Beyond sore throat and lymph nodes: Epstein-Barr virus infection presenting as acute acalculous cholecystitis

Primary Epstein-Barr virus (EBV) infection typically presents as infectious mononucleosis (IM), a clinical syndrome characterised by fever, pharyngitis and cervical lymphadenopathy. We describe a previously healthy 26-year-old woman who presented with fever and right-sided abdominal pain. There was no associated pharyngitis or enlarged cervical lymph nodes. Laboratory investigations demonstrated atypical lymphocytosis with a mixed hepatocellular-cholestatic pattern of liver enzyme derangement. Initial contrast-enhanced computed tomography of the abdomen and pelvis (CTAP) was unremarkable. As polymerase chain reaction was positive for EBV DNA (6290 copies/ml) in her serum, she was initially managed as for EBV hepatitis. Over 5 days, her abdominal pain worsened with development of positive Murphy’s sign and repeat CTAP demonstrated a distended gallbladder with diffuse mural oedema without cholelithiasis, suggestive of acute acalculous cholecystitis (AAC). She made a full recovery with supportive management alone. AAC is a rare complication of primary EBV infection and may occur without features of IM. Early in the course of AAC, Murphy’s sign may be absent, and CT may be non-diagnostic. Clinicians should maintain a high index of suspicion for AAC in patients with primary EBV infection who have right sided abdominal pain. Repeat imaging may be required if abdominal findings progress.