54 CLINICAL FOCUS
54 CLINICAL FOCUS
14JULY 2023
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Case Report
An intriguing instance of icterus
Clinical detective work is required to crack this curious case of jaundice .
Dr Behzad Rafiee GP in Brisbane , Queensland .
TED is a 48-year-old real estate agent who presents with a sore throat that he has had for three days . He tested negative for COVID-19 on a rapid antigen test . His medical history includes depression , eczema and plantar fasciitis . Ted is an ex-smoker and does not drink alcohol . He uses sertraline 100mg daily and methylprednisolone ointment as required .
Ted has no family history of note and no recent history of overseas travel .
Clinically , Ted looks well but has scleral icterus . He is afebrile and normotensive . He has mild pharyngitis . There is no hepatosplenomegaly and cardiorespiratory examination is unremarkable .
A provisional diagnosis of infectious mononucleosis is made and blood work is requested given the clinical jaundice .
Investigations
Ted ’ s pathology shows his FBC is normal , with no monocytosis . CRP and ESR are also in normal range . Biochemistry confirms conjugated hyperbilirubinaemia and deranged
LFTs ( see table 1 ), EUC , lipase , calcium , phosphate , eGFR , glucose , total protein , albumin and globulin are normal .
Infectious hepatitis screening is negative for acute hepatitis A , B and C . Epstein-Barr virus results are consistent with past infection and cytomegalovirus immunoglobulin G ( IgG ) and IgM are negative .
Progress
At follow-up , Ted ’ s jaundice is worsening . He now has pruritus and darkened urine . Further questioning reveals that , in addition to his prescription medications , he also takes vitamin D , fish oil and resveratrol for its antioxidant properties . His sore throat has resolved and he feels well in himself , remains afebrile and has no new findings on physical examination .
The GP recommends , until the cause is identified , to taper off the sertraline , as this can rarely cause hepatitis , jaundice and hepatic failure .
Ted ’ s blood work is repeated , which shows further LFT derangements as shown in table 1 . The FBC and remaining biochemistry are still normal . Fibrinogen is 4.83g / L ( normal 1.80-4.20 ), with otherwise normal coagulation studies . The CRP is now slightly increased with normal range ESR . Antinuclear antibodies , smooth muscle antibodies , liver / kidney / microsomal antibodies , anti-neutrophil cytoplasmic antibodies ,
hepatitis E IgG and IgM , alpha fetoprotein and ceruloplasmin are all normal .
Abdominal ultrasound shows cholelithiasis with several mobile calculi measuring up to 12mm but no features of cholecystitis . CT abdomen and pelvis confirms cholelithiasis with no features of biliary obstruction . There are no hepatic parenchymal abnormalities nor features of portal hypertension or hepatic failure .
Considering the worsening jaundice , hepatic derangement and unclear aetiology , the patient is discussed with a local gastroenterologist , who recommends admission via ED .
Diagnosis
While admitted , Ted undergoes magnetic resonance cholangiopancreatography which confirms cholelithiasis with no evidence of