Steven Krawitz, MD, is currently a third year fellow in the 3-year combined gastroenterology and advanced transplant hepatology fellowship at Thomas Jefferson University Hospital. He completed his undergraduate education at Johns Hopkins University in Baltimore. He then completed his medical school and internal medicine training at Thomas Jefferson University in Philadelphia.
A 54 year-old female with past medical history significant for diabetes and hypertension was transferred from an outside hospital to our institution for further care of elevated liver function testing and acute change in mental status. Given a language barrier and the patient’s altered mental status, most of her history was obtained from her family as well as through review of records from the transferring hospital.
Her family reports 3 days of progressive fatigue, lethargy, myalgias, and nausea with vomiting. They report the patient had been in her normal state of health while enjoying a trip to Pakistan until the night after returning home. They endorse subjective fevers and chills. They deny any sick contacts at home but report some family members in Pakistan had a brief mild illness while she was visiting. They deny any significant alcohol or substance abuse, and deny any family history of significant illness. The patient was born in Pakistan, however has been living in the United States since 2010.
On exam the patient is febrile at 100.6 F, pulse is 101, blood pressure is 101/51, and respiratory rate is 28 with oxygen saturation 95% on room air. In general she appeared to be in mild distress. She had scleral icterus. Her oropharyngeal exam was normal without lymphadenopathy. The patient was tachypnic but lungs were clear to auscultation bilaterally. Cardiac exam was unremarkable. Abdominal exam showed mild distention without tenderness to palpation or evidence of fluid wave. Peripheral exam showed marked anasarca. Skin examination was notable for scattered petechiae but no rash.
The patient’s blood count was notable for anemia with a hemoglobin of 8.5 g/dL and thrombocytopenia of 34 B/L with a bandemia and lymphopenia. She had an acute kidney injury with a creatinine of 2.3 mg/dL. Liver function testing on day of admission were as follows: protein 6.5 g/dL, albumin 3.1 g/dL, total bilirubin 6.6 mg/dL, direct bilirubin 5.3 mg/dL, AST 10705 IU/L, ALT 1924 IU/L, and alkaline phosphatase 208 IU/L. INR was elevated at 2.44 sec. Lactate was 28 mmol/L. Hepatitis panel was negative for hepatitis A, B, and C as were autoimmune serologies. Salicylate and acetaminophen levels were undetectable. Blood cultures and parasitic exam were negative. Abdominal ultrasound showed diffuse hepatic change consistent with fatty infiltration with a normal Doppler vascular exam.
Chest X-ray is shown in Figure 1. Patient underwent transjugular liver biopsy with resultant pathology shown in Figures 2 and 3.
Figure 1: Chest X-ray
Figures 2, 3: Liver biopsy pathology
Hepatocyte necrosis (H&E, 40X)
Zone 1 steatosis (H&E, 20X)
The patient’s hospital course was complicated by ventilator dependent respiratory failure, seizures, renal failure requiring dialysis, fulminant liver failure non-responsive to MARS, several ischemic cardiovascular accidents, and pneumonia culminating in severe sepsis which ultimately the patient succumbed to. On day number 7 of her hospital course her testing confirmed acute infection with Dengue fever by PCR and serology for strain 1 or 3.