EBV Encephalitis in Acute Infectious Mononucleosis
Case Study: A 9-year-old boy was admitted to our hospital after an epileptical seizure. He presented with a 6-day history of fever and general body aches. On clinical examination, he was found to have a tonsillitis and swollen cervical lymph nodes. Because of a decreasing vigilance, a lumbar puncture was performed 16 hours after admission. The analysis of cerebrospinal fluid (CSF) showed an increased cell count of 115/µL. We then started a therapy with aciclovir and cefotaxim. Because of inadequate improvement, an MRI scan was performed 32 hours after admission, which was seen as normal by the pediatric radiologists. The situation of the patient worsened further with decreasing consciousness and cerebral seizures, which could not be managed by levetiracetam. Overall, 72 hours after admission, he was transferred to the intensive care unit, intubated and anesthetized with thiopental. Suspecting a Epstein-Barr virus encephalitis, DD an Autoimmune Encephalitis another lumbar puncture was performed and a therapy with glucocorticoids was started. After positive EBV specific PCR on CSF and confirmed intrathecal EBV antibody production intravenous immunoglobulins were added for 3 days. With this therapy, the condition of the patient improved. He was extubated after 6 days and was discharged with only slight cognitive and motoric restrictions for rehabilitation after 3 weeks. In retrospective the initial MRI, in comparison to a follow-up MRI, showed a symmetrical hyperintensity of gray matter as well as a moderate compression of the ventricles, which are typical for the acute stage of EBV encephalitis.
Conclusion: EBV encephalitis is a rare complication of infectious mononucleosis. The unspecific symptoms, only subtle changes in MRI scan and often inconclusive CSF values make it difficult to diagnose and only possible if considered specifically. The therapy is not evidence based and symptomatic with glucocorticoids and immunoglobulins. The prognosis seems to be good when treated early.
Keywords: Ebstein-Barr virus, encephalitis, positive EBV specific PCR on CSF, glucocorticoids, immunoglobulins.