Anorexia And Fever - Case Study

A 22-year-old man presented with malaise and anorexia for 1 week. He vomited on one occasion, with no blood. He has felt feverish but has not taken his temperature. For 2 weeks he has had aching pains in the knees, elbows and wrists without any obvious swelling of the joints.
He has not noticed any change in his urine or bowels.
Five years ago he had glandular fever confirmed serologically. He smokes 25 cigarettes per day and drinks 20–40 units of alcohol per week. He has taken marijuana and ecstasy occasionally over the past 2 years and various tablets and mixtures at clubs without being sure of the constituents. He denies any intravenous drug use. He has had irregular homosexual contacts but says that he has always used protection. He claims to have had an HIV test that was negative 6 months earlier. He has not traveled abroad in the last 2 years.
He is unemployed and lives in a flat with three other people. There is no relevant family history.

Examination
He has a temperature of 38.6°C and looks unwell. He looks as if he may be a little jaundiced. He is a little tender in the right upper quadrant of the abdomen. There are no abnormalities to find on examination of the joints or in any other system.

Investigations
(normal values shown in brackets)
Haemoglobin 14.1 g/dL (13.3–17.7 g/dL)
Mean corpuscular volume (MCV) 85 fL (80–99 fL)
White cell count 11.5 × 109/L (3.9–10.6 × 109/L)
Platelets 286 × 109/L (150–440 × 109/L)
Prothrombin time 17 s (10–14 s)
Sodium 135 mmol/L (135–145 mmol/L)
Potassium 3.5 mmol/L (3.5–5.0 mmol/L)
Urea 3.2 mmol/L (2.5–6.7 mmol/L)
Creatinine 64 μmol/L (70–120 μmol/L)
Bilirubin 50 mmol/L (3–17 mmol/L)
Alkaline phosphatase 376 IU/L (30–300 IU/L)
Alanine aminotransferase 570 IU/L (5–35 IU/L)
Fasting glucose 4.1 mmol/L (4.0–6.0 mmol/L)

Questions
• What is your interpretation of the findings?
• What is the likely diagnosis?
• What treatment is required?

Answers And Discussion

The diagnosis is likely to be acute viral hepatitis. The biochemical results show abnormal liver function tests with a predominant change in the transaminases, indicating a hepatocellular rather than an obstructive problem in the liver. This might be caused by hepatitis A, B or C.
The raised white count is compatible with acute hepatitis.
Homosexuality and intravenous drug abuse are risk factors for hepatitis B and C. Other viral infections, such as cytomegalovirus and herpes simplex virus, are possible. As the drug ingestion history is unclear, there is a possibility of a drug-induced hepatitis. The prodromal joint symptoms suggest a viral infection as the cause, and this is more common with hepatitis B. Serological tests can be used to see whether there are immunoglobulin M (IgM) antibodies indicating acute infection with one of these viruses, to confirm the diagnosis. Viral loads can also be measured.
The reported negative HIV test 6 months earlier makes an HIV-associated condition unlikely
although patients are not always reliable in their accounts of HIV tests, and HIV seroconversion should also be considered.

This man has acute hepatitis B infection. About 30% of cases develop jaundice. Treatment is basically supportive in the acute phase. Antiviral drugs are not indicated in the vast majority of patients with acute hepatitis B. The prothrombin time in this patient is raised slightly but not enough to be an anxiety or an indicator of very severe disease. Liver function will need to be measured to monitor enzyme levels as a guide to progress. Alcohol and any other hepatotoxic drug intake should be avoided until liver function tests are back to normal. Rare complications of the acute illness are fulminant hepatic failure, aplastic anaemia, myocarditis and vasculitis.
The opportunity should be taken to advise him about the potential dangers of his intake of cigarettes, drugs and alcohol, and of sexually transmitted diseases and to offer him appropriate support in these areas. HBV can survive outside the body for some time and he should advise his flat mates not to share razors and toothbrushes with him. They should consider being vaccinated. Only about 5% of adults with acute hepatitis B will develop chronic infection. Patients with alcoholic liver disease who are infected with hepatitis B have a worse liver prognosis.

Key Points
• Viral hepatitis is often associated with a prodrome of arthralgia and flu-like symptoms.
• Confirmatory evidence should be sought for patients’ reports of HIV test results.
• Sexual transmission and intravenous drug use are the main methods of transmission of hepatitis B in adults in the developed world.
• Acute hepatitis B infection is a notifiable disease in the UK.