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

Nausea And Weight Loss In A 45 Year old Alcoholic... Case Study

A 45 years old man consults his general practitioner (GP) with a 6-month history of reduced appetite
and a weight loss, from 78 to 71 kg. During the last 3 months he has had intermittent nausea, especially in the mornings, and in the last 3 months the morning nausea has been accompanied by vomiting on several occasions. For 1 month he has noted swelling of his ankles. Despite his weight loss he has recently noticed his trousers getting tighter. He has had no abdominal pain. He has no relevant past history and knows no family history as he was adopted.
He takes no medication. From the age of 18 he has smoked 5–6 cigarettes daily and drunk 15–20 units of alcohol per week. He has been a chef all his working life, without exception in fashionable restaurants. He now lives alone as his wife left him 1 year ago.

Examination
He has plethoric features. There is pitting oedema of his ankles. He appears to have lost weight from his limbs, but not his trunk. He has nine spider naevi on his upper trunk.
His pulse is normal, and the rate is 92/min. His jugular venous pressure (JVP) is not raised, and his blood pressure is 146/84 mmHg.
The cardiovascular and respiratory systems are normal.
The abdomen is distended. He has no palpable masses, but there is shifting dullness and a fluid thrill

Investigations: 
Haemoglobin = 12.6 g/dL (normal = 13.3–17.7 g/dL)
White cell count = 10.2 × 109/L (normal = 3.9–10.6 × 109/L)
Platelets = 121 × 109/L (normal = 150–440 × 109/L)
Sodium = 131 mmol/L (normal = 135–145 mmol/L)
Potassium = 4.2 mmol/L(normal = 3.5–5.0 mmol/L)
Urea = 2.2 mmol/L (normal = 2.5–6.7 mmol/L)
Creatinine  = 101 μmol/L (normal = 70–120 μmol/L)
Total protein = 48 g/L (normal = 60–80 g/L)
Albumin = 26 g/L (normal = 35–50 g/L)
Bilirubin =  25 mmol/L (normal = 3–17 mmol/L)
Alanine transaminase = 276 IU/L (normal = 5–35 IU/L)
Gamma-glutamyl transaminase = 873 IU/L (normal = 11–51 IU/L)
Alkaline phosphatase = 351 IU/L (normal = 30–300 IU/L)
International normalised ratio (INR) = 1.4 (normal = 0.9–1.2)

Urinalysis: no protein; no blood

• What is the diagnosis?
• How would you manage this patient?

A 40 Year old patient presenting with nausea, vomiting and abnormal liver function tests...

A 40-year-old school teacher develops nausea and vomiting at the beginning of the fall semester. Over the summer she had taught preschool children in a small town in Mexico. She is sexually active, but has not used intravenous drugs and has not received blood products.
Physical examination reveals scleral icterus, right upper quadrant tenderness, and a palpable liver. Liver function tests show aspartate aminotransferase of 750 U/L (normal < 40) and alanineaminotransferase of 1020 U/L (normal < 45). The bilirubin is 13 mg/dL (normal < 1.4) and the alkaline phosphatase is normal.

What further diagnostic test is most likely to be helpful?
a. Liver biopsy
b. Abdominal ultrasound
c. IgM antibody to hepatitis A
d. Antibody to hepatitis B surface antigen
e. Determination of hepatitis C RNA

Answer:

A patient presenting with fever and deranged LFTs ....

A 29-yr-old Catholic priest returns from a trip to Brazil with fevers and deranged LFTs. He has an ALT of 2500 U/l and bilirubin of 75 μmol/l. He attended a travel clinic and was vaccinated prior to travel. He also took mefloquine malaria prophylaxis.

What is the most likely diagnosis?

A. Malaria
B. Hepatitis A
C. Hepatitis B
D. Hepatitis E
E. Dengue fever

Answer:

Regarding Adverse Effects of Interferon - alpha...

A 36-year-old former intravenous drug user is to commence treatment for hepatitis C with interferon-alpha and ribavirin. Which of the following adverse effects are most likely to occur when patients are treated with interferon-alpha?
A. Diarrhoea and transient rise in ALT
B. Cough and haemolytic anaemia
C. Flu-like symptoms and transient rise in ALT
D. Haemolytic anaemia and flu-like symptoms
E. Depression and flu-like symptoms

Answer:

Non-Alcoholic Fatty Liver Disease

A 52-year-old woman is diagnosed with non-alcoholic steatohepatitis following a liver biopsy. What is the single most important step to help prevent the progression of her disease?

A. Stop smoking
B. Start statin therapy
C. Eat more omega-3 fatty acids
D. Start sulfonylurea therapy
E. Weight loss

Answer:

An isolated hyperbilirubinaemia in a 22-year-old male...

A 22-year-old male with no history of any illness comes to donate blood. His blood work before donation shows following results:

• Bilirubin 41 μmol/L 
• Alkaline phosphatase 84 U/L 
• ALT 23 U/L 
• Albumin 41 g/L 

Dipstick urinalysis normal

What is the most likely diagnosis?
A. Gilbert's syndrome
B. Dubin-Johnson syndrome
C. Rotor syndrome
D. Hepatitis C infection
E. Infectious mononucleosis

Answer:

Regarding Management Of Esophageal Varices Bleeding

A 45-year-old man with a history of alcohol excess is diagnosed as having grade 3 esophageal varices during an outpatient endoscopy. Of the following options, what is the most appropriate management to prevent variceal bleeding?

