beLIVER it or not Christel Seno, MD A Case of Jaundice of Unknown Etiology

1. “beLIVER it or not”
A case of jaundice of
undetermined origin
TUESDAY CASE PRESENTATION
Christel D. Seno, MD
January 31, 2017

2. OBJECTIVES
• To present an out-patient case of a 28 year old
male with jaundice of undetermined etiology
• To discuss the algorithm on approach to
patients with jaundice

3. CASE PROFILE: MB
28
Tricycle
driver
Ilocos
Sur
Male

4. CHIEF COMPLAINT
• jaundice

5. HISTORY
4 mos
• Flu- like symptoms à 3 weeks later: icteric sclera
2 mos
• jaundice, acholic stools, tea colored urine, pruritus
• Consult at Tagudin Hospital
• UTZ: unremarkable
• HbSAg reactive
• Meds : cetirizine and essential phospholipids

6. 1 month
• Persistence of jaundice, pruritus, acholic stools
• No follow up done
6 days
• Consult at Lorma due to persistence of above
symptoms

7. • PAST MEDICAL HISTORY:
No history surgeries, no past blood transfusions,
no history of PTB, no previous medications intake,
no previous Hepatitis vaccination
• FAMILY HISTORY:
No heredofamilial diseases, no hepatitis, no
cancer

8. PERSONAL, SOCIAL AND ENVIRONMENTAL HISTORY
• previous smoker 6 pack years
• Alcoholic beverage drinker usually drinks 1 2x2 gin
with friends 2-3 per week
• Fond of eating street food
• No tattoos and body piercing
• Denies illicit drug use
• Occupation: tricycle driver

9. • SEXUAL HISTORY
1 previous sexual partner

10. • REVIEW OF SYSTEMS:
• No weight loss, no anorexia
• No photophobia, no blurring of vision, no hyperemia
• No ear pain, no discharge, no tinnitus
• No epistaxis, no discharge
• No gum bleeding, no fissure
• No sore throat, no hoarseness
• No cough, no difficulty of breathing
• No flank pain, no dysuria, no hematuria, no frequency
• No polyphagia, no polydipsia, no polyuria, no heat intolerance
• No easy bruisability, no rashes

11. PHYSICAL EXAMINATION
• Awake, coherent, not in cardiorespiratory distress
• BP: 120/70 CR 81 RR 19 Temp 36.8
• SKIN: dry skin no pallor, with jaundice, no cyanosis, no
rashes,warm to touch, no palmar erythema
• HEENT:(+) icteric sclerae, , pink palpebral conjunctiva,
(-) tonsillipharyngeal congestion, (-) cervical
lymphandeonpathy, (-) neck vein distention

12. • CHEST & LUNGS: Symmetric chest expansion, (-)
gynecomastia, (-) retractions, (-) lagging,
bronchovesicular breath sounds
• Abdomen: Flabby, soft, normoactive bowel
sounds, (-) tenderness, (-) spider angioma(-)
hepatomegaly, (-) splenomegaly, (-) ascites
• Extremities:(-)cyanosis, (-) edema,

13. LABORATORY RESULTS
LAB RESULTS
Hbs Ag Reactive
Anti HCV Non Reactive
Anti HBc IgM Non reactive
Anti HBc IgG Non reactive
Hepa A IgM Non- reactive
Anti- HBe Non- reactive

14. LABS RESULT REFERENCE
VALUES
Alkaline
Phosphatase
188.2 35-104
ALT 251.46 323.4 0-45
AST 343.56 208.1 0-35
Total bilirubin 351.9 3.4-17.1
Direct bilirubin 226.44 0-3.4
Indirect bilirubin 125.46 3.4-13.7
5x
7x
20x
66x 64%
9x
7x
5x

15. LABS RESULT REFERENCE
VALUE
Total protein 89.88 (63-83)
Albumin 48.14 (48-55)
Globulin 41.74 (21-28)
A/G ratio 11.53:10 14-27:10
Prothrombin time 24.7 (control 12.1) 13.7 (after Vit K)
INR 2.21 1.09 (after Vit K)

