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Saturday, December 25, 2010

Clinical Vignette: Young Married Woman With Amenorrhea and Jaundice

Clinical Vignette: A 27-year-old married woman with amenorrhoea of 7 months duration is found to have mild jaundice, hepatosplenomegaly, lymphadenopathy and palmar erythema.
Investigations show:
  •     Hb 10.4 g/dL
  •     WBC 2.8 × 109/L
  •     Platelets 72 × 109/L
  •     ESR 29 mm in first hour
  •     Plasma bilirubin 58 μmol/L
  •     Plasma AST 190 IU/L (normal range 5–35)
  •     Plasma ALT 105 IU/L (normal range 2–17)
  •     Plasma alkaline phosphatase 65 IU/L (normal range 30–100)
  •     Serum albumin 35 g/L
  •     Serum globulin 68 g/L
  •     Hepatitis B surface antigen negative
  •     Antinuclear factor positive at titre of 1/512
  •     Anti-smooth muscle antibodies positive
  •     Anti-mitochondrial antibodies positive at titre of 1/64
1 What is the diagnosis?
    (a) Primary biliary cirrhosis
    (b) Chronic active hepatitis
    (c) Wilson’s disease
    (d) Hepatitis C infection
    (e) Drug toxicity
Answer to clinical vignette | case: (b)

The diagnosis is based on the differential of jaundice associated with elevated transaminases (transaminitis) rather than an obstructive picture. In the presence of autoimmune serology, an
autoimmune disease is the most likely cause.

Causes Of Hepatocellular Jaundice:

Infections
– Viral
  •        Hepatitis A, B, C, D, E
  •        EBV
  •        CMV
  •        HIV
  •        Arboviruses
– Spirochaetes
  •        Leptospira
– Protozoa
  •        Toxoplasma
  •        Amoeba
- Toxins
- Drugs
  •       Nitrofurantoin
  •       Halothane
  •       Isoniazid
  •       Many others
- Inherited disorders
  •       Wilson’s disease
  •       Galactosaemia
- Autoimmune disease/connective tissue disorders
  •       Chronic active hepatitis
  •       SLE
  •       Scleroderma