Dr Jennifer Roberts is a GP in Sydney .

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She experienced moderate intermittent myalgia for six days , but nothing focal . She suspected she had mild fever a couple of nights while away , with alternating sensations of being hot and cold . She thought that her urine looked a little more ‘ orange ’ than usual .

She was otherwise in good health , exercising most days and eating reasonably well . She denied use of recreational drugs or tobacco . She reported drinking up to four standard drinks on five days of the week .

She had been told during the previous Christmas period ( three months prior ), that she had a mildly elevated GGT , and the doctor advised her to reduce her alcohol intake in line with NHMRC guidelines , and retest , which had not yet been performed . She lived alone , and reported having only male sexual partners ; her periods were regular and she had not had intercourse or travelled overseas in the preceding six months .

Examination On examination , Victoria was afebrile and her vital signs were normal . BMI was 22 .

Examination of the chest and abdomen were unremarkable , and there was no axillary or inguinal lymphadenopathy . She had no rash , photophobia or neck stiffness . Her hands and joints were normal and she was grossly neurologically intact .

She appeared slightly pale , but her palmar creases and conjunctivae were normal .

BLOOD TESTS RESULTS

• EUC , CRP , amylase / lipase , TSH were normal

• FBE showed a mild lymphocytosis ; 4.44 x 10 9 ( 1.0- 4.0 )

• Total bilirubin was 15 µ mol / L ( 3-15 )

• ALP 326 U / L ( 20-15 )

• GGT 206 U / L ( 5-35 )

• LDH 441 U / L ( 120-250 )

• AST 617 U / L ( 10-35 )

• ALT 1416 U / L ( 5-30 )

• Total cholesterol was 7.0mmol / L ( 3.9 - 5.5 ) with LDL 5.1 ( 1.7 - 3.5 )

• Ferritin was 563ug / L ( 15 - 200 )

• HIV and hepatitis serology were negative

• EBV VCA IgM was positive

Investigation Victoria was reassured that her illness was most likely to be viral in aetiology and probably self-limiting . However , she was asked to provide a urine sample and referred for serological testing in the event that her symptoms persisted beyond another 48 hours .

Her urine dipstick showed a trace amount of blood and a urine pregnancy test was negative . The urine was slightly dark in colour . Urine microscopy and culture proved negative . Nasopharyngeal swab was negative for respiratory viruses including influenza .

Progress Two days later , Victoria developed moderately severe pruritus and returned for review . Her

aches and fevers had settled . Examination was unchanged from the previous consultation . Blood tests were performed as planned ( see box ).

Management Victoria was informed that her liver enzymes were elevated secondary to infection with Epstein-Barr virus ( EBV ), or glandular fever . She was asked to minimise alcohol intake , particularly in light of her previous GGT result , and return for repeat LFTs in two weeks to ensure that they were normalising . She was advised to rest , drink plenty of fluids , and allow time to recuperate . Her pruritus settled gradually over 2-3 days with a trial of promethazine 10mg tds prn .

Within three weeks of initial presentation , her