A 54 year-old-man comes to the office due to a 3-day history of fever, malaise, and loss of appetite. The patient has not experienced weight loss, headache, cough, dyspnea, rash, vomiting, or bloody stools. Medical history is unremarkable, and he takes no medications. He lives in an overcrowded homeless shelter, drinks several beers a day, and intermittently smokes marijuana but denies other illicit drug use. The patient is not sexually active and has not traveled outside of the United States. Family history is unremarkable. Temperature is 38.1 C (100.6 F), blood pressure is 135/80 mm Hg, and pulse is 85/min. Scleral icterus is absent. Cardiopulmonary and skin examinations are unremarkable. The abdomen is soft and nondistended. Hepatomegaly is present. Laboratory results are as follows: Which of the following is the most likely diagnosis?

Question

A 54 year-old-man comes to the office due to a 3-day history of fever, malaise, and loss of appetite.  The patient has not experienced weight loss, headache, cough, dyspnea, rash, vomiting, or bloody stools.  Medical history is unremarkable, and he takes no medications.  He lives in an overcrowded homeless shelter, drinks several beers a day, and intermittently smokes marijuana but denies other illicit drug use.  The patient is not sexually active and has not traveled outside of the United States.  Family history is unremarkable.  Temperature is 38.1 C (100.6 F), blood pressure is 135/80 mm Hg, and pulse is 85/min.  Scleral icterus is absent.  Cardiopulmonary and skin examinations are unremarkable.  The abdomen is soft and nondistended.  Hepatomegaly is present.  Laboratory results are as follows:  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d26e_3f3d_bc81_2732ce27bd02_MD0003_00 This patient has fever, fatigue, and anorexia associated with severely elevated liver aminotransferases. These features are likely due to hepatitis A. Hepatitis A virus (HAV) is fecal-orally transmitted; outbreaks have been linked to contaminated water and food (eg, shellfish), as well as to overcrowded homeless shelters. Other groups at increased risk include international travelers, men who have sex with men, and illicit drug users. Symptoms of hepatitis A develop abruptly. Initial symptoms include nausea, vomiting, anorexia, fever, and right upper quadrant pain. A few days later, dark urine (bilirubinuria) and/or pale stools (lacking bilirubin pigment) may be seen. These are usually followed by jaundice and pruritus (40%-70% of cases). Jaundice typically peaks within 2 weeks. Aminotransferases rise early in the disease process, with aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels often exceeding 1,000 U/L. Bilirubin and alkaline phosphatase levels rise several days later. The diagnosis is confirmed by anti-HAV IgM. Treatment for acute hepatitis A is supportive, and complete recovery is common. Postexposure prophylaxis (eg, vaccine, hepatitis A immunoglobulin) should be given to close contacts of infected patients. (Choice A) Acute cholangitis is an ascending infection associated with biliary obstruction (eg, choledocholithiasis, biliary stricture). Most patients are quite ill and have elevated alkaline phosphatase and significant direct hyperbilirubinemia. A significant hepatocellular injury pattern is uncommon. (Choice B) Acute cholecystitis results from cystic duct obstruction. Although fever may occur, most patients have right upper quadrant pain, and AST and ALT levels are typically <1,000 U/L. (Choice C) Concurrent alcohol use can worsen hepatitis A. However, hepatic transaminase levels in isolated alcoholic hepatitis are rarely >500 U/L and characteristically have an AST/ALT ratio of 2:1. (Choice D) Congestive hepatopathy results from impaired venous drainage of the liver, usually in the setting of right-sided heart failure. Severe elevations in transaminases can occur, but other features of heart failure (eg, dyspnea, jugular venous distension) would usually be present. Fever and leukocytosis are atypical. (Choice F) Locally invasive pancreatic cancer can obstruct the biliary tree, leading to jaundice and direct hyperbilirubinemia. Although mild elevations in AST and ALT can occur, levels >1,000 are atypical. Educational objective: Hepatitis A presents acutely with fever, malaise, anorexia, nausea, hepatomegaly, and, sometimes, jaundice. Severe elevations in hepatic transaminases (>1,000 U/L) occur early in the disease process, whereas bilirubin and alkaline phosphatase levels may increase several days later. The virus has fecal-oral transmission, and outbreaks have been linked to contaminated water or food, as well as to overcrowded homeless shelters. References: Hepatitis A. (http://www.ncbi.nlm.nih.gov/pubmed/23198670)

A 54 Year-Old-Man Comes to the Office Due to a 3-Day