Epstein-Barr virus hepatitis mimicking septic shoulder arthritis: case report and literature review

Epstein-Barr virus hepatitis mimicking septic shoulder arthritis: case report and literature review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Epstein-Barr virus hepatitis mimicking septic shoulder arthritis: case report and literature review Byung-Woong Jang, Hyung Suk Choi, Chang Hyun Kim, Gi-Won Seo, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4233780/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Septic arthritis is a medical emergency because it can cause irreversible damage to joint cartilage and lead to serious complications and life-threatening consequences. So early diagnosis and proper treatment of septic arthritis are critical. But, the physician may miss other systemic diseases or misdiagnose the patient in the process leading to diagnosis. Case presentation: A 16-year-old female was admitted with myalgia-like shoulder pain. She had a history of injection on both shoulders, and she was complaining of inflammatory patterned pain. Unlike our suspicion of septic arthritis, MRI showed normal findings. However, we were able to finally diagnose myalgia accompanied by acute hepatitis caused by Epstein-Barr virus (EBV) through the laboratory findings. The patient underwent conservative treatment including fluid therapy, hepatotonics, and restriction of medications which cause hepatotoxicity. Shoulder pain improved gradually from the second day of treatment. Within one week, both symptoms and laboratory findings fully improved. Conclusions If a young adult patient has myalgia-like joint pain with an inflammatory sign, a detailed diagnostic approach is needed including thorough history taking and laboratory tests. Additionally, in the process of diagnosing septic arthritis, it is necessary to consider a differential diagnosis of viral infection as part of systemic symptoms such as EBV hepatitis. Epstein-Barr virus acute hepatitis septic arthritis Figures Figure 1 Figure 2 Figure 3 Background Early diagnosis and proper treatment of septic arthritis are critical. If diagnosis of septic arthritis is delayed, complications such as irreversible bone and cartilage destruction, ankylosis, and sepsis may occur, and even severe cases of death.[ 1 , 2 ] Clinical symptoms of septic arthritis are acute swelling, as well as painful joints with reduced range of motion. Chills and fever are common, but may not occur. It is important to distinguish between these diseases and septic arthritis because these clinical symptoms can occur in many conditions including systemic diseases such as crystal arthritis and rheumatoid arthritis.[ 3 – 9 ] In the process leading to diagnosis, if the doctor is hasty, he or she may miss other systemic diseases or misdiagnose the patient. We experienced a case that led to an unexpected diagnosis in a patient misdiagnosed with septic arthritis of the shoulder joint. We report this case with a brief review of literature. Case presentation A 16-year-old female with no specific medical history was admitted to our hospital with left shoulder pain that occurred one week earlier. The patient had a history of three injections on both shoulders at the local clinic, three days before admission due to shoulder pain in the myalgia pattern. From that day on, she became worse with pain in her left shoulder and visited our outpatient clinic. On physical examination, forward flexion and abduction were limited to 90 degrees due to severe pain of the left shoulder, and pain persisted at rest, especially at night. There was local tenderness and diffuse heating sensation in the anterior shoulder area and non-specific positive findings were observed in the Neer and Hawkins test. The patient’s vital signs were normal range with heart rate of 71 bpm, respiratory rate 23 breaths per minute and blood pressure 115/70 mmHg, with general fever observed at 38.2 degrees. The patient was admitted to the hospital to differentiate septic arthritis based on injection history of the left shoulder, and diffuse heating sensation near the joint. The patient initially underwent fluid therapy as a symptomatic treatment and underwent lab analysis and enhanced shoulder MRI to determine appropriate diagnosis. On MRI taken at admission, unlike the expected, there were no findings suggestive of septic arthritis such as synovial enhancement, perisynovial edema and joint effusion, and MRI showed normal findings (Fig. 1 ). In laboratory findings, C-reactive protein (CRP) was mildly increased to 0.55 mg/dl (normal range 0 to 0.5 mg/dl) and the AST (normal range 8 to 38 IU/L) and ALT (normal range 4 to 44 IU/L) were significantly increased to 380 IU/L and 471 IU/L, respectively, and r-GT was elevated to 114 IU/L (normal range 11 to 45 IU/L). No other abnormal lab finding was observed. To evaluate the sudden rise of liver enzyme, we performed gastroenterologic intervention and history taking was performed again. As a result, we confirmed that there was a history of enlarged cervical lymph node with the symptom of body aches three days before her admission. The patient had antibodies against hepatitis B virus (HBV), and we also performed laboratory tests including antibody test for hepatitis (hepatitis A virus (HAV), hepatitis C virus (HCV), Epstein-Barr virus (EBV)), peripheral blood (PB) morphology and abdomen ultrasonography. Ultrasonographic findings show decreased parenchymal echogenicity with prominent wall echogenicity of portal vein radicles in both lobes of the liver, suggesting acute hepatic dysfunction (Fig. 2 ). In PB morphology, lymphocytosis was observed with lymphocytes 52% and 3,385/uL. Atypical (reactive) lymphocytes activated by antigen were