Primary Epstein-Barr Virus Infection With Marked Cholestasis, Warm Autoimmune Hemolytic Anemia, and Pancytopenia

Abstract

Primary Epstein-Barr virus (EBV) infection may rarely present with cholestatic hepatitis or hemolytic anemia. We share a case of EBV-associated infectious mononucleosis presenting with a unique triad of findings comprising cholestatic hepatitis with marked hyperbilirubinemia, warm autoimmune hemolytic anemia, and pancytopenia. Early diagnostic challenges included negative Monospot heterophile testing. Additional testing revealed EBV serologies consistent with acute primary infection, EBV viremia and bone marrow biopsy showing EBV-encoded RNA-positive cells. A tapered prednisone course was administered for warm autoimmune hemolytic anemia. Improvement in symptoms and laboratory findings occurred over 3 weeks.