A 43-year-old man is evaluated in the hospital for a medical illness. He has traveled to various countries on missionary trips and recently returned from South America. The patient has no prior medical history and takes no medications. His father has a history of alcohol dependence complicated by cirrhosis and portal hypertension. A liver biopsy is performed, and light microscopy of the tissue demonstrates spotty hepatocyte necrosis and inflammatory cell infiltration, as shown in the image below.
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Which of the following is the most likely initial clinical presentation of this patient?
This patient's liver biopsy findings and recent travel to an endemic region suggest acute hepatitis A infection. Acute viral hepatitis is characterized histologically by the presence of "spotty necrosis" with ballooning degeneration (hepatocyte swelling with wispy/clear cytoplasm), Councilman bodies (eosinophilic apoptotic hepatocytes), and mononuclear cell infiltrates.
Patients typically present acutely with a prodrome of fever, malaise, anorexia, nausea/vomiting, and right upper quadrant abdominal pain. After several days (up to 1 week), prodromal symptoms lessen as patients develop signs of cholestasis such as jaundice, pruritus, dark-colored urine (due to increased conjugated bilirubin levels), and acholic stool (lacks bilirubin pigment). The illness is self-limited and does not progress to chronic hepatitis, cirrhosis, or hepatocellular carcinoma.
(Choices A and C) Chronic cholestatic processes (eg, primary biliary cirrhosis, primary sclerosing cholangitis) may present initially with prolonged pruritus and fatigue. As these conditions progress, patients can develop acholic stools and malabsorption of fat-soluble vitamins (due to reduced bile flow to the small intestine). This can lead to vitamin D deficiency and metabolic bone disease (eg, osteoporosis, osteomalacia).
(Choice D) Skin pigmentation and diabetes mellitus are more suggestive of hemochromatosis, an inherited disease associated with iron overload in the liver, pancreas, heart, and other organs.
(Choice E) Upper gastrointestinal bleeding and ascites are more suggestive of portal hypertension, a condition that typically develops secondary to liver cirrhosis.
Educational objective:
Acute hepatitis A is a self-limited infection that typically presents acutely with prodromal symptoms (eg, fever, malaise, anorexia, nausea/vomiting, right upper quadrant pain) followed by signs of cholestasis (eg, jaundice, pruritus, dark-colored urine, clay-colored stool).