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May 6, 2019

Image challenge: An uncommon cause of fever and altered levels of liver enzymes

What caused fever and cute onset left upper-quadrant abdominal pain in a 48-year-old man with HIV infection?

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Gastroenterology clinical image challenge: A 48-year-old man with HIV infection (PCR undetectable CD4 483) who used cocaine and was a heavy user of alcohol presented with jaundice, fever and acute onset left upper-quadrant abdominal pain. The pain was exacerbated by breathing. He had associated intermittent fevers and weight loss starting three weeks before presentation. He denied chest pain, nausea, vomiting or a change in bowel habits. Home medications included dolutegravir, emtricitabine, tenofovir disoproxil fumurate, and recent intake of tamoxifen, clomifene, and chorionic gonadotropin to counteract the effects of anabolic steroids that were used four months before presentation.

 

On examination, his temperature was 39°C, he was jaundiced and he had icteric sclera. The abdomen was soft and nondistended with minimal left upper quadrant tenderness. Blood work showed a white blood cell count of 7800/μL, hemoglobin of 12.2 g/dL, platelets of 378,000/μL, alanine aminotransferase 236 IU/L (upper limit of normal [ULN], 65 IU/L), aspartate aminotransferase 166 IU/L (ULN, 50 IU/L), total bilirubin 3.4 mg/dL (ULN, 1.2 mg/dL), direct bilirubin 2.6 mg/dL (ULN, 0.3 mg/dL), alkaline phosphatase 1064 IU/L (ULN, 120 IU/L), γ-glutamyl transferase (GGT) of 655 (ULN, 50 IU/L), protein of 73 g/L and albumin of 34 g/L. Lipase, lactate dehydrogenase and international normalized ratio were normal. Blood smear was unrevealing. A contrasted computed tomography scan showed multiple subcentimetric mesenteric and multiple retroperitoneal lymph nodes, the largest of which was 1.3 cm in the aortocaval area. All medications were discontinued. Hepatitis A, B and C serologies were negative, including hepatitis B and C PCR. Epstein-Barr virus IgM was negative and cytomegalovirus IgM was equivocal.

 

During this hospitalization, his cholestatic liver enzymes continued to rise, reaching a maximum value of total bilirubin of 7.8 mg/dL, direct bilirubin of 6.5 mg/dL, and three days later, alkaline phosphatase of 1637 IU/L and GGT of 1171 IU/L. Alanine aminotransferase and aspartate aminotransferase slowly down trended during the hospitalization. Magnetic resonance cholangiopancreatography showed an edematous enlarged liver with minimal peripheral intrahepatic dilatation without an obstructing mass or extrahepatic biliary ductal dilatation. Comprehensive autoimmune hepatic serology, iron studies, ceruloplasmin and alpha-1 antitrypsin labs were negative. The patient remained febrile, so a positron emission tomography computed tomography scan was done and it showed active and enlarged (2.8-cm) portocaval and porta hepatis lymph nodes. Bone marrow biopsy showed no lymphoproliferative disorder, but there was a small poorly formed granuloma (Figure).

 

What other testing would you obtain to evaluate this patient’s fever and abnormal liver enzymes?

 

To find out the diagnosis, read the full case in Gastroenterology or download our Clinical Image Challenge app through AGA App Central, which features new cases each week. Sort and filter by organ, most popular or favorites. AGA App Central is available in both the Apple App Store and Google Play.

 

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