Small but mighty: a case report of epstein-barr virus encephalitis leading to unusual complications in a well controlled hiv + patient

SESSION TITLE: Critical Care Case Report Posters 20 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 12:00 pm - 12:45 pm INTRODUCTION: Epstein-Barr virus (EBV) is a rare cause of encephalitis with most affected being immunosuppressed.The following is a case report of a 66 year old female with controlled HIV who was diagnosed with EBV encephalitis and S. Pneumoniae bacteremia leading to rare, life threatening complications CASE PRESENTATION: A 66 year old female with controlled HIV, hypertension, heart failure, strokes, deep vein thrombosis presented for evaluation of altered mentation and vomiting. Patient was febrile (39.5 C), had nuchal rigidity with encephalopathy and seizures. She was started on empiric treatment for suspected meningitis with Vancomycin, Ceftriaxone, acyclovir, and dexamethasone. Patient was upgraded to ICU for worsening encephalopathy requiring intubation and shock requiring vasopressors. Initial labs showed elevated lactate and transaminitis. Blood cultures were positive for S. pneumoniae. MRI brain showed a questionable small acute/subacute infarct in the left occipital lobe, chronic infarcts, and scattered foci of T2/FLAIR signal hyperintensities in the periventricular and subcortical white matter. Lumbar puncture was significant for WBCs 240 (cells/mm3) with neutrophil predominance (91%), glucose of 45 (mg/dL), 485 protein (mg/dl). CSF Culture was negative while on antimicrobials, however, encephalitis AB panel was positive for EBV DNA by PCR. Serum EBV serology was elevated IGM 68.30 (U/ml), IGG 305 (U/ml) and viral load 71,171 copies/mL. CSF HSV-1, HSV-2, Adenovirus, CMV, VZV, HSV- 6, and enterovirus were negative. Patient was started on Ganciclovir leading to resolution of encephalitis and successful extubation. Hospital course was complicated by acalculous cholecystitis requiring percutaneous drainage and pancreatitis. After stabilization, patient was discharged to a nursing facility for rehabilitation. DISCUSSION: EBV is responsible for up to 3% of acute encephalitis, while S.pneumoniae is implicated in 70% of bacterial meningitis cases (1-2). Co-infections of meningitis and viral encephalitis are extremely rare but have been reported (3-5). MRI findings in patients with EBV encephalitis can vary from normal to leptomeningeal enhancement and hyperintensities (1,6-7). CSF PCR can be falsely-positive in patients with CNS inflammation and additional testing (CSF and serum) is needed for further diagnosis (8-9). Previous studies have suggested that co-infection of HIV and EBV was associated with higher mortality in patients with meningitis (4). Interestingly, some literature is suggestive of a rare but serious relationship between acute EBV infection and acalculous cholecystitis (10-12). There is currently no standard treatment for EBV encephalitis, recommendations range from steroids to treatment with Valganciclovir and ganciclovir (13-14). EBV encephalitis has a variable prognosis (1,15), while S. pneumoniae. meningitis carries mortality of approximately 20% (16). CONCLUSIONS: Co-infections of the CNS are extremely rare but have been reported. In cases with CNS inflammation EBV PCRs should be interpreted with caution as a positive result may be due to increased blood brain permeability or due to the influx of B cells in the CNS. In such cases additional serological or CSF studies are helpful in determining clinical significance. Although there is no current standardized treatment for EBV encephalitis, certain evidence supports the use of valganciclovir and ganciclovir for acute infections. Further research is needed into the role of EBV co-infections given the varied clinical presentations. REFERENCE #1: Khanal D, Singh T, Rabinstein A. Epstein Barr Virus Encephalitis in Adults: A Case Series (P1.293). Neurology. 2016;86(16 Supplement). Accessed March 24, 2023. https://n.neurology.org/content/86/16_Supplement/P1.293 REFERENCE #2: Zhang S, Feng J, Shi Y. Transient widespread cortical and splenial lesions in acute encephalitis/encephalopathy associated with primary Epstein–Barr virus infection. Int J Infect Dis. 2016;42:7-10. doi:10.1016/j.ijid.2015.11.009 REFERENCE #3: Di Carlo P, Trizzino M, Titone L, et al. Unusual MRI findings in an immunocompetent patient with EBV encephalitis: a case report. BMC Med Imaging. 2011;11:6. doi:10.1186/1471-2342-11-6 DISCLOSURES: No relevant relationships by Arij Azhar No relevant relationships by Rafael Garcia Sturgill No disclosure on file for James Gasperino No relevant relationships by Louis Gerolemou No relevant relationships by Wael Kalaji No relevant relationships by Olga Knap No relevant relationships by Ronni Levy No relevant relationships by Nabil Mesiha No relevant relationships by Steven Miller No relevant relationships by Kunal Nangrani No disclosure on file for Jose Orsini No relevant relationships by Gaurav Parhar Speaker/Speaker's Bureau relationship with Allergan Please note: $20001 - $100000 by Joshua Rosenberg, value=Honoraria Removed 03/30/2023 by Joshua Rosenberg, source=Web Response Speaker/Speaker's Bureau relationship with Sanofi Pasteur Please note: Present Added 03/30/2023 by Joshua Rosenberg, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with La Jolla Please note: Present Added 03/30/2023 by Joshua Rosenberg, source=Web Response, value=Honoraria Advisory Board and Marketing relationship with AbVie Please note: Present Added 03/30/2023 by Joshua Rosenberg, source=Web Response, value=Consulting Fee Advisory Board relationship with Merck Please note: Present Added 03/30/2023 by Joshua Rosenberg, source=Web Response, value=Consulting fee No relevant relationships by Anuj Shivalingaiah No relevant relationships by Viswanath Vasudevan No relevant relationships by Kiran Zaman