EBV and Vertigo/Bilirubin Elevation
EBV can cause neurological complications including vertigo as part of its clinical spectrum, and it can definitely cause elevated bilirubin levels with or without proportional liver enzyme elevations, particularly in cholestatic presentations.
EBV and Vertigo
EBV infection can manifest with neurological complications, though vertigo is not among the most commonly reported presentations. The evidence shows:
Neurological manifestations are recognized complications of both acute EBV infectious mononucleosis and chronic active EBV infection (CAEBV), including digestive tract, neurological, pulmonary, ocular, dermal, and cardiovascular disorders 1.
For encephalitis workup, when cerebellar involvement is present on neuroimaging, EBV PCR from CSF should be considered as part of the diagnostic algorithm 1.
However, vertigo as an isolated or primary manifestation of EBV infection is not well-documented in the guideline literature provided. The neurological complications more commonly described include encephalitis and other CNS manifestations rather than peripheral vestibular syndromes 1.
Clinical caveat: If a patient presents with vertigo and suspected EBV infection, consider that the vertigo may be coincidental or related to general systemic illness rather than direct EBV-mediated vestibular pathology. Evaluate for other causes of vertigo using standard diagnostic approaches 1.
EBV and Bilirubin Elevation Without Proportional Liver Enzyme Elevation
Yes, EBV can cause significant hyperbilirubinemia with disproportionately mild transaminase elevations, presenting as a cholestatic pattern:
Recognized Clinical Pattern
Cholestatic hepatitis is an established complication of EBV infection, where bilirubin elevation can be marked while transaminases remain relatively modest 2, 3.
In documented cases, median bilirubin levels reached 12.6 mg/dL (range 2.2-47.5 mg/dL) while median AST/ALT was only 179 IU/L (range 56-2518 IU/L), demonstrating the disproportionate elevation 3.
Biliary stasis and cholestatic patterns have been specifically reported with EBV infection, including cases with gallbladder wall thickening on imaging 4, 5.
Diagnostic Approach
When evaluating hyperbilirubinemia potentially related to EBV:
Order fractionated bilirubin to determine if predominantly conjugated (cholestatic pattern) or unconjugated 6.
Check EBV serology: VCA-IgM and VCA-IgG antibodies, along with EA antibodies for acute infection 1, 7.
Obtain complete liver panel including ALT, AST, alkaline phosphatase, and GGT to characterize the pattern of injury 6, 2.
Abdominal ultrasound should be performed to evaluate for biliary obstruction and may show hepatomegaly with gallbladder wall thickening in EBV hepatitis 6, 5.
Consider EBV PCR quantitative testing if diagnosis remains uncertain, particularly in immunocompromised patients 1.
Clinical Characteristics
Cholestatic EBV hepatitis typically presents with fever (72%), jaundice (67%), and splenomegaly (62%) 3.
Tender hepatomegaly and gallbladder thickening may be important predictors of significant liver involvement 5.
The condition is generally self-limiting with full recovery expected in immunocompetent patients, though bilirubin may remain elevated for weeks 5, 2, 3.
Multiple transaminase peaks may occur during the course of illness, corresponding with clinical deterioration, but this does not indicate need for antiviral therapy in immunocompetent patients 5.
Important Pitfall
Do not assume all hyperbilirubinemia with EBV requires elevated transaminases. The cholestatic pattern can predominate, and failing to consider EBV in the differential diagnosis of cholestasis (particularly in younger patients with fever and splenomegaly) can delay diagnosis 2, 3.