observed in 15% (within 5% of normal) (Fig. 3 ). Anti-HAV and anti-HCV tests were negative. However, positive EBV VCA IgG with 31.0 AU/ml, positive EBV VCA IgM with 160.0 AU/ml and positive EBV PCR were also observed. Finally the patient was diagnosed with acute hepatitis due to EBV infection. The patient’s symptoms are improved with conservative treatment such as fluid therapy, hepatotonics, and restriction of medications which cause hepatotoxicity. Shoulder pain, the main symptom at admission, gradually improved from the second day of treatment. AST/ALT, which was 380/471 IU/L at first visit, fell to 42/122 IU/L within one week of treatment, and CRP was normalized to 0.05 mg/dl after one week. Discussion and conclusions Septic arthritis occurs most commonly in knee and hip joints and accounts for 61–79% of all cases. The native shoulder joint is the third most common entity, representing 3–15% of all cases.[ 1 , 10 , 11 ] Infection as well as crystal-induced diseases such as osteoarthritis, trauma, and gout, and various types of systemic disease can cause painful, swollen peripheral joints. So, these diagnoses should be considered in differential diagnosis of acute monoarthritis (Table 1 ).[ 12 ] In particular, promptly distinguishing septic arthritis from other causes of monoarthritis is critical because it can be devastating. Septic arthritis begins to destroy cartilage within a day of onset, and despite tuse of antibiotics, the mortality rate of septic arthritis ranges from 7–15%.[ 13 – 17 ] So, early diagnosis and treatment of septic arthritis is critical. Table 1 Differential diagnosis for acute monoarthritis Infection (bacterial, fungal, mycobacterial, viral, spirochete) Rheumatoid arthritis Gout Pseudogout Apatite-related arthropathy Reactive arthritis Systemic lupus erythematosus Lyme arthritis Sickle cell disease Dialysis-related amyloidosis Transient synovitis of the hip Plant thorn synovitis Metastatic carcinoma Pigmented villonodular synovitis Hemarthrosis Neuropathic arthropathy Osteoarthritis Intra-articular injury (fracture, meniscal tear, osteonecrosis) *Adapted from Klippel et al. In this report, the patient was suspected of septic arthritis due to shoulder pain, diffuse heating sensation, and generalized fever. However, EBV hepatitis with myalgia-like joint pain that was finally identified was an unexpected result. MRI of the left shoulder which was the main pain site of the patient was normal. But, in the blood test, AST/ALT was elevated to 380/471 IU/L, so we performed a test for the cause of acute hepatitis. If chemistry panel tests including hepatic enzymes were not performed, hepatitis would be missed and initial diagnosis and treatment would have failed. PB morphology showed lymphocytosis including 15% of atypical lymphocytes (within 5% of normal). This finding is observed in the case of viral infections, infectious mononucleosis, cytomegalovirus (CMV) infection, and drug reaction. Among them, infectious mononucleosis is a generalized reticuloendothelial infection that occurs mainly in adolescents or young adults, and the causative virus is EBV of 3/4 and CMV of 1/4. In antigen and antibody test for acute hepatitis (HAV, HBV, and HCV) were negative, but positive for EBV. Viruses that mainly involve other organs such as EBV can cause liver damage. The most common clinical manifestations of EBV infection include triads of fever, generalized lymphadenopathy, and pharyngitis.[ 18 ] Diamantis et al. reported that 41 patients with EBV infection had fever in 93% and 12% had myalgia. 80.5% had palpable lymph nodes, among them, there were 27 patients with palpable cervical lymph node, four with cervical-axillary lymph node, and one with inguinal lymph node.[ 19 ] The patient had general fever of 38.2 ° at admission and had bilateral cervical lymphadenopathy and sore throat three days before admission on re-performed history taking after diagnosis of acute hepatitis. The patient had injections at the local clinic for shoulder pain of myalgia pattern without examining lymphadenopathy and asking about history of sore throat. This is commonly performed procedure, but strictly speaking, this was practice of negligence knowing the final diagnosis. Additionally, when the patient was admitted to our hospital with a history of injection in the shoulder joint, diagnosis was made with a focus on septic arthritis, and myalgia was considered as a systemic symptom of acute septic arthritis. Epstein-Barr virus (EBV), a member of the family of herpes viruses, infects up to 90% of the general population by age 20 such as the patient introduced in this case.[ 18 ] There are many cases in which there are no specific symptoms, but hepatitis may be the main symptom. Additionally, hepatitis caused by primary EBV infection is mostly a self-limited course, but rarely progresses to hepatic failure, and overall mortality. Progressing to hepatic failure is reported to be approximately 87%.[ 20 – 23 ] Most of EBV hepatitis is treated conservatively, but fulminant EBV-related hepatitis may also consider liver transplantation.[ 21 , 24 ] So, it is critical to accurately diagnose and treat EBV-related hepatitis at an early stage. Examination of lymph nodes in orthopedic physical examinations is often overlooked. Lymph nodes are widely present throughout the body and are linked by lymphatic vessels as a part of the circulatory system. Lymph nodes can be enlarged due to infection, tumor, autoimmune disease, drug reaction, or leukemia.