK, Verghese PS, Balfour HH, Jr. Primary Epstein-Barr virus infection. J Clin Virol. 2018: 84 [PMID: 29525635, https://doi.org/10.1016/j.jcv.2018.03.001]
2. Kang MJ, Kim TH, Shim KN, Jung SA, Cho MS, Yoo K, Chung KW. Infectious mononucleosis hepatitis in young adults: two case reports. Korean J Intern Med. 2009: 381 [PMID: 19949739, https://doi.org/10.3904/kjim.2009.24.4.381]
3. Yang SI, Geong JH, Kim JY. Clinical characteristics of primary Epstein Barr virus hepatitis with elevation of alkaline phosphatase and gamma-glutamyltransferase in children. Yonsei Med J. 2014: 107 [PMID: 24339294, https://doi.org/10.3349/ymj.2014.55.1.107]
4. Vine LJ, Shepherd K, Hunter JG, Madden R, Thornton C, Ellis V, Bendall RP, Dalton HR. Characteristics of Epstein-Barr virus hepatitis among patients with jaundice or acute hepatitis. Aliment Pharmacol Ther. 2012: 16 [PMID: 22554291, https://doi.org/10.1111/j.1365-2036.2012.05122.x]
5. Mellinger JL, Rossaro L, Naugler WE, Nadig SN, Appelman H, Lee WM, Fontana RJ. Epstein-Barr virus (EBV) related acute liver failure: a case series from the US Acute Liver Failure Study Group. Dig Dis Sci. 2014: 1630 [PMID: 24464209, https://doi.org/10.1007/s10620-014-3029-2]
6. Shingina A, Mukhtar N, Wakim-Fleming J, Alqahtani S, Wong RJ, Limketkai BN, Larson AM, Grant L. Acute Liver Failure Guidelines. Am J Gastroenterol. 2023: 1128 [PMID: 37377263, https://doi.org/10.14309/ajg.0000000000002340]
7. Fernandez J, Bassegoda O, Toapanta D, Bernal W. Acute liver failure: A practical update. JHEP Rep. 2024: 101131 [PMID: 39170946, https://doi.org/10.1016/j.jhepr.2024.101131]
8. Khoo A. Acute cholestatic hepatitis induced by Epstein-Barr virus infection in an adult: a case report. J Med Case Rep. 2016: 75 [PMID: 27037083, https://doi.org/10.1186/s13256-016-0859-x]
9. Moniri A, Tabarsi P, Marjani M, Doosti Z. Acute Epstein - Barr virus hepatitis without mononucleosis syndrome: a case report. Gastroenterol Hepatol Bed Bench. 2017: 147 [PMID: 28702140,
10. Joshi A, Jha D, Wari E, Saeed M, Hussain M, Hiatt TK. Cholestatic hepatitis in acute Epstein-Barr virus infection: A case report. Clin Case Rep. 2024: e9357 [PMID: 39176101, https://doi.org/10.1002/ccr3.9357]
11. Shah J, Lingiah V, Pyrsopoulos N, Galan M. Acute Liver Injury due to Severe Epstein-Barr Virus Infection. ACG Case Rep J. 2020: e00325 [PMID: 32309513, https://doi.org/10.14309/crj.0000000000000325]
12. Theodory B, Dopp M, Swisher AR, Flores RM, Robb PM. Epstein-Barr virus induced acute hepatitis with hyperferritinemia: A rare presentation. IDCases. 2023: e01872 [PMID: 37609447, https://doi.org/10.1016/j.idcr.2023.e01872]
13. Pamala C, Orabi M, Avinash S, Kamel I. Atypical Presentation of Epstein-Barr Virus Infectious Mononucleosis With Cholestatic Hepatitis and Hyperbilirubinemia in a Young Adult: A Case Report. Cureus. 2024: e71066 [PMID: 39380778, https://doi.org/10.7759/cureus.71066]
14. Zhang W, Chen B, Chen Y, Chamberland R, Fider-Whyte A, Craig J, Varma C, Befeler AS, Bisceglie AM, Horton P, Lai JP. Epstein-Barr Virus-Associated Acute Liver Failure Present in a 67-Year-Old Immunocompetent Female. Gastroenterology Res. 2016: 74 [PMID: 27785330, https://doi.org/10.14740/gr718e]
15. Njoku P, Ngemoh D, Amin S, Mandal AKJ, Missouris CG. Acute Epstein-Barr Virus Hepatitis With Cholestatic Jaundice and Hyperferritinaemia: A Case Report. Br J Hosp Med (Lond). 2025: 1 [PMID: 40265533, https://doi.org/10.12968/hmed.2024.0919]
16. Nishioka H, Kitagawa N. Epstein-Barr Virus-Related Infectious Mononucleosis Accompanied by Cholestatic Hepatitis. Cureus. 2025: e88392 [PMID: 40842806, https://doi.org/10.7759/cureus.88392]
17. Tak MB, Li Kam Wa A, Simkin L, Abdelnabi M, Tasneem A. Primary Epstein-Barr Virus Infection Presenting as Cholestatic Hepatitis Without Infectious Mononucleosis in an Immunocompetent Middle-Aged Adult: A Case Report. Cureus. 2025: e96907 [PMID: 41409949, https://doi.org/10.7759/cureus.96907]
18. De Paschale M, Clerici P. Serological diagnosis of Epstein-Barr virus infection: Problems and solutions. World J Virol. 2012: 31 [PMID: 24175209, https://doi.org/10.5501/wjv.v1.i1.31]
This work is licensed under a Creative Commons Attribution 4.0 International License.
Copyright (c) 2026 Hatem Ahmed , Motaz Almahmood, Khloud Abdelrazeq, Roy Arslan Ahmed, Amit H. Gangoli