Working Diagnosis:
Epstein Barr Virus Hepatitis

Treatment:
Treatment was supportive with fluids, observation, and activity restriction. She was held out of physical activity for 4 weeks from the onset of symptoms due to the risk of splenic rupture.

Outcome:
Symptoms resolved completely. The lab values returned to normal around one month after presentation.

Author's Comments:
Bilirubinuria reflects the presence of direct hyperbilirubinemia and is indicative of underlying hepatobiliary disease. It may rarely be associated with symptoms of dysuria. 90% of patients infected with EBV will develop a mild hepatitis that often goes undetected. Some patients present with hepatitis in the absence of the typical features of fever, malaise, and lymphadenopathy. Thus, EBV should be suspected in patients with vague complaints and abnormal liver function tests or bilirubinuria.
Splenomegaly occurs in 50-60% of patients who are infected with EBV. This usually begins to recede by the 3rd week of infection. Splenic rupture is one of the most concerning complications, and it occurs with an incidence of 1-2/1,000 patients. It may occur without history of illness or injury.

Return to play is key in managing athletes with EBV infection. Athletes involved in non-contact sports may return to training 3 weeks from symptom onset. Those involved in contact sports may begin training at a minimum of 4 weeks from onset.

References:
1. Bremnor, Judy D., Sadovsky, Richard. "Evaluation of Dysuria in Adults." American Family Physician 2002 Apr; 65(8): 1589-1597.
2. Crum, Nancy F. "Epstein Barr Virus Hepatitis: Case Series and Review." Southern Medical Journal 2006; 9(5):544-547.
3. Ghosh, A., Ghoshal, U.C., Kochhar, R., Ghoshal, P., Banerjee, P.K. "Infectious Mononucleosis Hepatitis: Report of Two Patients." Indian Journal of Gastroenterology 1997 Jul; 16(3): 113-114.
4. Aldrete, J.S. "Spontaneous Rupture of the Spleen in Patients with Infectious Mononucleosis." Mayo Clinic Proc. 1992 Sep; 67(9):910-912.
5. Asgari, M.M., Begos, D.G. "Spontaneous Splenic Rupture in Infectious Mononucleosis: A Review." Yale J Biol Med. 1997 Mar-Apr; 70(2): 175-182.
6. Waninger, Kevin N., Harcke, H. Theodore. "Determination of Safe Return to Play For Athletes Recovering From Infectious Mononucleosis: A Review of the Literature." Clinical Journal of Sports Medicine 2005 Nov; 15(6):410-416.
7. Auwaerter, Paul G. "Infectious Mononucleosis: Return to Play." Clinics in Sports Medicine 2004;23:495-497.

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