1. A 23-year-old registered nurse comes to the employee health clinic because she says, "I'm too tired to work." She has had increasing fatigue, malaise and anorexia during the past several days. Her serum bilirubin concentration is 1.8 mg/dL, prothrombin time is 13 sec, serum alanine aminotransferase (ALT) concentration is 1160 U/L and a screening test for hepatitis B surface antigen is positive. She is instructed to rest at home and return in 3 days if no new symptoms develop. Two days after the visit she calls to say that she has now developeed an urticarial rash and swelling of the joints of her fingers. At this time the most correct statement about her condition is:

a) The arthritis and rash are the result of an associated immune complex disorder
b) The arthritis and rash are unrelated to her liver disease
c) It is unlikely that her blood is infectious
d) She has a 50% risk for developing chronic liver disease
e) She should be given hepatitis B immune globulin

Chronic active hepatitis of unknown etiology ("auto-immune" or "lupoid" chronic hepatitis)

This classic form of chronic active hepatitis (CAH) cannot be attributed to any known cause, and the original histologic classification referred to earlier was developed primarily in studies of this entity. First described by Waldenstrom in 1950 and Kunkel in 1951, the disease was thought to occur primarily in young women and demonstrated many autoimmune characteristics, including a positive lupus erythematosus (LE) cell phenomenon. It is now recognized that the disease occurs in persons of all ages and both sexes. Endocrine abnormalities (amenorrhea, hirsutism, acne, obesity, cushingoid facies, pigmented abdominal striae) and the LE cell phenomenon occur in only a small minority of patients and correlate with severity of disease rather than indentifying a unique subgroup. In contrast to chronic hepatitis B, which typically affects men, 70% to 80% of the patients are women. In one third of patients, the initial disease is identical to acute viral hepatitis. The remainder present insidiously with nonspecific symptoms of malaise, fatigue, and anorexia; are identified serendipitously on a random serum chemistry drawn for other reasons; or present with fully developed complications of advanced liver disease (ascites, variceal bleeding, hepatic encephalopathy). At least 85% of the patients have no history of exposure to jaundiced persons or other hepatitis risk factors.

Common clinical features on presentation include progressive jaundice, severe anorexia, malaise and fatigue, asymptomatic hepatosplenomegaly, and abdominal pain. Less common (20% or less) are epistaxis, acne, persistent fever, and tender hepatomegaly. Extrahepatic manifestations may occur in 20% to 25% of patients, with arthralgias and skin rashes the most common. Other abnormalities include thyroiditis, ulcerative colitis, pleurisy, pericarditis, myocarditis, and pulmonary complications, including fibrosing alveolitis. Isolated occurrences of lichen planus, mixed connective tissue disease, macroglobulinemia, and uveitis have been recorded. The multitude of disparate findings further support the likelihood of an immune origin for this disease, but it should be noted that some of these immune abnormalities (skin rashes, glomerulonephritis, arthritis) can be found in chronic hepatitis B due to immune complex desposition.

HBsAg-The appearance of HBsAg is the first evidence of HBV infection, appearing before biochemical evidence of liver disease. HBsAg persists throughout the clinical illness. Persistence of HBsAg after the acute illness may be associated with clinical and laboratory evidence of chronic hepatitis for variable periods of time. The detection of HBsAg establishes infection with HBV and implies infectivity.

HBV is usually transmitted by inoculation of infected blood or blood products or by sexual contact and is present in saliva, semen, and vaginal secretions.

Related topics:

Chronic active hepatitis C

Up to 60% of patients with post-transfusion hepatitis C develop chronic liver disease. Most often, the patient is only mildly symptomatic and nonicteric. Transaminases range from 200 to 800 and may show marked fluctuations, with rapid rises and falls and intervening periods of normality. Although post-transfusion hepatitis C affects men and women equally, 75% of those developing chronic hepatitis in one study were men. Similar to chronic hepatitis B, serum autoantibodies, hypergammaglobulinemia, and stigmata of chronic liver disease are rare, although a false-positive test for antinuclear antibodies may be present in some cases, leading to confusion with autoimmune hepatitis.

No good prospective histologic data are available in this group of patients, but CAH (usually without bridging or cirrhosis) is most common. Although it was initially thought that chronic active hepatitis C was a relatively benign disease, there is increasing evidence of slow progression to cirrhosis and liver failure. At least 20% of patients with CAH progress to cirrhosis within 5 to 10 years. Hepatitis C is the most common cause of cryptogenic cirrhosis and a common reason for liver transplantation in the United States. A strong association with the development of hepatocellular carcinoma is also recognized, with a particularly high correlation in Japan and Spain. Hepatitis A and hepatitis E do not produce CAH or CPH, and hepatitis D produces these lesions only in patients also infected with hepatitis B. In the latter instance, the frequency and severity of chronic hepatitis is greater than with hepatitis B alone.