[ 25 ] In isolated limb infection, hypertrophy of the ipsilateral cervical or axillary lymph node in the upper limb infection and hypertrophy of the ipsilateral inguinal lymph node in the lower limb infection may be associated. This is not a specific finding, but a patient with this case who was suspected of having a single infection of the left shoulder may have been the first to consider a systemic cause if he had palpated the enlarged bilateral cervical lymph nodes. We experienced a case with EBV hepatitis which was unexpected diagnosis of a patient temporarily diagnosed with septic arthritis of the shoulder joint and scheduled for surgery. To the best of our knowledge, this case is the first to report EBV hepatitis mimicking septic arthritis. And, we report it with a review of literature. Although septic arthritis can affect people at any age, elderly patients (especially older than 80) and very young children are more frequently affected. It is rare in young adults who have not lost their immunity.[ 26 ] If a young adult patient has myalgia-like joint pain with inflammatory signs, a detailed history taking including sore throat is needed and detailed physical examination such as enlarged lymph node palpation is required. And chemistry panel tests including hepatic enzymes are recommended. Additionally, in the process of diagnosing septic arthritis, it is necessary to consider differential diagnosis of viral infections as part of systemic symptoms such as EBV hepatitis. Data availability The data the support the findings of this case report are available from the corresponding author upon reasonable request. Abbreviations EBV: Epstein-Barr virus; CRP: C-reactive protein; PB: peripheral blood; CMV; cytomegalovirus Declarations Acknowledgements Not applicable. Author’s contributions BW Jang provided patient care, designed the project, and drafted the manuscript. GW Seo and JJ Kim collected clinical information. CH Kim and HS Choi assisted with the analysis. YB Kim contributed to the project design. All authors have reviewed and approved the manuscript. The author(s) have read and approved the final version of the manuscript. Funding This work was supported by the Soonchunhyang University Research Fund. Ethics approval and consent to participate Not applicable. Consent for publication A written informed consent was obtained from the father of the patient for publication of this case report and any accompanying images. Competing interests The authors declare that they have no conflicting interests. References Leslie BM, Harris JM, 3rd, Driscoll D: Septic arthritis of the shoulder in adults . J Bone Joint Surg Am 1989, 71 (10):1516-1522. Garofalo R, Flanagin B, Cesari E, Vinci E, Conti M, Castagna A: Destructive septic arthritis of shoulder in adults . Musculoskelet Surg 2014, 98 Suppl 1 :35-39. Baker DG, Schumacher HR, Jr.: Acute monoarthritis . N Engl J Med 1993, 329 (14):1013-1020. Bong D, Bennett R: Pseudogout mimicking systemic disease . JAMA 1981, 246 (13):1438-1440. Cathcart ES: Fever and arthritis . Compr Ther 1979, 5 (8):55-59. Frischnecht J, Steigerwald JC: High synovial fluid white blood cell counts in pseudogout; Possible confusion with septic arthritis . Arch Intern Med 1975, 135 (2):298-299. Masuda I, Ishikawa K: Clinical features of pseudogout attack. A survey of 50 cases . Clin Orthop Relat Res 1988(229):173-181. Sack K: Monarthritis: differential diagnosis . Am J Med 1997, 102 (1A):30S-34S. Weinberger A, Kesler A, Pinkhas J: Fever in various rheumatic diseases . Clin Rheumatol 1985, 4 (3):258-266. Le Dantec L, Maury F, Flipo RM, Laskri S, Cortet B, Duquesnoy B, Delcambre B: Peripheral pyogenic arthritis. A study of one hundred seventy-nine cases . Rev Rhum Engl Ed 1996, 63 (2):103-110. Lossos IS, Yossepowitch O, Kandel L, Yardeni D, Arber N: Septic arthritis of the glenohumeral joint. A report of 11 cases and review of the literature . Medicine (Baltimore) 1998, 77 (3):177-187. Klippel JJGAF: Arthritis Foundation: Primer on the Rheumatic Diseases 12 th ed Atlanta . 2001. Gupta MN, Sturrock RD, Field M: A prospective 2-year study of 75 patients with adult-onset septic arthritis . Rheumatology (Oxford) 2001, 40 (1):24-30. Gupta MN, Sturrock RD, Field M: Prospective comparative study of patients with culture proven and high suspicion of adult onset septic arthritis . Ann Rheum Dis 2003, 62 (4):327-331. Lawrence RC, Helmick CG, Arnett FC, Deyo RA, Felson DT, Giannini EH, Heyse SP, Hirsch R, Hochberg MC, Hunder GG et al : Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States . Arthritis Rheum 1998, 41 (5):778-799. Swan A, Amer H, Dieppe P: The value of synovial fluid assays in the diagnosis of joint disease: a literature survey . Ann Rheum Dis 2002, 61 (6):493-498. Li SF, Henderson J, Dickman E, Darzynkiewicz R: Laboratory tests in adults with monoarticular arthritis: can they rule out a septic joint? Acad Emerg Med 2004, 11 (3):276-280. Cohen JI: Epstein-Barr virus infection . N Engl J Med 2000, 343 (7):481-492. Kofteridis DP, Koulentaki M, Valachis A, Christofaki M, Mazokopakis E, Papazoglou G, Samonis GJEjoim: Epstein Barr virus hepatitis . 2011, 22 (1):73-76. Ader F, Chatellier D, Le Berre R, Morand P, Fourrier F: Fulminant Epstein-Barr virus (EBV) hepatitis in a young immunocompetent subject . Med Mal Infect 2006, 36 (7):396-398. Feranchak AP, Tyson RW, Narkewicz MR, Karrer FM, Sokol RJ: Fulminant Epstein-Barr viral hepatitis: orthotopic liver transplantation and review of the literature . Liver Transpl Surg 1998, 4 (6):469-476. Kimura H, Nagasaka T, Hoshino Y, Hayashi N, Tanaka N, Xu JL, Kuzushima K, Morishima T: Severe hepatitis caused by Epstein-Barr virus without infection of hepatocytes . Hum Pathol 2001, 32 (7):757-762. Markin RS: Manifestations of Epstein-Barr virus-associated disorders in liver . Liver 1994, 14 (1):1-13. Drebber U, Kasper HU, Krupacz J, Haferkamp K, Kern MA, Steffen HM, Quasdorff M, Zur Hausen A, Odenthal M, Dienes HP: The role of Epstein-Barr virus in acute and chronic hepatitis . J Hepatol 2006, 44 (5):879-885. Hoffbrand AV, Moss PA: Hoffbrand's essential haematology , vol. 38: John Wiley & Sons; 2015. Kaandorp CJ, Van Schaardenburg D, Krijnen P, Habbema JD, van de Laar MA: Risk factors for septic arthritis in patients with joint disease. A prospective study . Arthritis Rheum 1995, 38 (12):1819-1825. