CASE 53
A 23-year old man presented to the emergency room of a general hospital with a 5-day history of fever, jaundice with dark yellow urine, and pale colored stools. He also complained about malaise, fatigue, abdominal pain, intermittent nausea, and vomiting, and he noted loss of appetite, to the point that even the sight of food made him nauseated.
LABORATORY STUDIES
Diagnostic Work-Up
Table 53-1 lists the likely causes of illness (differential diagnosis). A clinical diagnosis of viral hepatitis was considered. The viral hepatitides resemble each other clinically and can be differentiated only with the aid of specific virology lab tests. Assessment of risk factors is also important.
TABLE 53-1 Differential Diagnosis and Rationale for Inclusion (consideration)
Rationale: Hepatitis is a relatively common clinical syndrome associated with hepatocyte injury, jaundice, and elevation of liver enzymes (ALT and AST >500 IU/L). The major infectious causes of hepatitis are hepatitis viruses (HAV, HBV, or HCV), where elevation of ALT is more pronounced than is AST. Alcoholic liver injury does not usually lead to ALT or AST levels >500 IU/L, and AST is higher than ALT. The other listed agents may not cause such extreme elevations of ALT and AST, but they can also occur with similar symptoms. Sometimes risk factors can shed light on one etiology over others. Liver abscess can be detected with abdominal imaging and is not usually associated with significant jaundice. Drug-induced hepatic injury is not uncommon and is often associated with very high transaminases. Gallstone hepatitis may cause similar symptoms owing to blockage of bile but may not show marked increase in liver enzymes. Infection with CMV and EBV can be associated with elevated liver enzymes, but no significant jaundice.
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