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Acute Hepatitis in a 44-Year-Old Woman

Miles Medrano, MD; Richard W. Goodgame, MD
DISCLOSURES | January 03, 2002

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Case Presentation
The patient was a previously healthy 44-year-old Mexican American woman whose chief complaint
was jaundice and right upper quadrant pain.

For about 1 year, she had the sensation of dry mouth; there were no oral lesions or dysphagia. She
had no dry eyes or other features of the complete sicca syndrome. Six weeks prior to admission, she
sought advice from an herbalist and was given several herbal medications including desiccated liver,
"Texas elixir," peppermint leaf, and nopal. These medications worsened her oral symptoms, and she
stopped taking them after a few days. Over the next few weeks, she developed fatigue and a poor
appetite. The following week she developed jaundice, right upper quadrant abdominal pain, dark
urine, and clay-colored stool. At this point in time, the patient saw a physician and was told that she
had hepatitis. She was given esomeprazole, promethazine, clotrimazole, and rofecoxib.

Her past medical history was positive for 2 cesarean sections and an elective surgical abortion
(performed 4 months previously). She had no history of arthritis, pleurisy, thyroid disease, diabetes,
diarrhea, or Raynaud's syndrome. She has had no blood transfusions, no alcohol or tobacco use, no
substance abuse, no travel in the last 10 years, and no relevant family history of serious disease.

Physical examination showed a mildly obese, deeply jaundiced woman in mild distress due to fatigue
and right upper quadrant discomfort. There was a hint of palmar erythema (Figure 1) and a single
cutaneous vascular lesion on her anterior chest (Figure 2). There was no clubbing, edema, or
enlarged parotid glands. The liver was felt 3 cm below the right costal margin in the mid-clavicular
line; it was smooth, soft, and mildly tender. The spleen was not palpable.

Laboratory investigations disclosed the following values:

Hemoglobin: 12.6 g/dL

White blood cell count: 6200/mm3

Platelets: 170,000/mm3

Creatinine: 0.8 mg/dL

Prothrombin time: 18.2 sec

Partial thromboplastin time 52.7 sec

Total bilirubin: 24.7 mg/dL

Direct bilirubin: 13.7 mg/dL

Total protein 7.9 g/dL

Albumin: 2.5 g/dL

Alkaline phosphatase: 128 U/L

Aspartate aminotransferase (AST): 3017 U/L

Alanine aminotransferase: 2262 U/L

The patient had an ultrasound examination of the liver (Figures 3, 4) which showed hepatomegaly
but no mass lesions, gallstones, or dilated bile ducts. Doppler sonography showed normal portal and
hepatic venous flow (not shown).

What is the differential diagnosis of this patient's liver disease, based on medical history, results of
physical examination, and liver chemistries?

A. This patient presented with an acute hepatitis: jaundice, right upper quadrant pain, fatigue, and
markedly elevated aminotransferases. The ultrasound excluded obstruction, mass lesions, and
infiltrative diseases (although these were not suspected given the high aminotransferase levels
and mildly increased alkaline phosphatase).Viral hepatitis, which includes hepatitis A, B, C,
and coinfection or superinfection with D, were possibilities in this patient. However, she had
few risk factors. Drug- or toxin-induced hepatitis was also a consideration. The patient had
taken several herbal medications, which could have played a contributory role. Additionally,
many medications can have hepatotoxic effects. Several of the more commonly noted
reactions occur with isoniazid, sodium valproate, phenytoin, antibiotics, statins, nonsteroidal
anti-inflammatory drugs, and the -azole antifungals. Acetaminophen causes a dose-dependent
direct toxic effect on the liver and could give this clinical picture with acute ingestion of greater
than 12 g (or less, if alcohol is also ingested). Other agents that have toxic effects on the liver
include carbon tetrachloride, trichloroethylene, and mushroom poisons.[1] Additional
considerations include veno-occlusive disease, severe acute hepatic congestion, and acute
ischemic injury. However, history, physical examination, and ultrasound ruled out these
diagnoses.The final important cause of acute hepatitis is acute autoimmune hepatitis. This
patient had no history of autoimmune diseases, but the possibility of the sicca syndrome
prompted close questioning for any suggestion of collagen vascular and rheumatologic
disorders. The globulin fraction of the serum proteins was very high: 5.4 gm/dL. Although this
finding can be seen in a variety of acute and chronic liver diseases, it is part of the diagnostic
criteria for autoimmune hepatitis.

View the correct answer.

If the cutaneous vascular lesion and palmar erythema are from chronic liver disease, how does this
affect your differential diagnosis?

A. Causes of chronic hepatitis were also considered in the differential diagnosis of this patient.
Chronic viral and autoimmune hepatitis can have acute exacerbation and present as an acute
 hepatitis. These diseases and some of the hereditary causes of chronic liver disease such as
Wilson's disease, hereditary hemochromatosis, and alpha-1-antitrypsin deficiency may be
more susceptible to acute hepatic injury from drugs or toxins. The very high aminotransferases
made alcoholic liver disease unlikely. Primary biliary cirrhosis and primary sclerosing
cholangitis do not present as an acute severe hepatitis, and in the chronic phase have very
high alkaline phosphatase.

View the correct answer.

What blood tests should be obtained to arrive at a diagnosis?

A. Important laboratory studies for liver diseases or other autoimmune disorders included in the
differential diagnosis are as follows: serologic testing for hepatitis A, B, and C; testing for
autoantibodies and IgG concentrations for autoimmune hepatitis; iron studies; serum
ceruloplasmin; alpha-1-antitrypsin level; and serum thyroid-stimulating hormone (TSH).

View the correct answer.

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© 2001 Medscape

Cite this: Richard W Goodgame. Acute Hepatitis in a 44-Year-Old Woman - Medscape - Oct 15, 2001.

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