An 18-year-old man from India who emigrated to the United States 4 weeks earlier presented with fever, malaise, and anorexia for 4 days. The patient reported ingesting no prescription, over-the-counter, or herbal medications; alcohol; or illicit drugs. On physical examination, he was afebrile and had scleral icterus and a palpable liver edge. Initial laboratory test results showed a white blood cell count of 3.9 × 103/μL and elevations in total bilirubin (5.6 mg/dL), direct bilirubin (3.6 mg/dL), alkaline phosphatase (240 U/L), aspartate aminotransferase (3322 U/L), and alanine aminotransferase (6114 U/L). His platelet count was 126 000 × 109/μL and prothrombin time was 17 seconds. Testing for viral hepatitis was performed (Table). Antinuclear, antismooth muscle, and liver/kidney microsomal antibodies were not detected. Immunoglobulin G (1294 mg/dL) and ceruloplasmin (22 mg/dL) levels were normal. Right upper quadrant ultrasonography demonstrated a liver span of 16 cm, a common bile duct measuring 0.3 cm, and patent hepatic vasculature.
Mikolajczyk AE, Chung NL. Diagnostic Testing for Acute Hepatitis. JAMA. Published online February 13, 2020. doi:10.1001/jama.2019.21895
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