EPSTEIN-BARR VIRUS (EBV) ASSOCIATED ENCEPHALITIS IN YOUNG MALE
Khan N, Wani K, Almajed MR, and Entz A. EPSTEIN-BARR VIRUS (EBV) ASSOCIATED ENCEPHALITIS IN YOUNG MALE. J Gen Intern Med 2023; 38:S464-S465.
J Gen Intern Med
CASE: A 22-year-old Yemeni male acutely presented with alerted mentation and confusion. Two days prior, patient endorsed subjective fevers, chills and fatigue. He has no pertinent medical history. Upon presentation, patient was not alert nor oriented to time nor place. On examination, he was hypotensive with inability to follow commands or respond to stimuli. Laboratory work-up was largely unremarkable, including negative urine toxicology and urinalysis. Initial CT Head showed findings suggestive of idiopathic intracranial hypertension, but otherwise no acute process. Further CTA showed no evidence of intracranial arterial stenosis, occlusion, or aneurysm. Given concern for acute encephalitis, patient was empirically started on antibiotics and antiviral therapy. Lumbar puncture was obtained and demonstrated elevated lymphocytes and RBCs >2. CSF studies including CMV, VZV, HSV, and HIV were still pending. Given little improvement with empiric treatment, further EEG was obtained which showed bilateral temporal diffuse polymorphic as seen in HSV encephalopathy. Therapy was de-escalated to antiviral therapy due to concern for HSV. Initial CSF studies resulted, demonstrating EBV in the CSF. Patient began to clinically improve, becoming more responsive and following commands appropriately. Repeat lumbar puncture showed elevated lymphocytes but otherwise negative. Further therapies were discontinued given that patient returned to his baseline mentation.
IMPACT/DISCUSSION: EBV is a common virus that has infected the majority of the world's population. In adults, the virus typically causes a triad of fever, lymphadenopathy and pharyngitis, and less commonly hepatosplenomegaly and petechiae. However, in even rarer cases it can cause encephalitis or meningitis. Studies have shown that 1% of patients develop CNS sequalae with EBV. Our case represents a rare presentation of acute encephalitis due to EBV as most cases are seen in the pediatric population unlike our patient. Also, neurological symptoms secondary to EBV are non-specific and may not present with common findings of infectious mononucleosis including cervical lymphadenopathy. Use of corticosteroids and acyclovir have been seen in some cases. However, no standard of treatment exists, and most patients improve with conservative management as seen in our patient.
CONCLUSION: Internists should be aware of the neurological complications in patients with symptoms suggestive of infectious mononucleosis. While it is more commonly seen in pediatric patients, complications can occur in adults. Therefore, it is important that we continue to share cases on EBV-related encephalitis in order to identify and properly manage these patients.