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