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ID Case Conference 10-24-07

ID Case Conference 10-24-07. Gretchen Shaughnessy, MD Clinical Fellow Dept of Infectious Diseases. CC: Abdominal Pain.

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ID Case Conference 10-24-07

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  1. ID Case Conference 10-24-07 Gretchen Shaughnessy, MD Clinical Fellow Dept of Infectious Diseases

  2. 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)

  3. 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

  4. Medications • None • Allergies - none

  5. 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

  6. 7.1 10 132 97 3.6 158 27 0.7 3.6 23.0 94 Labs 8.1 Ferritin 462^ Hgb A1C 7.0 AST 584^ ALT 412^ Alk Phos 84 GGT 24 TBili 0.6 Lipase 45 Retic 1%v Abs retic ct 34v Hgb content 19.8v 1.9 2.6 N-3.3 L-0.3 M-0.1 E-0.0 B-0.0 MCV 65v TIron 11v Transferrin 274v TIBC 345v B12 733 Folate 15.0

  7. 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.

  8. 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.

  9. Radiology (cont) • MRI Abdomen - Patchy enhancement of the hepatic parenchyma without focal mass lesion with periportal edema-findings which can be seen with hepatitis-recommend 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.

  10. Discussion

  11. 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 Further Diagnostic Tests

  12. “A Diagnostic test was performed…” • HEPATITIS A IGM+

  13. 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

  14. HEPATITIS A VIRUS http://www.cdc.gov 10/23/07

  15. http://www.cdc.gov 10/23/07

  16. 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)

  17. RISK FACTORS ASSOCIATED WITH REPORTED HEPATITIS A, 1990-2000, UNITED STATES Source: NNDSS/VHSP http://www.cdc.gov 10/23/07

  18. Evanescent rash 11% Arthralgias 14% Leukocytoclastic vasculitis Glomerularnephritis Cryoglobulinemia TEN Myocarditis Optic Neuritis Transverse myelitis Thrombocytopenia Aplastic anemia Red Cell Aplasia Extrahepatic manifestations of Hepatitis A

  19. 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

  20. 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)

  21. 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.

  22. 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.

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