Transcript ID Case Conference 10-10-07

ID Case Conference 10-24-07
Gretchen Shaughnessy, MD
Clinical Fellow
Dept of Infectious Diseases
CC: Abdominal Pain
40 year old woman presents to the ED with 5 day
history of nausea and vomiting that has progressed to
mid-epigastric abdominal pain yesterday. Pain is
constant, nonradiating pain. Pain is not associated with
food or bowel movements.
Decreased appetite, normal bowel movements, no
diarrhea.
+Fevers +Chills +Myalgias for the past few days
+15 lb weight loss over the past 4 months (blames
emotional stress – going through divorce)
PMH
h/o C-section
h/o heavy menstrual bleeding and “borderline anemia”
Social History – works at a school cafeteria (handling
and serving food). No recent travel, no tobacco,
alcohol, or drugs. No history of risky sexual behavior.
Lives in Morrisville, has one son. No pets.
Family History – heart disease
Medications
None
Allergies - none
Physical Exam
Tmax 39.4, Tcurrent 38.6. BP 106/77 HR 112 RR 14
INAD
No e/e on OP, no scleral icterus, pale conjunctiva. Dry mucous
membranes
No cervical, supraclavicular, axillary, or inguinal lymphadenopathy. No
thyromegaly. No JVD.
Decreased breath sounds at the bases
RRR no m/r/g
Soft, nondistended, mild TTP in the mid epigastrium, well-healed
surgical scar. Liver palpable 4cm below costal margin span 14-15cm.
Pulses 2+ and equal in all 4 extremities. Mild nonpitting edema in B
ankles.
No joint tenderness, no CVA tenderness.
Neurologic exam grossly intact. No asterixis.
Skin exam – no breaks in skin, no lesions, no rashes
Labs
132 97
3.6 27
8.1
10
94 1.9
0.7
2.6
Ferritin 462^
Hgb A1C 7.0
AST 584^
7.1
ALT 412^
3.6
158
Alk Phos 84
23.0
GGT 24
N-3.3
MCV 65v
TBili 0.6
L-0.3
TIron 11v
M-0.1
Transferrin 274v Lipase 45
E-0.0
TIBC 345v
B-0.0
B12 733
Folate 15.0
Retic 1%v
Abs retic ct 34v
Hgb content 19.8v
Radiology
RUQ U/S - 1. Hepatosplenomegaly. 2. Sludge
noted in the gallbladder without gallstones.
There is variable gallbladder wall thickening
varying from 3-6.9 mm, however the gallbladder
is not distended. There is therefore no evidence
for cholecystitis.
Radiology (cont)
CT Abd/Pelvis - 1. There is no pancreatic mass. 2. No
gallstone is visualized. 3. There is a large amount of
pericholecystic fluid suggestive of acalculous
cholecystitis. 4. Periportal edema is noted. 5. Fluid
noted in the endometrial canal. 6. There are multiple
clearly defined hypodensities in the liver with dilated
hepatic vein representing congestion of liver secondary
to heart failure or multiple liver lesions. Further
evaluation with MRI is suggested.
Radiology (cont)
MRI Abdomen - Patchy enhancement of the hepatic
parenchyma without focal mass lesion with periportal
edema-findings which can be seen with hepatitisrecommend clinical correlation. 2. Bilateral pleural
effusions with associated consolidation. 3. Ascites and
periportal edema. The gallbladder wall is also thickened
which may be secondary to the ascites and correlation
with recent ultrasound is recommended.
Discussion
Further Diagnostic Tests
ANA neg
Anti-smooth muscle aby neg
Antimitrochondrial aby neg
Monospot neg
HepBCore total aby neg
HepBCIgM neg
HepBSAg neg
HepBSAby neg
HepB viral load neg
Hep C negative
CMV IgM and IgG neg
GC, Chlamydia neg
Haptoglobin 338 (elevated)
LDH 2851 (elevated)
Serum abys
IgG 707 (normal)
IgM 337 (elevated – nl range
25-210)
IgA 228 (normal)
HIV ELISA neg
“A Diagnostic test was performed…”
HEPATITIS A IGM+
Hepatitis A – Brief Overview
27nm nonenveloped, icosahedra, positive stranded RNA virus in
Heparnavirus genus of Picornaviridae.
