A patient between 20 – 30 years of age with jaundice and pain in joints and muscles

A previously healthy individual in the 20 – 30 years age bracket sought medical attention at the emergency unit late in the evening with malaise and generalised pain in muscles and joints. The symptoms had emerged in the previous few days. The patient complained of a slight cough, sore throat, flatulence but no abdominal pain. The patient reported an incident of pain in the lower part of the abdomen two weeks previously, and multiple occasions of vomiting one week before the contact, however the abdominal symptoms had passed before the visit to the emergency unit. The patient was unaware of any allergies, and did not use any kind of medication on a regular basis.

The laboratory results were as follows: ALT 989 U/l ((10) – 70), GGT 299 U/l ((10) – 80) and ALP 143 U/l (35 – 105). CK, electrolytes, bilirubin, creatinine, BUN, uric acid and blood glucose were within normal ranges. The patient consulted the GP the following day, and the GP noted slight jaundice of the conjunctiva. However, the finding was uncertain and blood tests showed a normal bilirubin value of 10 μmol/l ((9) – 25). AST was at 347 U/l (15 – 45). Clinical examination and auscultation of heart, lungs and abdomen provided no additional information.

At the hospital a thorough history was taken, and no specific hereditary conditions were noted. There were no unusual work-related or social exposures and the patient had not been abroad for the last 2 years. The patient had used no medication and did not abuse alcohol. The patient had eaten sushi for dinner the evening before the onset of joint pains. At admission the clinical examination of heart and lungs yielded no significant pathological findings, although a slight murmur was noticed over the right carotid artery. The patient did not present with a fever. The liver was noted as being slightly enlarged, the abdomen otherwise soft and with no tenderness. There was no blood in the stool and the rectal examination revealed nothing pathological. INR was 1.0 and albumin was 42 g/l (36 – 45). Ferritin and IgM were slightly elevated at 472 μg/l (30 – 400) and 2.3 g/l (0.4 – 2.1), respectively. AST was 295 U/l (15 – 45) and LDH 244 U/l (105 – 205). Electrolytes, arterial blood gas and CBC were all within normal ranges.

The tests showed no anti-smooth muscle antibodies, nor was there a positive ANA or anti-mitochondrial antibody titre, which cast doubt on the probability of an autoimmune hepatitis. Auto-antibodies of the following types were specifically screened for: DNA, RNP, Sm, SSA, SSB, Scl-70, CENP-B, Jo-1, fibrillarin, RNA polymerase III, Rib-P, PM-Scl, PCNA and Mi-2 to exclude the likelihood of an autoimmune hepatitis, lupus erythematosus, systemic sclerosis, polymyositis and mixed connective tissue disease. Levels of IgG, IgA, copper and iron were not elevated. The tests for Hepatitis A, B, C and Epstein Barr virus yielded negative results. A positive titre for cytomegalovirus IgG was discovered, however IgM was not present, making it unlikely that the infection was recently acquired.

Ultrasonography revealed the liver to be of normal size, but slightly hyperechogenic; however, no lesions, other pathology or parenchymal damage were detected.

Since the patient was showing signs of improvement and did not appear jaundiced, it was planned to discharge him from the hospital after two days. ALT had dropped to 604 U/l ((10) – 70) and transaminase and lactate dehydrogenase were also returning to normal levels.

The GP checked the transaminases one week after discharge, and these showed further improvement. Another consultation was scheduled one month later, during which the patient and GP in unison consulted various sources on the internet including UpToDate and the Norwegian Electronic Medical Handbook. The patient was curious as to the cause of the liver disease, and there was also a public health interest in finding any hepatotoxic agents in the local area.

Although some of the antibody tests were reperformed to reduce risk of a false negative, the results were unchanged. However, the patient had discovered other diseases online which could give rise to the symptoms concerned, among them hepatitis E.

The patient had no known contact with animals. Although there was no obvious route of transmission, the GP decided to test for this disease and sent the blood samples to the Norwegian Institute of Public Health. This test was taken two months after the initial visit to the GP. IgG and IgM against hepatitis E virus (HEV) were detected in two separate tests with two separate reagents. No HEV RNA was found in the subsequent PCR analysis.

The patient showed no further symptoms of disease and was in good health.