A 39-year-old man comes to the clinic with a month-long history of fever, fatigue, joint pain, and an urticarial skin rash. He did not seek attention immediately as he hoped his symptoms would resolve. The patient is generally improving but is still very easily fatigued. Past medical history is unremarkable and the patient takes no regular medications, although he has not seen a physician since early childhood. He is not married and has a history of multiple heterosexual partners. The patient recently stopped smoking, drinks alcohol socially and does not use illicit drugs. Physical examination is notable for a moderately enlarged and tender liver. No jaundice is seen. Laboratory studies show significant elevations in serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST). Which of the following is the most likely diagnosis in this patient?

Question

A 39-year-old man comes to the clinic with a month-long history of fever, fatigue, joint pain, and an urticarial skin rash.  He did not seek attention immediately as he hoped his symptoms would resolve.  The patient is generally improving but is still very easily fatigued.  Past medical history is unremarkable and the patient takes no regular medications, although he has not seen a physician since early childhood.  He is not married and has a history of multiple heterosexual partners.  The patient recently stopped smoking, drinks alcohol socially and does not use illicit drugs.  Physical examination is notable for a moderately enlarged and tender liver.  No jaundice is seen.  Laboratory studies show significant elevations in serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST).  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

This patient has features of acute hepatitis B (HBV), including systemic, skin, and joint symptoms; hepatomegaly; and elevated transaminase levels. Hepatitis B is a DNA virus with an incubation period of 30-180 days. Transmission can occur sexually, parenterally, or vertically. Onset is dominated by nonspecific symptoms, although patients may develop a serum sickness-like syndrome with joint pain, lymphadenopathy, and a pruritic urticarial vasculitis rash. Right upper quadrant pain can also be present. Acute HBV is characterized by significant elevations in aspartate aminotransferase and alanine aminotransferase, often >10 times the upper limit of normal. Most patients will have nonicteric hepatitis, but icteric hepatitis with jaundice and elevated bilirubin is also common. Impaired hepatic synthetic function, as indicated by a prolonged prothrombin time, confers a poor prognosis. The most important early marker of acute infection is hepatitis B surface antigen (HBsAg), which may be detectable prior to symptoms or changes in transaminase levels. IgM anti-hepatitis B core (anti-HBc) may also be positive. Hepatitis B e antigen (HBeAg) and HBV DNA counts correlate with infectivity. (Choice B) Acute hepatitis C is typically asymptomatic; dermatologic manifestations (eg, cryoglobulinemia) are seen in chronic infection. This patient is unlikely to have hepatitis C as he does not use intravenous drugs and sexual transmission is rare. (Choice C) Gilbert syndrome is a common disorder characterized by mild unconjugated hyperbilirubinemia. Patients are almost always asymptomatic. (Choice D) Hemochromatosis is due to abnormal iron absorption resulting in iron overload. Chronic manifestations include cirrhosis, hyperpigmentation, and diabetes mellitus ("bronze diabetes"). (Choice E) Hepatic steatosis is characterized by excessive deposition of lipids in the liver and is usually caused by chronic alcohol abuse or obesity (and insulin resistance). Steatosis may lead to cirrhosis, but it does not cause acute symptoms. (Choice F) Wilson disease presents with acute or chronic hepatitis in patients age <30. Neurologic manifestations (eg, cognitive or motor deficits) are frequent. Kayser-Fleischer rings (green or golden corneal deposits) are a common incidental finding. Educational objective: Acute hepatitis B infection can cause a serum sickness-like syndrome with joint pain, lymphadenopathy, and a pruritic urticarial rash. Other features may include right upper quadrant pain, hepatomegaly, and elevated hepatic transaminase levels. __________ References: Cutaneous manifestations of viral hepatitis. (http://www.ncbi.nlm.nih.gov/pubmed/25809574)

A 39-Year-Old Man Comes to the Clinic with a Month-Long