A 38-year-old woman comes to the office due to jaundice. Her eyes have been yellow for the past 8 days, and she has also had pruritus, fever, nausea, and vomiting. The patient has had no unexpected weight loss or bloody stools. Medical history is significant for hypertension; current medications include amlodipine and an oral contraceptive. The patient works in a day care center, where some of the children were recently ill. She drinks alcohol but does not use illicit drugs and is in a monogamous relationship with her husband. Family history is unremarkable. Temperature is 38.7 C (101.7 F), blood pressure is 125/80 mm Hg, and pulse is 80/min. Scleral icterus is present. Oropharyngeal and cardiopulmonary examinations are unremarkable. The neck is supple without lymphadenopathy. The abdomen is nontender and nondistended. The liver edge is smooth and palpable below the right costal margin. Laboratory evaluation reveals the following:
| Complete blood count | |
| Hemoglobin | 13.7 g/dL |
| Platelets | 290,000/mm3 |
| Leukocytes | 12,000/mm3 |
| Liver function studies | |
| Albumin | 3.9 g/dL |
| Total bilirubin | 4.2 mg/dL |
| Total protein | 6.8 g/dL |
| Alkaline phosphatase | 130 U/L |
| Aspartate aminotransferase (SGOT) | 1534 U/L |
| Alanine aminotransferase (SGPT) | 1722 U/L |
Which of the following is the most likely diagnosis?
Hepatitis A | |
Transmission |
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Diagnostic |
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Management |
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This patient most likely has hepatitis A, which typically begins with fever, vomiting, and mild right upper quadrant (RUQ) pain. Jaundice develops a few days later, often with pruritus, dark urine, and acholic stools. Hepatitis A virus (HAV) undergoes fecal-oral transmission and is commonly acquired from unsanitary food (eg, shellfish) and water supplies; outbreaks may occur in facilities with poor sanitation, such as homeless shelters and day care centers (children often do not have jaundice and may go undiagnosed). Unvaccinated persons are at increased risk, as are international travelers and men who have sex with men.
Hepatomegaly (eg, liver edge palpable below right costal margin) is common in hepatitis A. Liver transaminases (eg, aspartate aminotransferase [AST], alanine aminotransferase [ALT]) rise early, often to >1,000 U/L. Direct hyperbilirubinemia and mildly elevated alkaline phosphatase are seen soon thereafter and correlate with jaundice. Anti-HAV IgM serology confirms the diagnosis. Treatment is supportive; complete recovery typically occurs within 2-3 months. Fulminant liver failure necessitating liver transplant is rare.
(Choice A) Alcoholic hepatitis can cause moderate elevations in liver transaminases, but AST and ALT are rarely >500 U/L; the AST/ALT ratio is usually >2:1. Although this patient uses alcohol, the profound elevations in transaminases are atypical for alcoholic hepatitis.
(Choice B) Pyogenic liver abscess can cause fever, hepatomegaly, and elevated liver transaminases, but patients are acutely ill (eg, shaking chills) and have significant leukocytosis. Examination shows marked hepatic tenderness, often with guarding and rocking tenderness (pain caused by gently rocking the abdomen); rebound tenderness may be present.
(Choice C) Acute hepatic vein thrombosis (eg, Budd-Chiari syndrome) causes severe RUQ pain, ascites, and hepatosplenomegaly. Absence of ascites and significant RUQ tenderness makes this less likely in this patient.
(Choice E) Infectious mononucleosis can cause fever and sometimes jaundice, but splenomegaly is more common than hepatomegaly; patients typically have pharyngitis and cervical lymphadenopathy.
(Choice F) Primary biliary cholangitis is characterized by autoimmune destruction of intralobular bile ducts. Typical findings include profound elevations of alkaline phosphatase and bilirubin but near-normal aminotransferase levels.
(Choice G) A ruptured hepatic adenoma, which is associated with oral contraceptive use, causes severe RUQ pain and hemorrhagic shock. Although fever, and elevated liver enzymes are common, hypotension, tachycardia, and anemia would also be present.
Educational objective:
Hepatitis A causes fever, vomiting, jaundice, hepatomegaly, and severe elevations in hepatic transaminases (eg, aminotransferase levels >1,000 U/L). Unvaccinated individuals are at increased risk, as are day care workers, homeless shelter residents, international travelers, and men who have sex with men.