Aaron Woofter, MD; Norman Sussman, MD Series Editor: Richard Goodgame, MD


February 16, 2006

Case Presentation

A 59-year-old Indian man became ill during a trip to India and now presents with jaundice.

The patient is a long-time resident of the United States. Two weeks ago he returned from a 1-month trip to his native home in India. One week prior to his return from India, he developed a mild illness characterized by diarrhea, nausea, and 1 episode of vomiting. No one else associated with his trip had a similar illness. Since his return, he has had fever to 102° F, associated with chills and night sweats. He believes the fever occurs every other day. He has lost 20 pounds during these 2 weeks. Five days ago he was evaluated by his primary care physician for these complaints. A malaria smear was negative. The main abnormality found during that evaluation was abnormal liver chemistries. Three months ago his liver chemistries had been normal (they had been tested because of chronic treatment with pravastatin). He was referred to our hospital for worsening liver chemistries, increasing international normalized ratio (INR), and the recent appearance of jaundice.

The patient has no prior history of gastrointestinal or liver disease. He is followed by his primary care physician for stable type 2 diabetes mellitus, hypertension, and hyperlipidemia for which he has taken metformin, glimepiride, pravastatin, and hydrochlorothiazide for many years. He did not take any new medications for his recent trip to India, including no prophylaxis for malaria or traveler's diarrhea. He took no local medicines or herbal treatments and had no known exposure to toxins. He rarely drinks alcohol, never uses illegal drugs, and has had no new sexual partners. There is no family history of gastrointestinal or liver disease.

Physical examination revealed normal vital signs except for a temperature of 101.3° F. He was obese. There was no edema, cyanosis, or finger clubbing. There were no stigmata of chronic liver disease. There was mild scleral icterus. There were no palpable lymph nodes. The heart and lung examination was normal. The abdomen was obese but otherwise normal. There was no palpable spleen and the liver edge was smooth, soft, and nontender, palpable just below the right costal margin. The remainder of the examination was unremarkable.

The patient came to our hospital with laboratory and imaging reports from the referring physicians. Results of complete blood count, including the peripheral blood smear, had been completely normal twice in the last 5 days. The basic metabolic panel, including electrolytes, glucose, and renal function tests, had also been normal. Serum albumin and total protein were also reported as normal. The bilirubin level had risen from 3.5 to 5.0 mg/dL, and his serum aminotransferases had increased from approximately 1000 to 3000 units/L. Findings on ultrasound examination had revealed only mild steatosis and mild hepatomegaly. Magnetic resonance imaging (MRI) scan was also normal, except for a small lesion in the right lower lobe suspicious for a hemangioma.

Results of laboratory studies performed at our institution revealed the following: normal complete blood count and basic metabolic panel: total bilirubin, 9.2 mg/dL; direct bilirubin, 7.7 mg/dL; alanine aminotransferase (ALT), 4180 units/L; aspartate aminotransferase, 3465 units/L; and alkaline phosphatase, 160 units/L. The INR was initially 1.2 and increased to 1.5 in 24 hours, and prothrombin time increased from 16 seconds to 18 seconds.


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