Intended for healthcare professionals

Endgames Case Review

Epstein Barr virus, abdominal pain, and jaundice

BMJ 2017; 358 doi: (Published 03 August 2017) Cite this as: BMJ 2017;358:j3386
  1. Alexandra Khoury, foundation year 2 doctor1,
  2. Francois Porté, consultant radiologist2,
  3. Masud Haq, consultant in diabetes and endocrinology2
  1. 1Conquest Hospital, Hastings, UK
  2. 2Tunbridge Wells Hospital, Tunbridge Wells, UK
  1. Correspondence to Alexandra Khoury aakhoury{at}

A 22 year old man presented to the emergency department with abdominal pain, jaundice, itching, and fever. His urine was dark and stools pale.

His temperature was 38.7°C and he was icteric with abdominal tenderness, worst in the right upper quadrant with a negative Murphy’s sign. The gall bladder was impalpable. The oropharynx was inflamed with cervical and axillary lymphadenopathy.

Liver function tests (alkaline phosphatase 327, aspartate aminotransferase 358, bilirubin 109) suggested cholestasis. White cell count was high (20.8) and c reactive protein raised (17). Platelets were low (168). Monospot test was positive (Epstein Barr virus), confirmed by positive Epstein Barr virus serology. Hepatitis A, B, and C serology were negative.

Ultrasound revealed splenomegaly with normal hepatopetal flow and a markedly thickened (10 mm) gallbladder wall but no gallstones or sludge (fig 1). The common bile duct was not dilated.

Fig 1

Ultrasound image showing a markedly thickened gallbladder (arrows); no stones visible


  • 1. What is the most likely diagnosis?

  • 2. What further imaging might be useful?

  • 3. How is this condition managed?


1. What is the most likely diagnosis?

Short answer

Acute acalculous cholecystitis secondary to infectious mononucleosis is the most likely diagnosis in view of the history, blood tests, and ultrasound findings.


Ultrasound features were consistent with acute acalculous cholecystitis in the absence of gallstones, with marked thickening of …

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