A jaundiced man

27 Jan
2009

 

Here is a puzzle for you to consider.  One of my residents told me that I needed to post more clnical problems.

Patient is  28-year-old white male with new jaundice.  His only significant medical history is a 6-month history of grand mal seizures with a normal head CT.

He has noticed pale stools and dark urine for 3 days.  He complains of epigastric pain.

Social history – previous work as an EMT ambulance worker. Had significant blood exposure 6 months ago (saved the life of a woman who jumped out of window).

His exam was remarkable for jaundice and a slightly enlarged liver.

Lab tests:

Normal CBC, normal basic metabolic panel

Liver tests

Destruction   Obstruction   Factory  
AST 966 alk phos 188 albumin 3.9
ALT 1784 T. Bili. 7.5 INR

1.1

 

 

 

 

 

 Direct bilirubin – 5.8

Your job:

construct a differential diagnosis and make your best guess for the correct answer.  We do know the answer.

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7 Responses to A jaundiced man

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John

January 27th, 2009 at 2:44 pm

I’m going to guess gallstones. Abdominal CT or sonography to confirm. Please be kind to my guess by the way, I’m in my 3rd year of a 6 year med program and I have not taken laboratory diagnosis.

Avatar

david

January 27th, 2009 at 3:18 pm

dilantin induced hepatitis

Avatar

Grant

January 27th, 2009 at 5:58 pm

hep c?

Avatar

alexa-blue

January 27th, 2009 at 7:38 pm

Pt’s enzymes c/w icteric phase hepatitis (despite elevated dbili, overall picture is more suggestive of hepatocellular damage); with seizures makes me think about Wilson’s disease. Blood exposure suggests the usual stuff. Dilantin a good thought, though you’re still left trying to explain the new seizures. Can get a post-ictal fulminant hepatitis. I guess should also think about alcohol, though that wouldn’t really explain chronic seizures, and ALT/AST pattern is wrong. Would get the usual hep stuff (infectious panels, tylenol), ceruloplasmin, dilantin level (if he’s on it). Second line – autoimmune stuff, ferritin, HIV. Awaiting smarter people.

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Mogi

January 27th, 2009 at 10:54 pm

The coincident onset of the seizures and exposure suggest an infectious etiology, such as an unusual presentation of HCV or HIV?

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shadowfax

January 28th, 2009 at 1:58 am

Differential Diagnosis. Diff-er-en-ti-al Di-a-gno-sis. Hmm. Can’t say I’ve heard of the term before. What is it?

The boy be blocked. Get pictures, call GI or surgery, send upstairs. Next!

If you want to be fancy, I might suggest that the malignancy blocking his CBD may have a brain met causing the seizures. But that’s super speculative….

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Number Seven

January 28th, 2009 at 1:26 pm

Has he been taking anything for the seizures? The values seem suggestive of biliary obstruction rather than than an infectious process or toxicity, but never hurts to ask. He could have been having a malignancy for the last six months that has been causing the seizures that just now caused a blockage.

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