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4233780","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":308345985,"identity":"05facfda-eb89-493d-8ee0-465c56327cf2","order_by":0,"name":"Byung-Woong Jang","email":"","orcid":"","institution":"Soonchunhyang University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Byung-Woong","middleName":"","lastName":"Jang","suffix":""},{"id":308345986,"identity":"b257a822-3c39-4ecd-83c0-baf49fe75123","order_by":1,"name":"Hyung Suk Choi","email":"","orcid":"","institution":"Soonchunhyang University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hyung","middleName":"Suk","lastName":"Choi","suffix":""},{"id":308345988,"identity":"f1726703-eeff-4f77-b0a8-eecf54bbe95e","order_by":2,"name":"Chang Hyun Kim","email":"","orcid":"","institution":"Soon Chun Hyang University Cheonan Hospital","correspondingAuthor":false,"prefix":"","firstName":"Chang","middleName":"Hyun","lastName":"Kim","suffix":""},{"id":308345989,"identity":"277b9885-889f-4730-b78a-68efaa369efa","order_by":3,"name":"Gi-Won Seo","email":"","orcid":"","institution":"Soonchunhyang University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Gi-Won","middleName":"","lastName":"Seo","suffix":""},{"id":308345990,"identity":"4d51dcc2-7b72-4ad6-9176-b461d19c0569","order_by":4,"name":"Jinjae Kim","email":"","orcid":"","institution":"Soonchunhyang University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jinjae","middleName":"","lastName":"Kim","suffix":""},{"id":308345992,"identity":"18652843-3271-4311-9d91-bae0817e366e","order_by":5,"name":"Yong Beom Kim","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1ElEQVRIiWNgGAWjYBACNv7+5z8+/LBhYJCAikjgVQ8EfBJnGCRn9qSRoEWOIYdBmoftMAla2BjOHjDg4Tlvzz+7O/EDQ40dg+TsAwS0MPclJEhY3E6ccefsZgmGY8kM0nwJhGw5YAC05naCgUTuNiD3AIMcD0GHJRg2JLCds4do+UeUlhxjhgNsBxg3gLQwth0ABgYhLRLH0hgbe5ITZ9zI3SyR2JfMI9lDQIt8f/Mx5j8/7Oz5Z+Ru/PDhm50cMKJIAQkMDIScNQpGwSgYBaOAGAAAZUY76bdQZj0AAAAASUVORK5CYII=","orcid":"","institution":"Soonchunhyang University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Yong","middleName":"Beom","lastName":"Kim","suffix":""}],"badges":[],"createdAt":"2024-04-08 04:14:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4233780/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4233780/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":57947273,"identity":"762d5dfb-dafd-437f-a2e2-acd196bf2821","added_by":"auto","created_at":"2024-06-07 20:21:01","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2653095,"visible":true,"origin":"","legend":"\u003cp\u003eIn T2-weighted contrast-enhanced MRI of the patient’s left shoulder, there was no evidence of septic arthritis, and normal MRI finding was confirmed. A, coronal view. B, axial view.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4233780/v1/44ce33c6e8ff9921a0fd62c0.png"},{"id":57947272,"identity":"eb0a34f5-df38-484e-8cca-d1a133d1022d","added_by":"auto","created_at":"2024-06-07 20:21:01","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1236521,"visible":true,"origin":"","legend":"\u003cp\u003eIn liver sonography, there was decreased parenchymal with bright echogenic dots (starry sky appearance) and prominent wall echogenicity of portal vein radicles in both lobes of liver (red arrow). These findings suggest acute hepatic dysfunction.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4233780/v1/881c18cb1eb6210e5f22a3c1.png"},{"id":57947852,"identity":"e27314f4-c92e-4f43-9b89-0c3e7bb11d5c","added_by":"auto","created_at":"2024-06-07 20:29:01","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":4337342,"visible":true,"origin":"","legend":"\u003cp\u003eAtypical lymphocytes of various appearances on peripheral blood smear of the patient. (Wright’s stain, x 1,000) A, vacuoles in cytoplasm. B, similar shape to plasma cells. C, cytoplasm with atypical feature. D, cleaved nuclei.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-4233780/v1/9da2e8de6f1cc817f05cfce4.png"},{"id":59564513,"identity":"fbfd2d99-5bc4-4e51-a71e-4d45027cc687","added_by":"auto","created_at":"2024-07-03 08:52:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":14756468,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4233780/v1/d8e150e7-c6bd-4222-bbe8-6f8ab4f5a466.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Epstein-Barr virus hepatitis mimicking septic shoulder arthritis: case report and literature review","fulltext":[{"header":"Background","content":"\u003cp\u003eEarly diagnosis and proper treatment of septic arthritis are critical. If diagnosis of septic arthritis is delayed, complications such as irreversible bone and cartilage destruction, ankylosis, and sepsis may occur, and even severe cases of death.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eClinical symptoms of septic arthritis are acute swelling, as well as painful joints with reduced range of motion. Chills and fever are common, but may not occur. It is important to distinguish between these diseases and septic arthritis because these clinical symptoms can occur in many conditions including systemic diseases such as crystal arthritis and rheumatoid arthritis.[\u003cspan additionalcitationids=\"CR4 CR5 CR6 CR7 CR8\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] In the process leading to diagnosis, if the doctor is hasty, he or she may miss other systemic diseases or misdiagnose the patient.