A 22-year-old man comes to the office due to yellow eyes lasting a day. Over the past 3 days, the patient has had fever, fatigue, nasal discharge, and sore throat. He has no chronic medical conditions. His only medication is acetaminophen as needed for current symptoms. The patient drinks 4 or 5 alcoholic beverages a week, and the last drink was 3 days ago. Temperature is 38 C (100.4 F), blood pressure is 120/78 mm Hg, pulse is 80/min, and respirations are 16/min. Examination shows scleral icterus; the oropharynx is erythematous without exudates. There is no pallor or lymphadenopathy. Liver span is 11 cm, and a firm, nontender liver edge is palpable. There is no splenomegaly. Laboratory results are as follows: What is the most likely cause of jaundice in this patient?

Question

A 22-year-old man comes to the office due to yellow eyes lasting a day.  Over the past 3 days, the patient has had fever, fatigue, nasal discharge, and sore throat.  He has no chronic medical conditions.  His only medication is acetaminophen as needed for current symptoms.  The patient drinks 4 or 5 alcoholic beverages a week, and the last drink was 3 days ago.  Temperature is 38 C (100.4 F), blood pressure is 120/78 mm Hg, pulse is 80/min, and respirations are 16/min.  Examination shows scleral icterus; the oropharynx is erythematous without exudates.  There is no pallor or lymphadenopathy.  Liver span is 11 cm, and a firm, nontender liver edge is palpable.  There is no splenomegaly.  Laboratory results are as follows:  What is the most likely cause of jaundice in this patient?

Quizplus · Accepted Answer

11ec25c8_d222_41b6_bc81_5d73d2983010_MD0003_00 This patient has scleral icterus and indirect (unconjugated) hyperbilirubinemia in the setting of an upper respiratory tract infection (eg, fever, fatigue, nasal discharge, sore throat). This presentation is consistent with Gilbert syndrome, the most common inherited disorder of bilirubin glucuronidation. Gilbert syndrome is characterized by episodic jaundice due to decreased activity of UDP glucuronosyltransferase, the hepatic enzyme responsible for bilirubin conjugation. These benign episodes can be precipitated by periods of stress, such as febrile illness (as seen in this patient), dehydration, fasting, vigorous exercise, menstruation, or surgery. bilirubin conjugation A presumptive diagnosis of Gilbert syndrome is made based on the presence of persistent indirect hyperbilirubinemia in the absence of other laboratory abnormalities (eg, hepatic aminotransferases, complete blood count, reticulocyte count). This condition is benign, and reassurance should be provided. (Choice A) Excessive alcohol consumption (typically >6 drinks/day) can lead to alcoholic hepatitis, which causes fever and jaundice. However, aspartate aminotransferase (AST) and alanine aminotransferase (ALT) would be elevated in a ≥2:1 ratio. In addition, tender hepatomegaly is typical and in contrast to this patient's nontender, normal-sized (≤15 cm) liver. (Choice B) Rotor syndrome, a rare autosomal recessive disorder, can cause episodic jaundice due to impaired intrahepatic storage of conjugated bilirubin. However, a predominantly direct (conjugated) hyperbilirubinemia would be expected. (Choice D) Hemolytic anemia, which may be triggered by certain viral infections (eg, Epstein-Barr virus, HIV), increases unconjugated bilirubin production due to red blood cell destruction. In contrast to this patient, a low hemoglobin level and an increased reticulocyte count would be expected in a patient with hemolytic anemia. (Choice E) Acute viral hepatitis can cause fever, jaundice, and hyperbilirubinemia. However, significant elevations in AST and ALT, sometimes exceeding 1,000 U/L, would be expected, making this diagnosis very unlikely. In addition, predominant indirect hyperbilirubinemia in the absence of hemolysis is not common with viral infections. Educational objective: Gilbert syndrome is characterized by intermittent jaundice and indirect (unconjugated) hyperbilirubinemia in the absence of other laboratory abnormalities. Jaundice is often triggered by periods of stress, such as febrile illness, dehydration, fasting, vigorous exercise, menses, and surgery. References: Gilbert syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/22160004)

A 22-Year-Old Man Comes to the Office Due to Yellow