Thread by @medrants

1/
#UncleBob shares his reflections #5goodminutes) on a #VMR from last Wed- clinicalproblemsolving.com/wp-content/upl…

This was a complex case that started w/ chest pain, fevers, weakness, etc. After seeing the labs, I guessed the diagnosis.
@CPSolvers @rabihmgeha @DxRxEdu @RosenelliEM

2/
Cognitive autopsies are always valuable - for mistakes and for guessing the correct answer. Did I make a sound diagnosis, or was I just lucky? Why did I suggest Hepatitis A?

Let's examine the liver tests and how they stimulated my thinking:

3/
I divide liver tests into 3 categories - cellular destruction:
AST 2160 ALT 1750; obstruction: alkaline phophatase 240 T Bili 3.4 Direct 2.4; loss of factory function: albumin 2.3 but PT not reported.

Thus, I emphasized massive acute cellular destruction.

4/
What can cause such massive cellular destruction?

Shock - no evidence of shock
Drugs - no evidence of acetaminophen or herbal "remedies"
Viruses - A, B, C, D, E, HSV, EBV, CMV

5/
I do not expect any of the genetic diseases to have levels this high. Autoimmune hepatitis usually has a more insidious presentation.

We were not given any reason for B, C, D or E. B & C - IV drugs, possibly sex (B>C), tattoos. E usually travel overseas

6/
HSV is certainly possible but very unusual
EBV and CMV probably usually do not have elevations at this level
A is ubiquitous - need a diet history - but certainly presents like this.

7/
I would have gotten the US that they got which excluded severe hepatobiliary disease. I think the alkaline phosphatase would be higher with cholangiocarcinoma or common duct stone or primary sclerosing cholangitis.

8/
Apparently severe acute hepatitis A is an unusual hospital diagnosis. @tony_breu shared a wonderful article he authored: A Multicenter Study Into Causes of Severe Acute Liver Injury cghjournal.org/article/S1542-… - hepatitis A was 1/400+

9/
In retrospect I think my reasoning was solid. Most hepatitis A does not lead to hospital admission. The liver tests stimulated my reasoning. Hepatitis A likely caused enough stress to produce the other symptoms.