A. Propranolol
B. Isosorbide mononitrate
C. Endoscopic sclerotherapy
D. Terlipressin
E. Lansoprazole

Answer: A. Propranolol

Discussion:

Esophageal Varices - Management: 

Acute treatment of variceal haemorrhage 
 ABC: patients should ideally be resuscitated prior to endoscopy

Regarding Primary Biliary Cirrhosis

Primary biliary cirrhosis is most characteristically associated with:
A. Anti-nuclear antibodies
B. Anti-ribonuclear protein antibodies
C. Anti-mitochondrial antibodies
D. Rheumatoid factor
E. Anti-neutrophil cytoplasmic antibodies

Answer:

Interpreting Hepatitis Serology

A 42-year-old man presents to his GP complaining of persistent lethargy. Routine bloods show abnormal liver function tests so a hepatitis screen is sent. The results are shown below:
Anti-HAV IgG negative
HBsAg negative
Anti-HBsAb positive
Anti-HBcAg negative
Anti-HCV positive
What do these results most likely demonstrate?
A. Hepatitis B infection
B. Hepatitis C infection
C. Previous vaccination to hepatitis B and C
D. Hepatitis C infection with previous hepatitis B vaccination
E. Hepatitis B and C infection

Answer:

A 45 Year Old Woman presents To ER With Epigastric pain, Nausea, Vomiting & Jaundice

A 45-year-old woman presents to the emergency room when you are on call. She complains of epigastric pain, radiating to the back. She also has nausea and vomiting. She states that she has had similar symptoms for many years but has never felt this bad. She does not use tobacco or alcohol. You suspect obstruction of the common bile duct because the patient is jaundiced. The optimal diagnostic study is:

A. Ultrasound evaluation
B. Computerized tomography (CT) scan of the abdomen
C. Plain abdominal films, flat and upright
D. HIDA scan
E. Endoscopic retrograde cholangiopancreatography

 Answer :

Drug-Induced Liver Disease

A 54-year-old woman presents with jaundice shortly after being discharged from hospital. Liver function tests are reported as follows:
Albumin = 49 g/l, Bilirubin = 89 mmol/l, Alanine transferase (ALT) = 66 iu/l,
Alkaline phosphatase (ALP) = 245 mmol/l, Gamma glutamyl transferase (yGT) = 529 u/l.
Which of the following antibiotics is she most likely to have received?
A. Co-amoxiclav
B. Gentamicin
C. Ciprofloxacin
D. Trimethoprim
E. Ceftazidime

Answer:

A Patient On Warfarin With Increased INR

A 65-year-old with a history of chronic atrial fibrillation is being monitored while on warfarin therapy. The nurse calls to inform you the patient’s international normalized ratio (INR) is measured at 7. He has no active signs of bleeding, but is at increased risk of bleeding. Appropriate management at this time includes which of the following:

A) Stop warfarin, observe, and repeat INR in 3 days.
B) Stop warfarin and observe; repeat INR in 24 hours.
C) Stop warfarin, give vitamin K, and repeat INR in 24 hours.
D) Stop warfarin, give vitamin K and fresh-frozen plasma with daily INRs.

Answer:

Primary Sclerosing Cholangitis

A 38-year-old English male was investigated after he was found to have an abnormal liver function test during a health insurance medical check. He worked in an information technology firm. Apart from occasional fatigue he was well. He consumed less than 20 units of alcohol per week. The patient had only traveled out of Europe twice and on both occasions he had been to North America. He took very infrequent paracetamol for aches and pains in his ankles and knees. There was no history of hepatitis or transfusion or blood products. He had been married for 5 years.
Systemic inquiry revealed infrequent episodes of loose stool for almost 4 years.
On examination he appeared well. There were no stigmata of chronic liver disease.
Abdominal examination revealed a palpable liver edge 3 cm below the costal margin. There were no other masses.
Examination of the central nervous system was normal.
Investigations were as shown.

• Hb 12.6 g/dl ,WCC 8 109/l ,Platelets 210 109/l, MCV 90 fl
• Sodium 136 mmol/l, Potassium 4.1 mmol/l
• Urea 6 mmol/l , Creatinine 100 mmol/l 
• AST 60 iu/l (NR 10–40 iu/l) , ALT 78 iu/l (NR 5–30 iu/l)
• Alkaline phosphatase 350 iu/l (NR 25–100 iu/l)
• Bilirubin 22 mmol/l (NR 2–17 μmol/l)
• Albumin 38 g/l (NR 34–48 g/l)
• Total cholesterol 5.2 mmol/l , Triglyceride 3.1 mmol/l
• Blood glucose 6 mmol/l
• Ferritin 256 mg/l (NR 15–250 mg/l) , Serum Fe 28 mmol/l( NR 14–32 mmol/l) , TIBC 50 mmol/l (NR 40–80 mmol/l)
• Serum Slightly reduced caeruloplasmin , 24-hr urine copper Slightly elevated
• IgG 19 g/l (NR 7–18 g/l), IgA 4.2 g/l (NR 0.8–4.0 g/l) ,IgM 5.0 g/l (NR 0.4–2.5 g/l)
• Anti-nuclear Positive 1/32 antibodies ,Smooth muscle Not detected antibodies,  Antimitochondrial Not detected antibodies
• Hep B sAg Not detected , Hep C virus Not detected antibodies
• Abdominal ultrasound Normal

What is the most probable diagnosis?
a. Autoimmune hepatitis.
b. Primary sclerosing cholangitis.
c. Primary biliary cirrhosis.
d. Haemochromatosis.
e. Wilson’s disease.

Answer: