Epstein-Barr encephalitis in immunocompetent adolescent

*Correspondence: [e-mail].

Abstract

Case Presentation: Female, 11 years old, previously healthy, started with fever and vomiting, progressing to generalized tonic-clonic seizures and lowered level of consciousness. She required mechanical ventilation and intensive care. In the suspicion of nervous system infection, empirical treatment for meningitis was initiated. In the cerebrospinal fluid (CSF), a positive test of polymerase chain reaction (PCR) for Epstein Barr virus (EBV) was obtained. Magnetic resonance imaging (MRI) of the skull showed hypersignal in the caudate nuclei and putamen on T2/FLAIR. Ophthalmologic examination revealed EBV macular retinopathy. She was treated with phenytoin, phenobarbital, carbamazepine, sodium valproate and levetiracetam. During the rehabilitation process, she presented new fever peaks, focal dysperceptive seizures and generalized tonic-clonic seizures, in addition to the appearance of erythematous papules on the trunk and limbs. In case of suspected pharmacodermia, all medications were suspended, remaining only with clobazam and then with levetiracetam. Skin biopsy showed Toxic Epidermal Necrolysis (TEN). After managing the condition and adequate control of the seizures, there was regression of the lesions and only facial myoclonus remained.

Discussion: The prevalence of EBV encephalitis amounts to 2-30%, being higher in children up to 4 years old or in those hospitalized for infectious mononucleosis (IM). The manifestations are, in general, nonspecific, and the diagnosis must be made with the presence of EBV antibodies and PCR in the blood or CSF. In this case, the patient was older than expected, without initial symptoms of MI, making the diagnosis challenging. Therefore, EBV should be considered as the cause of viral encephalitis in childhood, and PCR research for EBV is important. The neuroimaging (MRI) findings in the case described are similar to those reported in the literature. Currently, there is no standard protocol for the treatment of EBV encephalitis, with supportive measures being the mainstay of therapy, which was the approach followed in the reported case, in addition to treatment to control the seizures.

Final Comments: Therefore, EBV encephalitis is mainly found in immunocompromised individuals, and needs to be consider in children who have a suspected central nervous system infection, even in the absence of IM symptoms. Diagnosis is challenging and early recognition and adequate supportive treatment are crucial for a good prognosis.

Publication History

Article published online:
12 May 2025