Peripheral facial paralysis in a liver transplant patient with Epstein-Barr virus infection

*Correspondence: [e-mail].

Abstract

Case Presentation: A.S.S., female, 1 year old, liver transplanted for cirrhosis secondary to biliary atresia. History of Epstein-Barr virus infection. During hospitalization, the assistant team observed right peripheral facial paralysis, then prescribed acyclovir and prednisolone for 5 days, empirically, without resolution of the condition. A gradual decrease in immunosuppression was chosen according to tolerance. On neurological examination, the patient was in good general condition, clinical condition compatible with right peripheral facial paralysis, she kept the cervical region preferably flexed to the right, managed to close the eyes, but did not show resistance to passive opening of the eyelid. Cranial magnetic resonance imaging showed thickening and contrast enhancement inside the internal auditory canal and right cerebellopontine angle, as well as in the trigeminal nerve on this side, nonspecific. Examination of the cerebrospinal fluid showed: leukocytes 4/μL, erythrocytes 1/μL, total protein 19 mg/dL, lactate 1.47 mmol/L, glucose 60 mg/dL, absence of bacterial growth, negative fungal and mycobacterial culture, VDRL non-reactive and Epstein-Barr (EBV) positive.

Discussion: Peripheral facial palsy due to EBV in immunosuppressed children is infrequent. In the reported case, the imaging exam suggested an inflammatory process compatible with the clinical picture and the agent was identified by PCR in the cerebrospinal fluid. Although the treatment of choice in immunosuppressed patients is rituximab, we decided not to start it due to the low viral load. With the increase in viral load, treatment with rituximab was started and 1 month after the start of treatment, the viral load evolved with a decrease and the control neuroimaging no longer showed alterations.

Final Comments: In patients undergoing solid organ or hematopoietic cell transplantation, exposure to EBV can be avoided by selecting donors without EBV contamination; However, this is not always possible. Thus, patients are typically monitored for EBV infection, and strategies to reduce the risk of post-transplant lymphoproliferative disease are implemented if EBV viremia is detected.

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Artikel online veröffentlicht:
12. Mai 2025