A kiss that 'took my legs away': A rare case of EBV in a 70-year-old woman – a case report

Initial assessment

The patient’s medical history included hypercholesterolaemia and a past cholecystectomy. She denied any recent colds, unusual dietary intake, contact with animals, or travel abroad or to rural areas. Clinical examination revealed jaundice but no abdominal tenderness.

Initial blood tests showed significantly elevated bilirubin, alkaline phosphatase (ALP), alanine aminotransferase (ALT), and slightly elevated C-reactive protein (CRP). By the second day of admission, haemoglobin levels had dropped rapidly from 115 to 93 g/L (normocytic anaemia). Elevated reticulocyte counts, low haptoglobin, and a positive direct antiglobulin test (DAT) indicated haemolysis. Abdominal and pelvic computed tomography (CT) and subsequent magnetic resonance imaging (MRI) revealed no structural cause for the jaundice. The findings suggested suspected autoimmune haemolytic anaemia (AIHA).

Lower limb weakness

On the seventh day of hospitalisation, the patient developed lower limb weakness, paraesthesia, and sensory loss extending from the lower limbs to the mid and upper abdomen. Later, urinary and faecal incontinence emerged.

Clinical examination showed normal strength and sensation in the upper limbs, except for bilaterally reduced grip strength. In the lower limbs, there was bilateral hip flexion weakness, diminished sensation, and reduced reflexes, including plantar flexor reflexes. Hyperreflexia was noted in the upper limbs, while cranial nerve function remained intact.

The neurology team suspected spinal cord involvement, with transverse myelitis being highly probable. Cerebrospinal fluid (CSF) analysis revealed elevated white blood cells and proteins and mild lymphocytic pleocytosis, findings consistent with myelitis.

An unusual diagnosis

Autoimmune and viral tests were negative except for one result confirming an acute Epstein–Barr virus infection. EBV infection typically occurs in childhood or adolescence, presenting with the classic triad of fever, pharyngitis, and cervical lymphadenopathy. EBV is present in saliva and spreads through coughing, shared food, or kissing, hence its nickname 'the kissing disease.' Infection beyond the age of 40 is exceptionally rare. Jaundice occurs in fewer than 5% of cases.

Treatment course

From the 11th day of admission, the patient was treated with high-dose intravenous methylprednisolone, to which she responded well. After five doses, there was a marked improvement in neurological symptoms, and repeated MRI of the entire spine showed no new findings. In consultation with a virologist, antiviral therapy was deemed unnecessary due to the clinical improvement.

Liver function tests and blood counts normalised before discharge. Repeated EBV antibody tests remained positive but showed a significant reduction in viral load. Physiotherapy progressively improved the patient’s mobility.

Conclusion

Primary EBV infection incidence peaks at age 17, with cases in patients over 40 being rare but not impossible. In addition to saliva and sexual transmission, EBV can rarely be transmitted via organ transplantation or blood transfusion. Given the patient’s history and age, it is presumed that she was exposed to EBV through contact with saliva. The neurological symptoms were a result of the immune response to the primary EBV infection. This case illustrates that EBV infection should not be overlooked in the differential diagnosis of older patients.

Editorial Team, Medscope.pro

Sources:

1. Mahmood H., Kiani M., Madani Y. 'A kiss that took my legs away': a rare presentation of Epstein–Barr virus in the older population. Clin Med (Lond) 2023; 23 (6): 621–624, doi: 10.7861/clinmed.2023-0415.
2. Roháčová H. Diseases caused by Epstein–Barr virus. Interní medicína pro praxi 2005; 6: 301–302.