Worldwide infection, declining incidence in U.S. thanks to
vaccination
Spread via fecal oral-route
Can be associated with outbreaks linked to food (especially
shellfish). More resistant to heat than other picornaviridae
incubation at 60degrees centigrade for 10-20 hours only results in partial
inactivation
Complete inactivation seen at 70C after 4 minutes, 80C after 5 seconds
Steaming may not be enough
HEPATITIS A VIRUS
http://www.cdc.gov 10/23/07
http://www.cdc.gov 10/23/07
Hepatitis A – Clinical Manifestations
Usually an acute, self limited illness
Rarely leads to fulminant hepatic failure, poor prognosis
Risk factors include underlying liver disease.
Incubation period averages 30 days (15 to 49 days)
Infection can be silent or subclinical in children
Most common physical findings are jaundice and HSM
(70-80% of symptomatic patients)
RISK FACTORS ASSOCIATED WITH
REPORTED HEPATITIS A,
1990-2000, UNITED STATES
Sexual or
Household
Contact 14%
International
travel 5%
Unknown
46%
Men who have
sex with men
10%
Injection drug use
6%
Child/employee in
day-care 2%
Other Contact
8%
Source: NNDSS/VHSP
Contact of daycare
child/employee
6%
Food- or
waterborne
outbreak 4%
http://www.cdc.gov 10/23/07
Extrahepatic manifestations of
Hepatitis A
Evanescent rash 11%
Arthralgias 14%
Leukocytoclastic
vasculitis
Glomerularnephritis
Cryoglobulinemia
TEN
Myocarditis
Optic Neuritis
Transverse myelitis
Thrombocytopenia
Aplastic anemia
Red Cell Aplasia
Hematologic Abnormalities in
Hepatitis A
Thrombocytopenia, Aplastic anemia, Red Cell Aplasia,
rare cases of hemophagocytic syndrome, TTP
Most of the cases in the literature in the pediatric
population
Anemia and thrombocytopenia usually self limited
Acute transient pure red cell aplasia generally responds
well to transfusions and corticosteroids
Hepatitis Associated Aplastic
Anemia
Study of hepatitis associated aplastic anemia
from 1990-1996, 7/10 patients referred to NIH
showed good response to immunosuppression.
3/10 died from complications of stem cell
transplantation.
(in this study none had Hepatitis A)
Our patient
Good outcome, improved with symptomatic care.
LFTs completely normal 5 months after hospitalization.
Patient received blood transfusion during
hospitalization. Maintained counts after discharge.
Never received corticosteroids. Sent home on PO iron.
Hospital Epidemiology and Public Health department
involved, decided when this patient could go back to
work.
No reported cases of hepatitis A from school cafeteria.
Sources
Walia A, Thapa BR, Das R. Pancytopenia in a child associated with hepatitis A infection.
Trop Gastroenterol. 2006 Apr-Jun;27(2):89-9.
Smith D, Gribble TJ, Yeager AS, Greenberg HB, Purcell RH, Robinson W, Schwartz HC.
Spontaneous resolution of severe aplastic anemia associated with viral hepatitis A in a 6-year-old
child.
Am J Hematol. 1978;5(3):247-52.
Maiga MY, Oberti F, Rifflet H, Ifrah N, Cales P. Hematologic manifestations related to hepatitis A
virus. 3 cases. Gastroenterol Clin Biol. 1997;21(4):327-30.
http://www.cdc.gov/travel/diseases/ 10/23/07.
UpToDate 2007.
Brown KE, Tisdale J, Barrett AJ, Dunbar CE, Young NS. Hepatitis-associated aplastic anemia. N
Engl J Med. 1997 Apr 10;336(15):1059-64.
Tomonari A, Hirai K, Aoki H, Mima N, Kashiwagi S, Masuda K, Shinohara M, Kosaka M. Pure red
cell aplasia and pseudothrombocytopenia associated with hepatitis A. Rinsho Ketsueki. 1991
Feb;32(2):147-51.
Della Loggia P, Cremonini L. Acute hepatitis-associated pure red cell aplasia: a case report. Infez
Med. 2002 Dec;10(4):236-8.