\u003c/p\u003e \u003cp\u003eWe experienced a case that led to an unexpected diagnosis in a patient misdiagnosed with septic arthritis of the shoulder joint. We report this case with a brief review of literature.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 16-year-old female with no specific medical history was admitted to our hospital with left shoulder pain that occurred one week earlier. The patient had a history of three injections on both shoulders at the local clinic, three days before admission due to shoulder pain in the myalgia pattern. From that day on, she became worse with pain in her left shoulder and visited our outpatient clinic. On physical examination, forward flexion and abduction were limited to 90 degrees due to severe pain of the left shoulder, and pain persisted at rest, especially at night. There was local tenderness and diffuse heating sensation in the anterior shoulder area and non-specific positive findings were observed in the Neer and Hawkins test. The patient\u0026rsquo;s vital signs were normal range with heart rate of 71 bpm, respiratory rate 23 breaths per minute and blood pressure 115/70 mmHg, with general fever observed at 38.2 degrees.\u003c/p\u003e \u003cp\u003eThe patient was admitted to the hospital to differentiate septic arthritis based on injection history of the left shoulder, and diffuse heating sensation near the joint. The patient initially underwent fluid therapy as a symptomatic treatment and underwent lab analysis and enhanced shoulder MRI to determine appropriate diagnosis.\u003c/p\u003e \u003cp\u003eOn MRI taken at admission, unlike the expected, there were no findings suggestive of septic arthritis such as synovial enhancement, perisynovial edema and joint effusion, and MRI showed normal findings (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In laboratory findings, C-reactive protein (CRP) was mildly increased to 0.55 mg/dl (normal range 0 to 0.5 mg/dl) and the AST (normal range 8 to 38 IU/L) and ALT (normal range 4 to 44 IU/L) were significantly increased to 380 IU/L and 471 IU/L, respectively, and r-GT was elevated to 114 IU/L (normal range 11 to 45 IU/L). No other abnormal lab finding was observed.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTo evaluate the sudden rise of liver enzyme, we performed gastroenterologic intervention and history taking was performed again. As a result, we confirmed that there was a history of enlarged cervical lymph node with the symptom of body aches three days before her admission. The patient had antibodies against hepatitis B virus (HBV), and we also performed laboratory tests including antibody test for hepatitis (hepatitis A virus (HAV), hepatitis C virus (HCV), Epstein-Barr virus (EBV)), peripheral blood (PB) morphology and abdomen ultrasonography.\u003c/p\u003e \u003cp\u003eUltrasonographic findings show decreased parenchymal echogenicity with prominent wall echogenicity of portal vein radicles in both lobes of the liver, suggesting acute hepatic dysfunction (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In PB morphology, lymphocytosis was observed with lymphocytes 52% and 3,385/uL. Atypical (reactive) lymphocytes activated by antigen were observed in 15% (within 5% of normal) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Anti-HAV and anti-HCV tests were negative. However, positive EBV VCA IgG with 31.0 AU/ml, positive EBV VCA IgM with 160.0 AU/ml and positive EBV PCR were also observed. Finally the patient was diagnosed with acute hepatitis due to EBV infection.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe patient\u0026rsquo;s symptoms are improved with conservative treatment such as fluid therapy, hepatotonics, and restriction of medications which cause hepatotoxicity. Shoulder pain, the main symptom at admission, gradually improved from the second day of treatment. AST/ALT, which was 380/471 IU/L at first visit, fell to 42/122 IU/L within one week of treatment, and CRP was normalized to 0.05 mg/dl after one week.\u003c/p\u003e"},{"header":"Discussion and conclusions","content":"\u003cp\u003eSeptic arthritis occurs most commonly in knee and hip joints and accounts for 61\u0026ndash;79% of all cases. The native shoulder joint is the third most common entity, representing 3\u0026ndash;15% of all cases.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] Infection as well as crystal-induced diseases such as osteoarthritis, trauma, and gout, and various types of systemic disease can cause painful, swollen peripheral joints. So, these diagnoses should be considered in differential diagnosis of acute monoarthritis (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] In particular, promptly distinguishing septic arthritis from other causes of monoarthritis is critical because it can be devastating. Septic arthritis begins to destroy cartilage within a day of onset, and despite tuse of antibiotics, the mortality rate of septic arthritis ranges from 7\u0026ndash;15%.[\u003cspan additionalcitationids=\"CR14 CR15 CR16\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] So, early diagnosis and treatment of septic arthritis is critical.