“beLIVER it or not” A case of jaundice of undetermined origin

TUESDAY CASE PRESENTATION Christel D. Seno, MD

January 31, 2017

OBJECTIVES

• To present an out-patient case of a 28 year old male with jaundice of undetermined etiology

• To discuss the algorithm on approach to patients with jaundice

CASE PROFILE: MB

28

Tricycle driver

Ilocos Sur

Male

CHIEF COMPLAINT

• jaundice

HISTORY

4 mos •  Flu- like symptoms à 3 weeks later: icteric sclera

2 mos

•  jaundice, acholic stools, tea colored urine, pruritus •  Consult at Tagudin Hospital

•  UTZ: unremarkable •  HbSAg reactive •  Meds : cetirizine and essential phospholipids

1 month

•  Persistence of jaundice, pruritus, acholic stools •  No follow up done

6 days

•  Consult at Lorma due to persistence of above symptoms

• PAST MEDICAL HISTORY:

No history surgeries, no past blood transfusions, no history of PTB, no previous medications intake, no previous Hepatitis vaccination

• FAMILY HISTORY:

No heredofamilial diseases, no hepatitis, no cancer

PERSONAL, SOCIAL AND ENVIRONMENTAL HISTORY

• previous smoker 6 pack years • Alcoholic beverage drinker usually drinks 1 2x2 gin

with friends 2-3 per week • Fond of eating street food

• No tattoos and body piercing

• Denies illicit drug use • Occupation: tricycle driver

• SEXUAL HISTORY 1 previous sexual partner

• REVIEW OF SYSTEMS: • No weight loss, no anorexia

• No photophobia, no blurring of vision, no hyperemia

• No ear pain, no discharge, no tinnitus

• No epistaxis, no discharge

• No gum bleeding, no fissure

• No sore throat, no hoarseness

• No cough, no difficulty of breathing

• No flank pain, no dysuria, no hematuria, no frequency

• No polyphagia, no polydipsia, no polyuria, no heat intolerance

• No easy bruisability, no rashes

PHYSICAL EXAMINATION

• Awake, coherent, not in cardiorespiratory distress

• BP: 120/70 CR 81 RR 19 Temp 36.8

• SKIN: dry skin no pallor, with jaundice, no cyanosis, no rashes,warm to touch, no palmar erythema

• HEENT:(+) icteric sclerae, , pink palpebral conjunctiva, (-) tonsillipharyngeal congestion, (-) cervical lymphandeonpathy, (-) neck vein distention

• CHEST & LUNGS: Symmetric chest expansion, (-) gynecomastia, (-) retractions, (-) lagging, bronchovesicular breath sounds

• Abdomen: Flabby, soft, normoactive bowel sounds, (-) tenderness, (-) spider angioma(-) hepatomegaly, (-) splenomegaly, (-) ascites

• Extremities:(-)cyanosis, (-) edema,

LABORATORY RESULTS

LAB RESULTS

Hbs Ag ReactiveAnti HCV Non ReactiveAnti HBc IgM Non reactiveAnti HBc IgG Non reactiveHepa A IgM Non- reactiveAnti- HBe Non- reactive

LABS RESULT REFERENCE VALUES

AlkalinePhosphatase

188.2 35-104

ALT 251.46 323.4 0-45

AST 343.56 208.1 0-35

Totalbilirubin 351.9 3.4-17.1

Directbilirubin 226.44 0-3.4

Indirectbilirubin 125.46 3.4-13.7

5x

7x

20x

66x 64%

9x

7x

5x

LABS RESULT REFERENCE VALUE

Total protein 89.88 (63-83)

Albumin 48.14 (48-55)

Globulin 41.74 (21-28)

A/G ratio 11.53:10 14-27:10

Prothrombin time 24.7 (control 12.1) 13.7 (after Vit K)

INR 2.21 1.09 (after Vit K)

• Whole abdominal UTZ:

Liver is not enlarged, hepatic echotexture is within normal limits.

Bile ducts not dilated. Gallbladder is contracted and measures 5.2 x 1.3 cm

No luminal stone noted. Pancreas, spleen is unremarkable

OPD COURSE

• On the first hospital visit

Essentiale forte BID

Branched chain amino acid 2x a day

Ursodeoxycholic acid once a day

Vitamin K 1 amp IV,

Diphenhydramine 50mg/tab BID PRN for pruritus.

Suggested abdominal CT scan and referral to gastro service.

Repeat ALT/AST

• On the second hospital visit

still icteric and jaundice

decreased pruritus

less acholic stools

no complaints of abdominal pain, nausea and vomiting, fever nor loss of appetite.

• seen by gastro rotator

• requested to have upper abdominal CT scan , HbSAg titer, anti HAV titer

• Phospholipids + Multivitamins BID continued, ursodeoxycholic acid was increased to twice a day

QUESTIONS

1. What is the etiology of this patient’s prolonged jaundice? • Cholestatic vs Hepatocellular?

History: -  flu-like symptoms prior to jaundice -  Denies previous BT, hepatotoxic

meds, illicit drug use, tattooing -  1 sexual partner -  Alcohol intake: 140gms/drinking

session PE: -  Jaundice -  (-) spider angioma, ascites or other

signs of liver cirrhosis -  No RUQ tenderness

TB 351.9 Dir Bil 226.44 (64% of the total) Ind Bil 125.46 (Direct Bilirubinemia) ALT 251.26 (5x elevated) AST 343.56 (7x elevated) (Ratio: 1.3:1) Alk Phos 188.42 (UL of NV: 104, slightly elevated) Albumin 48.14 (normal) PT 24.1 (elevated), INR 2.21

QUESTIONS

1.  What is the etiology of this patient’s jaundice? •  Cholestatic vs Hepatocellular?

2. If hepatocellular, what is the specific etiology?

140 gm/drinking session ~2-3x/week

UTZ: unremarkable

Points for

Presence and

elevated globulin

Predominant ALT/AST elevation

Points against

male

Presence of viral hepatitis marker:

HBsAg reactive

ANA negative

History: -  flu-like symptoms prior to jaundice

LAB RESULTS

Hepa A IgM Non- reactive

LAB RESULTS

Anti HCV Non Reactive

LAB RESULTS

Hbs Ag Reactive

HEPATITIS D INFECTION •  COINFECTION •  SUPER INFECTION

HEP E DOESN’T PRESENT WITH PROLONGED JAUNDICE

ELEVATED ALT/AST

LAB RESULTS

Hbs Ag Reactive

Anti HBc IgM Non reactive

Anti HBc IgG Non reactive

Anti- HBe Non- reactive

Hbe Ag Non-reactive

QUESTIONS

1.  What is the etiology of this patient’s jaundice?

•  Hepatocellular 2.  If hepatocellular, what is the specific etiology?

•  Viral hepatitis, Alcoholic Hepatitis

3.  How do I interpret the hepatitis profile? Is this a case of false negative lab?

4.  What other diagnostics would be appropriate for this case?

HEPATITIS PROFILE: HOW DO WE INTERPRET?

HEPATITIS DIAGNOSTIC DILEMMA

• HBsAg without detectable anti HBc

Mechanisms:

1.lack of responsiveness to HBcAg in immune compromise patients

2. false negative anti-HBc due to assay insensitivity

Ref: Victorian Infectious Diseases Reference Laboratory

PLANS FOR THE PATIENT

• Repeat HBsAg QUANTITATIVE, HBV DNA

• Repeat AST, ALT

THANK YOU