Acute pancreatitis is an inflammatory disorder of the pancreas; the incidence rate is 3–13 cases per 100000 per year in pediatric population [2, 3], and 5–60 cases per 100000 persons per year in adulthood . The most common etiology of acute pancreatitis is gallstones or microlithiasis; other causes include alcohol misuse, trauma, metabolic disorders (hypertriglyceridemia, hypercalcemia), infections (parotitis, mumps, influenza, herpes viruses, hepatitis viruses, coxsackieviruses, mycoplasma), systemic disease (hemolytic uremic syndrome, systemic lupus erythematosus, Henoch-Schönlein purpura, Kawasaki disease, inflammatory bowel disease), and autoimmune pancreatitis [4, 5]. EBV infection is a rare cause of acute pancreatitis; the pathophysiology remains unclear: both direct viral infection and inflammatory process induced by the virus are plausible pathogenic mechanisms [6, 7].
A review of the English literature revealed only 10 pediatric [6, 8–16] and 6 adult cases [7, 17–21]. As regards pediatric reports (Table I), median age and mean age was 12 and 11.8 years respectively (range 3–18), 36% were male and 64% were female. As regards pancreatitis symptoms, abdominal pain was described in all cases, vomiting in 55%, and nausea in 27%; eight patients (73%) had also mononucleosis symptoms, like fever, lymphadenitis, and pharyngitis. Amylase and/or lipase levels were increased up to three times the normal limit in 100% of the cases. In 5 children, there was evidence of acute pancreatitis on abdominal computerized tomography (CT), while only in our case, ultrasound (US) revealed an enlarged pancreas with a heterogeneous echotexture. According to the American College of Gastroenterology guidelines , the diagnosis of pancreatitis was confirmed in all patients. Six children presented other complications related to EBV infection: the most common was cholestatic hepatitis (50%); cholecystitis, pneumonia, proctitis, portal vein thrombosis, and septic shock were also reported. Serological documentation for EBV infection was obtained in 10 cases, while in 1 child, the diagnosis was made clinically. All cases were treated with supportive care, that were fasting and parenteral nutrition; in 1 patient, antibiotics only was added, while in another case, antivirals and antibiotics were also used. All children recovered.
As regards adult patients (Table II), EBV-associated acute pancreatitis affects manly young adult (range 21–45 years), with a slight female predominance (66%). All cases presented abdominal pain, associated sometimes with nausea, fever, and vomiting. In 3 patients (50%), signs and symptoms related to infectious mononucleosis were also observed. The diagnosis of EBV infection was made by positive serology in 5 patients; also in 2 cases, serum EBV-DNA was detected. Abdominal CT was executed in 5 patients, revealing signs of acute pancreatitis, such as enlarged and edematous pancreas; in 1 case, areas of necrosis were also noticed. All patients except one had complications related to systemic EBV infection: hepatitis with or without cholestasis, gastritis, pneumonia with pleural effusion, ascites, pericardial effusion, autoimmune hemolytic anemia, and multi-organ failure. The patients were treated with symptomatic therapy; when a complicated disease course occurred, antibiotics, antivirals, and steroids were also administered. All patients except one fully recovered.
In conclusion, EBV infection is characterized by clinical heterogeneity; multiple organs could be involved, also the pancreas, both in children and young adults. Active surveillance is needed for prompt diagnosis and early treatment. In patients with signs and symptoms of acute pancreatitis, EBV infection should always be considered, even in the absence of the typical clinical and hematological features of infectious mononucleosis. Generally, EBV-associated acute pancreatitis is characterized by a favorable prognosis, with a spontaneous resolution.