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDifferential diagnosis for acute monoarthritis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfection (bacterial, fungal, mycobacterial, viral, spirochete)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRheumatoid arthritis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGout\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePseudogout\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eApatite-related arthropathy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReactive arthritis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSystemic lupus erythematosus\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLyme arthritis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSickle cell disease\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDialysis-related amyloidosis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransient synovitis of the hip\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlant thorn synovitis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMetastatic carcinoma\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePigmented villonodular synovitis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemarthrosis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeuropathic arthropathy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOsteoarthritis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntra-articular injury (fracture, meniscal tear, osteonecrosis)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"1\"\u003e*Adapted from Klippel et al.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn this report, the patient was suspected of septic arthritis due to shoulder pain, diffuse heating sensation, and generalized fever. However, EBV hepatitis with myalgia-like joint pain that was finally identified was an unexpected result. MRI of the left shoulder which was the main pain site of the patient was normal. But, in the blood test, AST/ALT was elevated to 380/471 IU/L, so we performed a test for the cause of acute hepatitis. If chemistry panel tests including hepatic enzymes were not performed, hepatitis would be missed and initial diagnosis and treatment would have failed. PB morphology showed lymphocytosis including 15% of atypical lymphocytes (within 5% of normal). This finding is observed in the case of viral infections, infectious mononucleosis, cytomegalovirus (CMV) infection, and drug reaction. Among them, infectious mononucleosis is a generalized reticuloendothelial infection that occurs mainly in adolescents or young adults, and the causative virus is EBV of 3/4 and CMV of 1/4. In antigen and antibody test for acute hepatitis (HAV, HBV, and HCV) were negative, but positive for EBV.\u003c/p\u003e \u003cp\u003eViruses that mainly involve other organs such as EBV can cause liver damage. The most common clinical manifestations of EBV infection include triads of fever, generalized lymphadenopathy, and pharyngitis.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] Diamantis et al. reported that 41 patients with EBV infection had fever in 93% and 12% had myalgia. 80.5% had palpable lymph nodes, among them, there were 27 patients with palpable cervical lymph node, four with cervical-axillary lymph node, and one with inguinal lymph node.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] The patient had general fever of 38.2 \u0026deg; at admission and had bilateral cervical lymphadenopathy and sore throat three days before admission on re-performed history taking after diagnosis of acute hepatitis.\u003c/p\u003e \u003cp\u003eThe patient had injections at the local clinic for shoulder pain of myalgia pattern without examining lymphadenopathy and asking about history of sore throat. This is commonly performed procedure, but strictly speaking, this was practice of negligence knowing the final diagnosis. Additionally, when the patient was admitted to our hospital with a history of injection in the shoulder joint, diagnosis was made with a focus on septic arthritis, and myalgia was considered as a systemic symptom of acute septic arthritis.\u003c/p\u003e \u003cp\u003eEpstein-Barr virus (EBV), a member of the family of herpes viruses, infects up to 90% of the general population by age 20 such as the patient introduced in this case.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] There are many cases in which there are no specific symptoms, but hepatitis may be the main symptom. Additionally, hepatitis caused by primary EBV infection is mostly a self-limited course, but rarely progresses to hepatic failure, and overall mortality. Progressing to hepatic failure is reported to be approximately 87%.[\u003cspan additionalcitationids=\"CR21 CR22\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] Most of EBV hepatitis is treated conservatively, but fulminant EBV-related hepatitis may also consider liver transplantation.[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] So, it is critical to accurately diagnose and treat EBV-related hepatitis at an early stage.\u003c/p\u003e \u003cp\u003eExamination of lymph nodes in orthopedic physical examinations is often overlooked. Lymph nodes are widely present throughout the body and are linked by lymphatic vessels as a part of the circulatory system. Lymph nodes can be enlarged due to infection, tumor, autoimmune disease, drug reaction, or leukemia.[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] In isolated limb infection, hypertrophy of the ipsilateral cervical or axillary lymph node in the upper limb infection and hypertrophy of the ipsilateral inguinal lymph node in the lower limb infection may be associated. This is not a specific finding, but a patient with this case who was suspected of having a single infection of the left shoulder may have been the first to consider a systemic cause if he had palpated the enlarged bilateral cervical lymph nodes.\u003c/p\u003e \u003cp\u003eWe experienced a case with EBV hepatitis which was unexpected diagnosis of a patient temporarily diagnosed with septic arthritis of the shoulder joint and scheduled for surgery. To the best of our knowledge, this case is the first to report EBV hepatitis mimicking septic arthritis. And, we report it with a review of literature.