Acute acalculous cholecystitis associated with severe EBV hepatitis in an immunocompetent child

Abstract

SUMMARYAcute acalculous cholecystitis (AAC) is an inflammation of the gallbladder in the absence of demonstrated stones, which is rarely seen in paediatric population. The diagnosis is accomplished mainly through abdominal ultrasonography in the appropriate but usually nonspecific clinical picture. Complicated cases need surgical intervention; the medical management is mainly constituted by supportive and antibiotic therapy, as most AAC are observed in the setting of systemic bacterial or parasitic infections. However, AAC has been rarely reported in association with Epstein-Barr virus (EBV) infection, where the gastrointestinal involvement is often mild and thus unrecognised. We report a case of EBVrelated AAC associated with unusually severe hepatitis in an immunocompetent and otherwise healthy patient. We describe its benign clinical course, despite the serious liver impairment, by a medical management characterised by the prompt discontinuation of broadspectrum antibiotics, as soon as EBV aetiology is ascertained, and by the appropriate analgesia and fluid resuscitation. BACKGROUND

Epstein‐Barr virus infection with acute acalculous cholecystitis in previously healthy children

“…These observations were similar to those of other authors . The clinical presentation of AAC is non‐specific and identical to that of cholelithiasis . In our study, hepatomegaly and splenomegaly were more often seen in AAC(+) children, but these symptoms may be associated with diseases other than cholecystitis.…”

A Rare Comlication of Ebstein-Barr Virus Infection: Acalculous Cholecystitis

“…Ultrasonografik görüntülemede safra kesesi duvar kalınlıkları 4,2-19 mm arası bildirilmiştir. Bu hastaların genel özellikleri Tablo I'de özetlenmiştir (5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18). Hastamız da bu komplikasyonun nadir görüldüğü yaş grubundaydı.…”

Epstein–Barr virus hepatitis: Importance of PCR assay/serology and significance of γ‐GTP

“…The use of polymerase chain reaction (PCR) assay, however, was equally necessary, because it enabled exclusion of co-infection with other herpesviruses and, in particular, with CMV. 2 Indeed, as it was in that case, CMV-IgM serology is often positive during EBV infection, due to antibody cross-reaction, but the co-infection cannot be excluded a priori and, especially in complicated and/or severe clinical settings, it is important to discriminate between viral serology cross-reaction and co-infection, which could affect the clinical course, as regards the duration and/or the severity. Therefore, we completely agree with Tsunoda et al that the combination of PCR assay and viral serology must be used in order to achieve a precise etiological diagnosis in cases of severe acute liver dysfunction unrelated to hepatitis viruses, both in immunocompromised and immunocompetent children.…”

“…In 2014 we described a case of severe EBV hepatitis in a previously healthy 7-year-old girl of Asiatic ethnicity. 2 We achieved a diagnosis of primary EBV infection based on the serology only, given that specific viral capsid antigen (VCA)-immunoglobulin (Ig)M was clearly positive and, despite the presence of high VCA-IgG, EBV nuclear antigen (EBNA)-IgG was absent. The use of polymerase chain reaction (PCR) assay, however, was equally necessary, because it enabled exclusion of co-infection with other herpesviruses and, in particular, with CMV.…”

“…3 Interestingly, in our study severe EBV hepatitis was also associated with AAC. 2 Thus, a greater increase of c-GTP (often indicative of an underlying infectious AAC) might be associated with EBV infection more often, but further research including larger cases series is needed to support such a hypothesis. 4 CMVrelated AAC was almost exclusively described in immunocompromised patients (because of transplantations or HIV infection) and, to our knowledge, only one pediatric case of AAC due to HHV-6 infection was reported very recently.…”