16. • Whole abdominal UTZ:
Liver is not enlarged, hepatic echotexture is within
normal limits.
Bile ducts not dilated. Gallbladder is contracted and measures
5.2 x 1.3 cm
No luminal stone noted. Pancreas, spleen is unremarkable

17. OPD COURSE
• On the first hospital visit
Essentiale forte BID
Branched chain amino acid 2x a day
Ursodeoxycholic acid once a day
Vitamin K 1 amp IV,
Diphenhydramine 50mg/tab BID PRN for pruritus.

18. Suggested abdominal CT scan and referral to gastro
service.
Repeat ALT/AST

19. • On the second hospital visit
still icteric and jaundice
decreased pruritus
less acholic stools
no complaints of abdominal pain, nausea and
vomiting, fever nor loss of appetite.

20. • seen by gastro rotator
• requested to have upper abdominal CT scan , HbSAg
titer, anti HAV titer
• Phospholipids + Multivitamins BID continued,
ursodeoxycholic acid was increased to twice a day

21. QUESTIONS
1. What is the etiology of this patient’s
prolonged jaundice?
• Cholestatic vs Hepatocellular?

22. History:
- flu-like symptoms prior to jaundice
- Denies previous BT, hepatotoxic
meds, illicit drug use, tattooing
- 1 sexual partner
- Alcohol intake: 140gms/drinking
session
PE:
- Jaundice
- (-) spider angioma, ascites or other
signs of liver cirrhosis
- No RUQ tenderness

23. TB 351.9
Dir Bil 226.44 (64% of the total)
Ind Bil 125.46
(Direct Bilirubinemia)
ALT 251.26 (5x elevated)
AST 343.56 (7x elevated)
(Ratio: 1.3:1)
Alk Phos 188.42
(UL of NV: 104, slightly elevated)
Albumin 48.14 (normal)
PT 24.1 (elevated), INR 2.21

24. QUESTIONS
1. What is the etiology of this patient’s jaundice?
• Cholestatic vs Hepatocellular?
2. If hepatocellular, what is the specific
etiology?

25. 140 gm/drinking session
~2-3x/week
UTZ: unremarkable

26. Points
for
Presence
and
elevated
globulin
Predominant
ALT/AST
elevation
Points
against
male
Presence of viral
hepatitis marker:
HBsAg reactive
ANA
negative

27. History:
- flu-like symptoms prior to jaundice
LAB RESULTS
Hepa A IgM Non- reactive

28. LAB RESULTS
Anti HCV Non Reactive

29. LAB RESULTS
Hbs Ag Reactive
HEPATITIS D INFECTION
• COINFECTION
• SUPER INFECTION
HEP E DOESN’T PRESENT
WITH PROLONGED JAUNDICE

30. ELEVATED ALT/AST

31. LAB RESULTS
Hbs Ag Reactive
Anti HBc IgM Non reactive
Anti HBc IgG Non reactive
Anti- HBe Non- reactive
Hbe Ag Non-reactive

33. QUESTIONS
1. What is the etiology of this patient’s jaundice?
• Hepatocellular
2. If hepatocellular, what is the specific etiology?
• Viral hepatitis, Alcoholic Hepatitis
3. How do I interpret the hepatitis profile? Is this a case of false negative
lab?
4. What other diagnostics would be appropriate for this case?

34. HEPATITIS PROFILE: HOW DO WE INTERPRET?

35. HEPATITIS DIAGNOSTIC DILEMMA
• HBsAg without detectable anti HBc
Mechanisms:
1.lack of responsiveness to HBcAg in immune compromise
patients
2. false negative anti-HBc due to assay insensitivity
Ref:Victorian Infectious Diseases Reference Laboratory

36. PLANS FOR THE PATIENT
• Repeat HBsAg QUANTITATIVE, HBV DNA
• Repeat AST, ALT

37. THANK YOU