\u003c/p\u003e \u003cp\u003eAlthough septic arthritis can affect people at any age, elderly patients (especially older than 80) and very young children are more frequently affected. It is rare in young adults who have not lost their immunity.[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] If a young adult patient has myalgia-like joint pain with inflammatory signs, a detailed history taking including sore throat is needed and detailed physical examination such as enlarged lymph node palpation is required. And chemistry panel tests including hepatic enzymes are recommended. Additionally, in the process of diagnosing septic arthritis, it is necessary to consider differential diagnosis of viral infections as part of systemic symptoms such as EBV hepatitis.\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData availability\u003c/h2\u003e \u003cp\u003eThe data the support the findings of this case report are available from the corresponding author upon reasonable request.\u003c/p\u003e \u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eEBV: Epstein-Barr virus; CRP: C-reactive protein; PB: peripheral blood; CMV; cytomegalovirus\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBW Jang provided patient care, designed the project, and drafted the manuscript. GW \u0026nbsp;Seo and JJ Kim collected clinical information. CH Kim and HS Choi assisted with the analysis. YB Kim contributed to the project design. All authors have reviewed and approved the manuscript. The author(s) have read and approved the final version of the manuscript.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Soonchunhyang University Research Fund.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot\u0026nbsp;applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA written informed consent was obtained from the father of the patient for publication of this case report and any accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflicting interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLeslie BM, Harris JM, 3rd, Driscoll D: \u003cstrong\u003eSeptic arthritis of the shoulder in adults\u003c/strong\u003e. \u003cem\u003eJ Bone Joint Surg Am \u003c/em\u003e1989, \u003cstrong\u003e71\u003c/strong\u003e(10):1516-1522.\u003c/li\u003e\n\u003cli\u003eGarofalo R, Flanagin B, Cesari E, Vinci E, Conti M, Castagna A: \u003cstrong\u003eDestructive septic arthritis of shoulder in adults\u003c/strong\u003e. \u003cem\u003eMusculoskelet Surg \u003c/em\u003e2014, \u003cstrong\u003e98 Suppl 1\u003c/strong\u003e:35-39.\u003c/li\u003e\n\u003cli\u003eBaker DG, Schumacher HR, Jr.: \u003cstrong\u003eAcute monoarthritis\u003c/strong\u003e. \u003cem\u003eN Engl J Med \u003c/em\u003e1993, \u003cstrong\u003e329\u003c/strong\u003e(14):1013-1020.\u003c/li\u003e\n\u003cli\u003eBong D, Bennett R: \u003cstrong\u003ePseudogout mimicking systemic disease\u003c/strong\u003e. \u003cem\u003eJAMA \u003c/em\u003e1981, \u003cstrong\u003e246\u003c/strong\u003e(13):1438-1440.\u003c/li\u003e\n\u003cli\u003eCathcart ES: \u003cstrong\u003eFever and arthritis\u003c/strong\u003e. \u003cem\u003eCompr Ther \u003c/em\u003e1979, \u003cstrong\u003e5\u003c/strong\u003e(8):55-59.\u003c/li\u003e\n\u003cli\u003eFrischnecht J, Steigerwald JC: \u003cstrong\u003eHigh synovial fluid white blood cell counts in pseudogout; Possible confusion with septic arthritis\u003c/strong\u003e. \u003cem\u003eArch Intern Med \u003c/em\u003e1975, \u003cstrong\u003e135\u003c/strong\u003e(2):298-299.\u003c/li\u003e\n\u003cli\u003eMasuda I, Ishikawa K: \u003cstrong\u003eClinical features of pseudogout attack. A survey of 50 cases\u003c/strong\u003e. \u003cem\u003eClin Orthop Relat Res \u003c/em\u003e1988(229):173-181.\u003c/li\u003e\n\u003cli\u003eSack K: \u003cstrong\u003eMonarthritis: differential diagnosis\u003c/strong\u003e. \u003cem\u003eAm J Med \u003c/em\u003e1997, \u003cstrong\u003e102\u003c/strong\u003e(1A):30S-34S.\u003c/li\u003e\n\u003cli\u003eWeinberger A, Kesler A, Pinkhas J: \u003cstrong\u003eFever in various rheumatic diseases\u003c/strong\u003e. \u003cem\u003eClin Rheumatol \u003c/em\u003e1985, \u003cstrong\u003e4\u003c/strong\u003e(3):258-266.\u003c/li\u003e\n\u003cli\u003eLe Dantec L, Maury F, Flipo RM, Laskri S, Cortet B, Duquesnoy B, Delcambre B: \u003cstrong\u003ePeripheral pyogenic arthritis. A study of one hundred seventy-nine cases\u003c/strong\u003e. \u003cem\u003eRev Rhum Engl Ed \u003c/em\u003e1996, \u003cstrong\u003e63\u003c/strong\u003e(2):103-110.\u003c/li\u003e\n\u003cli\u003eLossos IS, Yossepowitch O, Kandel L, Yardeni D, Arber N: \u003cstrong\u003eSeptic arthritis of the glenohumeral joint. A report of 11 cases and review of the literature\u003c/strong\u003e. \u003cem\u003eMedicine (Baltimore) \u003c/em\u003e1998, \u003cstrong\u003e77\u003c/strong\u003e(3):177-187.\u003c/li\u003e\n\u003cli\u003eKlippel JJGAF: \u003cstrong\u003eArthritis Foundation: Primer on the Rheumatic Diseases 12 th ed Atlanta\u003c/strong\u003e. 2001.\u003c/li\u003e\n\u003cli\u003eGupta MN, Sturrock RD, Field M: \u003cstrong\u003eA prospective 2-year study of 75 patients with adult-onset septic arthritis\u003c/strong\u003e. \u003cem\u003eRheumatology (Oxford) \u003c/em\u003e2001, \u003cstrong\u003e40\u003c/strong\u003e(1):24-30.\u003c/li\u003e\n\u003cli\u003eGupta MN, Sturrock RD, Field M: \u003cstrong\u003eProspective comparative study of patients with culture proven and high suspicion of adult onset septic arthritis\u003c/strong\u003e. \u003cem\u003eAnn Rheum Dis \u003c/em\u003e2003, \u003cstrong\u003e62\u003c/strong\u003e(4):327-331.\u003c/li\u003e\n\u003cli\u003eLawrence RC, Helmick CG, Arnett FC, Deyo RA, Felson DT, Giannini EH, Heyse SP, Hirsch R, Hochberg MC, Hunder GG\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eEstimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States\u003c/strong\u003e. \u003cem\u003eArthritis Rheum \u003c/em\u003e1998, \u003cstrong\u003e41\u003c/strong\u003e(5):778-799.