Hepatitis

1
Hepatitis

• Dr. Alex Ulitsky
• Dr. Samer Gawrieh
• 8/6/07

2
HPI

• Pt is a 27 y/o previously healthy female who came
  to a walk-in clinic complaining of 3 days of
  vaginal burning/discomfort and painful oral
  ulcers
• On exam, small shallow vaginal ulcers were noted
  on posterior wall, as well as oral ulcers.
• Pt was given Metronidazole vaginal gel and
  lidocaine jelly

3
HPI Continued

• Her vaginal burning improved and oral ulcers
  resolved after 2 days.
• 3 days later she began to have fevers to 102F,
  muscle aches, fatigue and noted dark urine and
  severe diffuse itching
• Denied jaundice, icterus, abdominal distention or
  pain, no nausea, vomiting, diarrhea
• Pt seen by PCP, work-up initiated

4
PMH/PSH

• POTS syndrome (postural orthostatic tachycardia)
• RBBB
• No surgeries
• Soc Hx Pt is sexually active with her husband
  only, no hx of STDs no hx of ETOH use or drugs,
  no travel
• Fam Hx No hx of liver or GI disorders.

5
Medications

• Nadolol 40mg po daily
• Birth control pills
• Claritin 10 mg po daily
• Metrogel vaginal 0.75
• Lidocaine vaginal gel 2
• No herbals or OTC drugs

6
Physical Exam

• Gen NAD
• HEENT mild scleral icterus, mild pharyngitis
  with tonsillar exudates bilaterally
• Neck posterior cervical LAD bilat, non-tender
• Abd soft, n/t, liver 12 cm in span, n/t, spleen
  tip felt, no fluid
• Skin no spiders, no palmar erythema, no jaundice

7
Labs

• WBC 3.4 57 Neut 25 Lymph 12 Mono,
• Hg 13.5 Plts 130
• Tbili 4.6 Dbili 2.4 Tprot 6.9 Alb 3.5 ALT 320 AST
  190 Alk phos 210 INR 0.8
• HSV I II IGG positive HSV NAAT negative
• GC/Chlamydia negative HIV negative
• Monospot negative EBV IGG negative
• Parvovirus IGG/IGM negative
• Acute viral hepatitis panel negative
• ANA negative

8
Patient Course

• Pts vaginal and oral sores completely resolved.
• Her fevers resolved as well, but she continued to
  feel tired, c/o sore throat and muscle aches
• EBV IGM was sent and was strongly positive
• 2 weeks later, she feels well except for mild
  sore throat
• Repeat LFTs 3 weeks after initial presentation
  normalized except for ALT of 51

9
Final Diagnosis

• Acute infectious mononucleosis

10
Discussion

• EBV is transmitted by contact with oral
  secretions, usually by kissing
• Common symptoms include sore throat, fatigue,
  tender lymphadenopathy and fever
• Genital ulcerations have been described in only
  10 case reports as a presenting symptom of IM
• LFTs are abnormal in about 90 of cases, usually
  with mildly elevated transaminases bilirubin is
  elevated 40 of the time
• This can rarely progress to fulminant hepatitis

11
Discussion

• Diagnosis is usually made by monospot or
  heterophile antibody test
• This test is positive in only 40 of patients
  during the first week of illness, 80-90 during
  3rd week
• Thus important to order EBV IgM as a marker of
  acute infection if monospot is negative and
  clinical suspicion is high.

12
References

• Cheng,S.X., et al, Genital ulcers caused by EBV
  J of Amer Academy of Derm. 51(1) July 2004 68-74
• Harrisons Textbook of Medicine, 15th edition