ID Case Conference 10-24-07ID Case Conference 10-24-07

Gretchen Shaughnessy, MDClinical FellowDept of Infectious Diseases

CC: Abdominal PainCC: 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)

PMHPMH

h/o C-sectionh/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

MedicationsMedications

None

Allergies - none

Physical ExamPhysical Exam

Tmax 39.4, Tcurrent 38.6. BP 106/77 HR 112 RR 14INADNo e/e on OP, no scleral icterus, pale conjunctiva. Dry mucous membranesNo cervical, supraclavicular, axillary, or inguinal lymphadenopathy. No thyromegaly. No JVD.Decreased breath sounds at the basesRRR no m/r/gSoft, 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

LabsLabs

23.03.6

7.1158

1323.6

9727

10

0.794 Ferritin 462^

Hgb A1C 7.0AST 584^ALT 412^Alk Phos 84GGT 24TBili 0.6Lipase 45

N-3.3L-0.3M-0.1E-0.0B-0.0

8.11.92.6

MCV 65vTIron 11vTransferrin 274vTIBC 345vB12 733Folate 15.0

Retic 1%vAbs retic ct 34vHgb content 19.8v

RadiologyRadiology

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.

Radiology (cont)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.

Radiology (cont)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.

Discussion

Further Diagnostic TestsFurther Diagnostic Tests

ANA negAnti-smooth muscle aby negAntimitrochondrial aby negMonospot negHepBCore total aby negHepBCIgM negHepBSAg negHepBSAby negHepB viral load negHep C negative

CMV IgM and IgG negGC, Chlamydia negHaptoglobin 338 (elevated)LDH 2851 (elevated)Serum abys

IgG 707 (normal)IgM 337 (elevated – nl range 25-210)IgA 228 (normal)

HIV ELISA neg

“A Diagnostic test was performed…”“A Diagnostic test was performed…”

HEPATITIS A IGM+

Hepatitis A – Brief OverviewHepatitis A – Brief Overview

27nm nonenveloped, icosahedra, positive stranded RNA virus in Heparnavirus genus of Picornaviridae. Worldwide infection, declining incidence in U.S. thanks to vaccinationSpread 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 inactivationComplete inactivation seen at 70C after 4 minutes, 80C after 5 secondsSteaming may not be enough

HEPATITIS A VIRUS

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

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

Hepatitis A – Clinical ManifestationsHepatitis A – Clinical Manifestations

Usually an acute, self limited illnessRarely 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 childrenMost common physical findings are jaundice and HSM (70-80% of symptomatic patients)

Unknown 46%

Contact of day-care

child/employee 6%

Other Contact 8%

Child/employee in day-care 2%

Food- or waterborne

outbreak 4%

Injection drug use 6%

Sexual or Household

Contact 14%

Men who have sex with men

10%

International travel 5%

RISK FACTORS ASSOCIATED WITH REPORTED HEPATITIS A,

1990-2000, UNITED STATES

Source: NNDSS/VHSP

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

Extrahepatic manifestations of Hepatitis AExtrahepatic manifestations of Hepatitis A

Evanescent rash 11%Arthralgias 14%Leukocytoclastic vasculitisGlomerularnephritisCryoglobulinemiaTEN

MyocarditisOptic NeuritisTransverse myelitisThrombocytopeniaAplastic anemiaRed Cell Aplasia

Hematologic Abnormalities in Hepatitis AHematologic 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 populationAnemia and thrombocytopenia usually self limitedAcute transient pure red cell aplasia generally responds well to transfusions and corticosteroids

Hepatitis Associated Aplastic AnemiaHepatitis 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)

Our patientOur 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.

SourcesSources

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.