\u003c/li\u003e\n\u003cli\u003eSwan A, Amer H, Dieppe P: \u003cstrong\u003eThe value of synovial fluid assays in the diagnosis of joint disease: a literature survey\u003c/strong\u003e. \u003cem\u003eAnn Rheum Dis \u003c/em\u003e2002, \u003cstrong\u003e61\u003c/strong\u003e(6):493-498.\u003c/li\u003e\n\u003cli\u003eLi SF, Henderson J, Dickman E, Darzynkiewicz R: \u003cstrong\u003eLaboratory tests in adults with monoarticular arthritis: can they rule out a septic joint?\u003c/strong\u003e \u003cem\u003eAcad Emerg Med \u003c/em\u003e2004, \u003cstrong\u003e11\u003c/strong\u003e(3):276-280.\u003c/li\u003e\n\u003cli\u003eCohen JI: \u003cstrong\u003eEpstein-Barr virus infection\u003c/strong\u003e. \u003cem\u003eN Engl J Med \u003c/em\u003e2000, \u003cstrong\u003e343\u003c/strong\u003e(7):481-492.\u003c/li\u003e\n\u003cli\u003eKofteridis DP, Koulentaki M, Valachis A, Christofaki M, Mazokopakis E, Papazoglou G, Samonis GJEjoim: \u003cstrong\u003eEpstein Barr virus hepatitis\u003c/strong\u003e. 2011, \u003cstrong\u003e22\u003c/strong\u003e(1):73-76.\u003c/li\u003e\n\u003cli\u003eAder F, Chatellier D, Le Berre R, Morand P, Fourrier F: \u003cstrong\u003eFulminant Epstein-Barr virus (EBV) hepatitis in a young immunocompetent subject\u003c/strong\u003e. \u003cem\u003eMed Mal Infect \u003c/em\u003e2006, \u003cstrong\u003e36\u003c/strong\u003e(7):396-398.\u003c/li\u003e\n\u003cli\u003eFeranchak AP, Tyson RW, Narkewicz MR, Karrer FM, Sokol RJ: \u003cstrong\u003eFulminant Epstein-Barr viral hepatitis: orthotopic liver transplantation and review of the literature\u003c/strong\u003e. \u003cem\u003eLiver Transpl Surg \u003c/em\u003e1998, \u003cstrong\u003e4\u003c/strong\u003e(6):469-476.\u003c/li\u003e\n\u003cli\u003eKimura H, Nagasaka T, Hoshino Y, Hayashi N, Tanaka N, Xu JL, Kuzushima K, Morishima T: \u003cstrong\u003eSevere hepatitis caused by Epstein-Barr virus without infection of hepatocytes\u003c/strong\u003e. \u003cem\u003eHum Pathol \u003c/em\u003e2001, \u003cstrong\u003e32\u003c/strong\u003e(7):757-762.\u003c/li\u003e\n\u003cli\u003eMarkin RS: \u003cstrong\u003eManifestations of Epstein-Barr virus-associated disorders in liver\u003c/strong\u003e. \u003cem\u003eLiver \u003c/em\u003e1994, \u003cstrong\u003e14\u003c/strong\u003e(1):1-13.\u003c/li\u003e\n\u003cli\u003eDrebber U, Kasper HU, Krupacz J, Haferkamp K, Kern MA, Steffen HM, Quasdorff M, Zur Hausen A, Odenthal M, Dienes HP: \u003cstrong\u003eThe role of Epstein-Barr virus in acute and chronic hepatitis\u003c/strong\u003e. \u003cem\u003eJ Hepatol \u003c/em\u003e2006, \u003cstrong\u003e44\u003c/strong\u003e(5):879-885.\u003c/li\u003e\n\u003cli\u003eHoffbrand AV, Moss PA: \u003cstrong\u003eHoffbrand\u0026apos;s essential haematology\u003c/strong\u003e, vol. 38: John Wiley \u0026amp; Sons; 2015.\u003c/li\u003e\n\u003cli\u003eKaandorp CJ, Van Schaardenburg D, Krijnen P, Habbema JD, van de Laar MA: \u003cstrong\u003eRisk factors for septic arthritis in patients with joint disease. A prospective study\u003c/strong\u003e. \u003cem\u003eArthritis Rheum \u003c/em\u003e1995, \u003cstrong\u003e38\u003c/strong\u003e(12):1819-1825.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Epstein-Barr virus, acute hepatitis, septic arthritis","lastPublishedDoi":"10.21203/rs.3.rs-4233780/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4233780/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSeptic arthritis is a medical emergency because it can cause irreversible damage to joint cartilage and lead to serious complications and life-threatening consequences. So early diagnosis and proper treatment of septic arthritis are critical. But, the physician may miss other systemic diseases or misdiagnose the patient in the process leading to diagnosis.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e \u003cp\u003eA 16-year-old female was admitted with myalgia-like shoulder pain. She had a history of injection on both shoulders, and she was complaining of inflammatory patterned pain. Unlike our suspicion of septic arthritis, MRI showed normal findings. However, we were able to finally diagnose myalgia accompanied by acute hepatitis caused by Epstein-Barr virus (EBV) through the laboratory findings. The patient underwent conservative treatment including fluid therapy, hepatotonics, and restriction of medications which cause hepatotoxicity. Shoulder pain improved gradually from the second day of treatment. Within one week, both symptoms and laboratory findings fully improved.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eIf a young adult patient has myalgia-like joint pain with an inflammatory sign, a detailed diagnostic approach is needed including thorough history taking and laboratory tests. Additionally, in the process of diagnosing septic arthritis, it is necessary to consider a differential diagnosis of viral infection as part of systemic symptoms such as EBV hepatitis.\u003c/p\u003e","manuscriptTitle":"Epstein-Barr virus hepatitis mimicking septic shoulder arthritis: case report and literature review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-07 20:20:56","doi":"10.21203/rs.3.rs-4233780/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"eac9236e-8507-4cd1-ab5f-ab2cf13f9f44","owner":[],"postedDate":"June 7th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-07-03T08:44:36+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-07 20:20:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4233780","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4233780","identity":"rs-4233780","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}