P1.018: A Complex Case of Confusion and Multiorgan Dysfunction: An Uncommon Presentation of a Common Disease

Introduction: From 1998 to 2023, there have been 47 cases worldwide of Epstein-Barr Virus (EBV) with neurologic complications in immunocompetent pediatric patients. This case describes a rare presentation of severe EBV with multiorgan involvement, including meningoencephalitis, hepatitis, rhabdomyolysis, and lung findings in an immunocompetent child.

Case Description: An 11-year-old previously healthy male presented with fever, muffled voice, generalized weakness, confusion, and syncope. He was initially diagnosed with strep pharyngitis prior to admission. He required PICU admission for acute hypoxic respiratory failure and altered mental status.

On hospital day 1, he developed hemoptysis and severe generalized abdominal pain. CT chest was notable for multifocal consolidative opacities and confluent lymph nodes of the right lung. He began having waxing and waning agitation requiring a dexmedetomidine infusion. On hospital day 2, he became obtunded and required intubation. His MRI brain was notable for pachymeningitis, a thin subdural hematoma, enlarged adenoids and tonsils with complete obliteration of the nasopharyngeal and oropharyngeal passages. He developed rhabdomyolysis and liver injury; peak CPK 122,946, ALT 1537, and AST 476. He was ultimately diagnosed with EBV with supporting monospot and EBV quantitative titers. With supportive care, he returned to neurologic baseline and had no lasting kidney or liver injury.

Discussion: EBV with severe neurologic, hepatic, and musculoskeletal complications is rare in immunocompetent pediatric patients. Although the exact pathogenesis of CNS invasion remains unclear, studies suggest the virus may directly disrupt the blood brain barrier. Serious neurologic sequelae in children have been reported, including acute disseminated encephalomyelitis, acute cerebellar ataxia, and brainstem encephalitis leading to long-term deficits. Neuroimaging can be a helpful diagnostic tool for EBV meningoencephalitis as over 60% of cases of CNS involvement showed CT or MRI changes, but changes were non-specific. EBV-associated kidney and liver injury can have serious complications as well, such as renal failure requiring dialysis. The mainstay of treatment is supportive care; utilization of antivirals remains controversial. Although some cases have reported using acyclovir for severe disseminated EBV, this patient recovered with supportive care alone.

Conclusion: EBV has many atypical manifestations and can be a diagnostic challenge. EBV should be considered as a causative agent of meningoencephalitis with multiorgan involvement.