Problem 54 A listless 45-year-old man
A 45-year-old schoolteacher is referred by his GP with deranged liver function tests. He presents with a 1-year history of persistent lethargy. There seem to be no exacerbating or relieving factors. There are no other specific symptoms. Initial blood tests have revealed some abnormalities of his liver enzymes and he has been referred to the hepatology clinic for further investigation. He has never been jaundiced.
On further questioning he admits to having used intravenous heroin in his teens, but says he has been clean since the age of 25. He has never been on a methadone replacement programme.
On examination he appears thin, but looks generally well. There is no evidence of jaundice or lymphadenopathy and he is afebrile. There are several tattoos on his upper torso and you notice some old scars in his antecubital fossae. There are a few spider naevi present on his upper chest, but no other signs of chronic liver disease. Cardiovascular and respiratory examination is unremarkable. The abdomen is soft and non-tender with no evidence of hepatosplenomegaly and no ascites. He is not encephalopathic.
You arrange some further blood tests. The results are as follows:
Investigation 54.1 Summary of results
| White cell count | 7.3 × 109/L | |
| Haemoglobin | 13.5 g/dL | |
| Platelets | 100 × 109/L | |
| INR | 1.3 | |
| Sodium | 138 mmol/L | |
| Potassium | 4.3 mmol/L | |
| Bicarbonate | 24 mmol/L | |
| Urea | 4.6 mmol/L | |
| Creatinine | 67 mmol/L | |
| Glucose | 5.6 mmol/L | |
| Cholesterol | 3.1 mmol/L | |
| Calcium | 2.23 mmol/L | |
| Phosphate | 0.88 mmol/L | |
| Total protein | 65 g/L | |
| Albumin | 43 g/L | |
| Globulin | 22 g/L | |
| ALP | 172 U/L | |
| Bilirubin | 20 mmol/L | |
| AST | 148 U/L | |
| ALT | 136 U/L | |
| GGT | 132 U/L | |
| Autoimmune profile | Negative | |
| IgG | 16.8 | |
| IgA | 3.9 | |
| IgM | 1.3 | |
| Thyroid function | Free T4: 18.1 | TSH: 3.5 |
The following tests are now available:
Investigation 54.2 Summary of results
| Hepatitis B surface antigen | Negative |
| Hepatitis C IgG | Positive |
| Hepatitis C PCR | Positive with a viral load of 1 324 000 IU/mL |
You review him in the outpatient clinic to discuss the results with him.
Investigation 54.3 Summary of results
| White cell count | 2.9 × 109/L |
| Haemoglobin | 10.3 g/dL |
| Platelets | 67 × 109/L |
| INR | 1.9 |
| Albumin | 28 g/L |
| Globulin | 22 g/L |
| ALP | 312 U/L |
| Bilirubin | 87 µmol/L |
| AST | 111 U/L |
| ALT | 165 U/L |
| GGT | 278 U/L |
| Alphafetoprotein 1885 kiu/L (0–5) |
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