JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
Beware of the RodentsWhen Confronted with Cholestasis, A Case Report
Muhammad Mubarak, MBBS, Kevin Cowley, MD, Harry Marty Vigo, MD, Christopher Parsons, MD, George Therapondos, MD
INTRODUCTION
Elevation in liver enzymes is one of the most common problems met in inpatient as well as outpatient clinical settings. A cholestatic pattern, characterized by disproportionate elevation in alkaline phosphatase and bilirubin when compared with serumaminotransferases, has a very broad differential diagnosis. Leptospirosis is a rare and potentially life threatening cause of cholestatic hepatitis, and thus should remain in the differential diagnosis of all clinicians. We describe a case of a previously healthy 56-year-old woman presenting with jaundice and acute renal failure secondary to severe infection by Leptospira.
biliary dilatation. Over the next two days after admission, patient developed worsening respiratory status and acute kidney failure requiring transfer to intensive care unit and initiation of renal replacement therapy. Computerized tomography of the chest, abdomen, and pelvis with contrast showed bilateral scattered ground-glass pulmonary opacities suggestive of pulmonary edema/hemorrhage (figure 1) in addition to hepatomegaly and abdominal ascites.
CASE
A 56-year-old female bartender without prior medical history presentedwith a oneweek history of progressivemalaise, nausea with non-bloody emesis, and yellowing of her eyes and skin. She also noticed decrease in her urine output, with very dark urine. She was taking ibuprofen sparingly for myalgias throughout the week prior to presentation. As part of her profession, patient acknowledged social drinking habits, usually consisting of four to five drinks on most weekend days. She denied everyday alcohol use. She did not use illicit drugs, nor did she take any medicines, besides occasional ibuprofen for aches and pains. An in-depth history also yielded occasional rodent handling in the bar room. On evaluation, patient was alert, oriented, and appropriate with deep jaundice and scleral icterus. There was mild conjunctival injection over the right eye. Abdominal exam showed no ascites or hepatosplenomegaly. Skin exam was notable for petechiae. Laboratory evaluation was significant for cholestatic liver injury total bilirubin 19.4, alkaline phosphatase 160, aspartate aminotransferase (AST) 69, alanine aminotransferase (ALT) 38, acute kidney injury (blood urea nitrogen (BUN) 96, Creatinine 8.5, estimated glomerular filtration rate (eGFR) 4.7), hyponatremia (Na+ of 129), anion gap of 24, leukocytosis (White blood cells 14), and thrombocytopenia (platelet 63). Coagulation parameters including prothrombin and partial thromboplastin time were preserved. Toxicology including acetaminophen, salicylate, alcohol, and urine drug screen were negative. Abdominal ultrasound showed a normal appearing liver and spleen. The gallbladder wall was upper limits of normal without pericholecystic fluid, and there was no evidence of
Figure 1: Computed tomography of the chest showing bilateral ground- glass opacities from pulmonary hemorrage.
Given multi-organ involvement, multiple specialties were consulted, including hepatology. Leptospiral IgM antibodies were obtained and patient was started on IV ceftriaxone. While awaiting Leptospiral antibody results, the patient underwent liver biopsy, showing acute lobular cholestatic hepatitis without steatosis or fibrosis. Patient slowly improved during the hospital course, with improved renal function with normal urine output. Total bilirubin peaked above 30, but then trended down. Leptospiral IgM Ab ultimately resulted positive, and patient completed treatment coursewith doxycycline. Patient hadmade full recovery at the time of outpatient follow-up approximately 4 weeks later.
J La State Med Soc VOL 169 SEPTEMBER/OCTOBER 2017 115
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