Type 2 Autoimmune Hepatitis Due to Acute Epstein Barr Virus Infection or is it the Other Way Around?

We present a case of a 19-year-old female who presented with abdominal pain and severe pruritus. Viral studies including complete hepatitis panel were negative for acute infection, however acute infectious mononucleosis heterophiles antibodies were positive along with liver kidney microsome (LKM-1) antibody. Patient’s liver on MRCP was markedly heterogenous and nodular with areas of confluent hepatic fibrosis consistent with cirrhosis. Subsequent liver biopsy confirmed findings of acute hepatitis with extensive parenchymal extinction and necrosis with moderate to severe mixed inflammation. The patient was initiated on cholestyramine 4 gm pack daily, prednisone and transferred to a tertiary center for liver transplant evaluation.