Jaundice in relation to immune activation during Epstein-Barr virus-induced infectious mononucleosis
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- Title: Jaundice in relation to immune activation during Epstein-Barr virus-induced infectious mononucleosis
- Author: Emilio-Manuel Páez-Guillán MD, Joaquín Campos-Franco MD, Ph.D, Rosario Alende MD, Héctor Lázare MD, Carmen Beceiro MD and Arturo Gonzalez-Quintela MD, Ph.D
- Publication: American Journal of the Medical Sciences
- Publisher: Elsevier Inc
- Year: 2023
- Language: English
- Pages: 9
- Format: PDF
- File size: 1.279 KB
- DOI: 10.1016/j.amjms.2022.12.004
- CBID: CBR132
Abstract
Background
Liver involvement during infectious mononucleosis is common, but jaundice is considered rare. This study aimed to investigate serum bilirubin concentrations in patients with infectious mononucleosis and immune abnormalities associated with jaundice.
Methods
We report on an adult patient with monoclonal B lymphocytosis and IgM-lambda gammopathy who developed a severe icteric hepatitis during infectious mononucleosis. We then reviewed the clinical records of 389 patients admitted to the hospital with infectious mononucleosis between 1995 and 2018 (51.7% male patients; median age, 19 years; range, 15-87 years) with focus on liver abnormalities and associated factors.
Results
Fifty-nine patients (15.1%) had serum bilirubin concentrations between 1.5 and 3 mg/dL, and 47 patients (12.0%) had serum bilirubin >3 mg/dL. Patients with increased bilirubin concentrations had a distinct clinical presentation, with more frequent abdominal pain, nausea and vomiting, and less frequent sore throat than patients with normal bilirubin. Age and sex were not significantly different for the patients with increased and normal serum bilirubin concentrations. The patients with increased serum bilirubin concentrations showed higher levels of immune activation markers than the patients with normal bilirubin, including blood lymphocyte counts, serum IgM, and β 2 -microglobulin concentrations. Heterophile antibody-positive patients (88.6%) showed similar bilirubin concentrations but higher aspartate aminotransferase and alkaline phosphatase levels than their heterophile-negative counterparts. Serum bilirubin elevations normalized quickly during follow-up.
Conclusions
Transient hyperbilirubinemia is common during severe (in-hospital) infectious mononucleosis in adult patients. Patients with hyperbilirubinemia have less frequent pharyngitis symptoms and more frequent abdominal symptoms. Hyperbilirubinemia during infectious mononucleosis is associated with immune activation markers .
Introduction
Infectious mononucleosis produced by primary Epstein-Barr virus (EBV) infection is characterized by fever, pharyngotonsillitis, lymphadenopathy, blood lymphocytosis, and a variety of potential systemic complications.
Liver involvement in the form of acute hepatitis (up to 5-fold increase in serum transaminase levels) is nearly universal in patients with infectious mononucleosis and is usually mild, clinically undetected, and resolves spontaneously. Jaundice is distinctly uncommon. Only 24 cases of cholestatic hepatitis were found in an extensive literature review in 2005. In classical descriptions of liver disease during mononucleosis, the frequency of jaundice has been reported as 5%-6% of cases, , and was confirmed in more recent series. Among 1995 consecutive patients attending a jaundice hotline clinic over a 13-year period, only 17 (0.85%) had EBV hepatitis. Severe hepatitis might be more common in adults. , Isolated cases of severe icteric hepatitis during infectious mononucleosis have been published in recent years, which is a sign of the disorder’s rarity. The pathogenesis of severe liver injury during infectious mononucleosis is unclear, but might be immune-mediated. The classical description of liver histopathology during infectious mononucleosis includes a characteristic mononuclear infiltration in lobular sinusoids in relation to liver injury markers. , More recently, studies have demonstrated that EBV infects lymphocytes infiltrating the liver but not hepatocytes in cases of severe hepatitis. , In fact, infectious mononucleosis is an acute, self-limiting lymphoproliferative disorder. In this article, we report on an adult patient with a low-grade lymphoproliferative disorder (monoclonal B lymphocytosis) who developed severe icteric hepatitis during EBV-induced infectious mononucleosis. We subsequently studied serum bilirubin concentrations in a larger sample of adult (older than 15 years) patients with infectious mononucleosis and factors associated with jaundice, particularly immune abnormalities.
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