Syndromic Approach—Fever and Jaundice
How to Cite: Priv. Pract. Infect. Dis., 2022, 2(3): 10; doi.org/10.55636/ppid2030010.
© 2022 Copyright by Author. Licensed as an open access article using a CC BY 4.0 license.
A 64-year-old male was admitted with fever, feeling fatigued and with significant jaundice for the past week. He is a moderate drinker of alcohol (3–6 cans of beer per day), and he just returned from a photographic safari trip to the Democratic Republic of the Congo in Africa. He had not lost weight and did not complain of headache, respiratory, cardiac or GU symptoms or rash. He had one episode of diarrhea the day prior to admission.
Working up jaundice with a fever will depend on many factors including history (drug or alcohol consumption, travel, previous surgery), physical exam and laboratory values. These all may distinguish the etiology of jaundice and fever in a patient who could have biliary obstruction, hemolysis, hepatic inflammation or others . Historically, this patient had a moderate history of EtOH use. Alcoholic hepatitis in this patient might arise if the AST is much higher than the ALT (which could be normal) and there are no signs of biliary obstruction . An ultrasound is an easy method to rule out obstruction, liver inflammation or abscess. His travel to Africa with some diarrhea might bring up the possibilities of malaria, dengue or enteric fevers including typhoid . Amebic liver abscesses in a traveler would be remote. The P.E. allows us to see changes in chronic liver disease (jaundice, hepatomegaly, splenomegaly, ascites, caput medusae, spider angiomata, palmar erythema and gynecomastia, to name a few) . The lab values are important to review. [Table 1] Bilirubin may be conjugated (biliary obstruction, intrahepatic cholestasis, hepatic injury), or unconjugated (hemolytic anemia, impaired hepatic uptake commonly known as Gilberts) .
On exam, he was obese (BMI 35), jaundiced and had some RUQ pain. There were no signs of chronic liver disease on exam. His heart and lungs were normal, but he had 2 + edema in his lower extremities and no rash.
His labs were remarkable for a WBC of 12,000 cells/mm3 with a slight left shift (bands were 10%), hemoglobin and hematocrit were 14 and 34 g/dL and his platelets were 100 ˆ 103/L. His transaminases were each in the 200–300 U/L range, and his direct bilirubin was 5 mg/dL. His alkaline phosphatase score was 420 U/L. Ultrasound of the abdomen showed a gall bladder with some stones and a dilated common bile duct of 8 mm. The HIDA scan revealed a blocked common bile duct.
This patient, based on his P.E., laboratory values and ultrasound, had a blockage of his common bile duct from cholelithiasis. He underwent an ERCP with complete resolution of his symptoms, and a laparoscopic cholecystectomy 2 weeks later .
This research received no external funding.
Conflicts of Interest
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