Acute Epstein-Barr virus hepatitis presenting clinically as ascending cholangitis in an immunocompetent patient


  • Rachel Colbran Department of General Surgery, Ipswich Hospital, Ipswich, Queensland
  • Jessica Ng Department of General Surgery, Ipswich Hospital, Ipswich, Queensland



Cholestatic jaundice, Epstein-Barr virus, Hepatitis, Jaundice


Symptomatic acute Epstein-Barr virus (EBV) hepatitis, without associated infectious mononucleosis syndrome, is exceptionally rare. A 30-year-old female presented to hospital with jaundice, fevers, and right upper quadrant abdominal pain. Her blood tests demonstrated marked hyperbilirubinemia and mild global liver function test abnormalities consistent with obstructive jaundice.  Preliminary imaging with ultrasound showed gallbladder wall thickening and cholelithiasis, suggestive of potential cholecystitis. Authors were concerned for potential ascending cholangitis in the setting of her hyperbilirubinemia. The diagnosis was refuted after magnetic resonance cholangiopancreatography demonstrated no choledocholithiasis. A hepatic panel was performed which revealed positive EBV IgM serology. This case highlights the importance of considering EBV hepatitis as a potential differential diagnosis in patients with right upper quadrant pain, fevers and jaundice in the absence of an obstructing cause.

Author Biography

Rachel Colbran, Department of General Surgery, Ipswich Hospital, Ipswich, Queensland

Ipswich Hospital, department of general surgery


Schechter S, Lamps L. Epstein-Barr Virus Hepatitis: A Review of Clinicopathologic Features and Differential Diagnosis. Archiv Pathol Lab Med. 2018;142(10):1191-5.

LoSavio AD, Te HS. Epstein-barr virus: an unusual cause of cholestatic hepatitis in older adults. Gastroenterol hepatol. 2007 Feb;3(2):101.

Crum NF. Epstein Barr virus hepatitis: case series and review. Southern Med J. 2006;99(5):544-8.

Hong MJ, Kim SW, Kim HC, Yang DM. Comparison of the clinical characteristics and imaging findings of acute cholangitis with and without biliary dilatation. Bri J Radiol. 2012;85(1020):e1219-25.

Agrawal S, O'Connor R, Aoun E, Babich M. Intense pruritus in Epstein-Barr virus (EBV) hepatitis treated with naloxone drip. BMJ Case Rep. 2015 Jan 27;2015:bcr2014207037.

Kofteridis DP, Koulentaki M, Valachis A, Christofaki M, Mazokopakis E, Papazoglou G, et al. Epstein Barr virus hepatitis. Eur J Intern Med. 2011;22(1):73-6.

Feranchak AP, Tyson RW, Narkewicz MR, Karrer FM, Sokol RJ. Fulminant Epstein‐Barr viral hepatitis: orthotopic liver transplantation and review of the literature. Liver Trans Surg. 1998;4(6):469-76.

Fuhrman SA, Gill R, Horwitz CA, Henle W, Henle G, Kravitz G, et al. Marked hyperbilirubinemia in infectious mononucleosis: Analysis of laboratory data in seven patients. Archiv Int Med. 1987;147(5):850-3.

Park JH, Noh JC, Park HM, Jung YS, Park SH, Hong HC, et al. A case of Epstein-Barr virus infection with gall bladder and common bile duct stones in an otherwise healthy child. Pediatr Gastroenterol, Hepatol Nutrit. 2012;15(1):57-61.

Georgiev KJ, Ahačič T, Najdenov P. Redek zaplet primarne okužbe z Epstein-Barr virusom. Slov Med J. 2019 May 31;88(5-6):276-81.

Petrova M, Kamburov V. Epstein-Barr virus: silent companion or causative agent of chronic liver disease?. World J Gastroenterol: WJG. 2010;16(33):4130.

Rigopoulou EI, Smyk DS, Matthews CE, Billinis C, Burroughs AK, Lenzi M, et al. Epstein-barr virus as a trigger of autoimmune liver diseases. Advan Virol. 2012;2012.

Kiewiet JJ, Leeuwenburgh MM, Bipat S, Bossuyt PM, Stoker J, Boermeester MA. A systematic review and meta-analysis of diagnostic performance of imaging in acute cholecystitis. Radiology. 2012;264(3):708-20.

Gilijaca V, Takwoingi Y, Higgie D, Poropat G, Štimac D, Davidson B, et al. Ultrasound versus liver function tests for diagnosis of common bile duct stones. Cochrane Database Syst Rev. 2015;2015(2).

Chen W, Mo J, Li C, Zhang J. Diagnostic value of magnetic resonance cholangiopancreatography in choledocholithiasis. World J Gastroenterol. 2015;21(11):3351-60.

Maudgal DP, Wansbrough-Jones MH, Joseph AE. Gallbladder abnormalities in acute infectious hepatitis. Digestive Dis Sci. 1984;29(3):257-60.

Yamada K, Yamada H. Gallbladder wall thickening in mononucleosis syndromes. J Clin Ultrasound. 2001;29(6):322-5.

Shkalim-Zemer V, Shahar-Nissan K, Ashkenazi-Hoffnung. Cholestatic hepatitis induced by epstein-barr virus in a pediatric population. Clin Pediatr. 2015;54(12):1153-7.

Yang SI, Geong JH, Kim JY. Clinical characteristics of primary Epstein Barr virus hepatitis with elevation of alkaline phosphatase and γ-glutamyltransferase in children. Yonsei Med J. 2014;55(1):107-12.

Moniri A, Tabarsi P, Marjani M, Doosti Z. Acute Epstein-Barr virus hepatitis without mononucleosis syndrome: a case report. Gastroenterol Hepatol Bed Bench. 2017;10(2):147.

Kang S, Yoon K, Hwang J. Epstein-Barr virus infection with acute pancreatitis associated with cholestatic hepatitis. Pediatr Gastroenterol Hepatol Nutr. 2013;16(1):61-4.

Doğan I, Ergün M, Cindoruk M, Unal S. Acute hepatitis induced by Epstein-Barr virus infection: a case report. Turkish J Gastroenterol: Offici J Turkish Soci Gastroenterol. 2007;18(2):119-21.

Fox R, Ghedia R, Nash R. Amoxicillin-associated rash in glandular fever. Case Rep. 2015;2015:bcr2015211622.

Adams LA, Deboer B, Jeffrey G, Marley R, Garas G. Ganciclovir and the treatment of Epstein‐Barr virus hepatitis. J Gastroenterol Hepatol. 2006;21(11):1758-60.

Mellinger JL, Rossaro L, Naugler WE, Nadig SN, Appelman H, Lee WM, et al. Epstein–Barr virus (EBV) related acute liver failure: a case series from the US Acute Liver Failure Study Group. Dig Dis Sci. 2014;59(7):1630-7.

Maggio MC, Liotta A, Cardella F, Corsello G. Stevens-Johnson syndrome and cholestatic hepatitis induced by acute Epstein–Barr virus infection. Eur J Gastroenterol Hepatol. 2011;23(3):289.






Case Reports