Unusual case of acute viral hepatitis in a 5 year old girl

Backround and aims: In most of the cases acute viral hepatitis in children is caused by hepatitis virus type A. There are rare cases where other types of hepatitis virus or other
viruses such as Ebstain Barr Virus (EBV) and Cytomegalovirus (CMV) can cause acute hepatitis. This is an unusual case of acute viral hepatitis in a 5 year old girl caused by concomitant EBV and CMV infection.
Methods: Five year old girl presented with fever, fatigue, headache, nausea, vomiting, abdominal pain, swelling of upper eyelids and darker urine. On physical examination
conscious, pale, febrile (39 C) dehydrated, icteric sclera, pharynx hyperemic, oedema of upper eyelids, pain and hepatosplenomegaly on abdominal palpation. Sucussio
renalis negative.Blood tests with leukocytosis (Le=28,35 with Ly=72,4%), Hgb= 108g/l, CRP= 34mg/l, AST= 470U/L, ALT= 684U/L, GGT= 95U/L, Total billirubin= 87.7umol/l, Direct Billirubin= 69,8 umol/l. Serological test for hepatitis
A, B, C were negative. EBV IgM and CMV IgM were positive. Urine test positive for aceton and billirubin. Abdominal ultrasound with small hepatosplenomegaly and 70 ml of free liquid in Douglas space
Results: After apropriate conservative treatment, with gradually decrease of hepatic enzymes and bilirubin values,
normalization of urine color, withdrawal of abdominal organomegaly, disapearing of free liquid in Douglas space and improvement of general condition.
Conclusion: Concomitant infection od EBV and CMV are rare causes
of acute hepatitis. In most of the cases it is manifested as
noncomplicated infective mononucleosis, but symptomatic
hepatitis is rare. We should consider infectious mononucleosis hepatitis in differentiating patients presenting with liver abnormality, fever, pharyngitis, and
lymphadenopathy.