2. A 19-year old archeology student comes to the student health service complaining of severe diarrhea with fifteen large-volume watery stools per day for the past 2 days. She has had no vomiting, hematochezia, chills or fever, but she is very week and very thirsty. She just returned from a 2-week trip to a remote Central American archeological research site. Physical examination shows temperature 37.2 C (99.0F), pulse 120/min, respirations 12/min and blood pressure 90/50 mm/Hg. Her lips are dry and skin turgor is poor. The most likely cause of the diarrhea is

a) anxiety and stress from traveling
b) inflammatory disease of the large bowel
c) poor eating habits during her trip
d) an osmotic diarrheal process
e) a secretory diarrheal process

Increased fecal water content can result from either a decrease in the amount of fluid absorbed or an increase in the secretion of fluid sufficient to overwhelm the absorptive capacity of the bowel distal to the secretory site. Decreased absorption of fluid can occur as a result of (1) inability to absorb osmotically active solutes, which subsequently retain water in the lumen of the gut (Chapter 42); (2) lack of contact between intraluminal contents and absorptive surfaces; (3) change in active ion transport; and (4) increase in tissue hydrostatic pressure.

Merck Manual Recommended Reading for Question 2:

DIARRHEA

Etiology and Pathophysiology
Complications of Diarrhea
Diagnosis
Treatment

a) a chest x-ray film
b) echocardiography
c) an exercise stress test
d) upper gastrointestinal endoscopy
e) 24-hour monitoring of cardiac rhythm

View Answer C: Exercise stress test

The main indication for exercise testing is to assist in the diagnosis of coronary artery disease in patients with chest pain. A second major indication is to evaluate functional capacity and aid in assessing the prognosis of patients with known coronary artery disease. When exercise stress is sufficient to produce a mismatch between myocardial O2 supply and demand, myocardial ischemia will develop and often is identified by certain alterations in the ECG's S-T segment. Although anginal chest pain induced by the test is strongly predictive of coronary artery disease, 1.0 mm of horizontal or downsloping S-T segment depression is considered a positive end-point for ischemia. The S-T depression must persist for 80 milliseconds (ms) or longer and must be recognized in at least three consecutive beats with a steady ECG baseline. Increasing S-T segment elevation can often be seen in leads demonstrating pathologic Q waves at rest in patients with prior myocardial infarction. These changes are predominantly observed in patients with a depressed ejection fraction and severe regional myocardial asynergy.

Quoted from the message group:

Effort testing is the way to go here
by IMG in distress!

Given the patient's symptoms and demographics, the most important thing to exclude would be ischaemic heart disease. In the absence of abnormal clinical features or dysrhythmia, investigations such as echo or CXR would be second line. Thus, to delineate the patient's response to an effort test would be the initial workup. Even in the event of there being an underlying occlusive/stenotic coronary lesion, the stress EKG would only be positive in about 40% of cases (I have heard figures ranging from 30 to 70%). Common questions clinically are (1) what determines a SEKG to be positive, (2) what further investigations one could perform if still suspicious about IHD (plus their rationale and mechanisms) and (3) what to do if the patient is not "stressable" (eg. persantin perfusion study).

Posted on Thursday, March 26, 1998 at 10:51 AM

Merck Manual Recommended Reading for Question 3:

a) acalculous cholecystitis
b) chronic relapsing pancreatitis
c) diverticulitis of the cecum
d) herpes zoster
e) penetrating duodenal ulcer

Herpes Zoster is also known as Shingles

H & P

• Prodrome of pain and paresthesia in involved dermatome which may simulate pleu7risy, MI, ulcer, or renal colic. The typical rash is localized, unilateral, and does not cross the midline. Grouped vesicles on a pink base form pustules and crusts.

Diagnosis

• Positive Tzank Smear demonstrating multinucleated giant cells, viral culture
• This diagnosis is the same as for varicella

Disease Severity

• Pain is more severe in elderly patients
• disease is more severe in immuocompromised = skin necrosis and scarring, postherapetic neuralgia, dissemination.

Concept and Application

• Infection is a recrudescence of latent infection with varicella-zoster infection, passed to the skin and mucosa by sensory nerves from dorsal ganglia
• cellular immunity is more important in host resistnace (increased incidence of infection in patients with HIV or immunocompromise)

Management

• Topical
  • Cool compresses
  • Calamine Lotion
  • Antibiotics for secondary bacterial infection
• Systemic
  • Acyclovir 800 mg 5 times/d for 1 week
  • Famciclovir 500 mg 3 times/d, analgesics
• Postherpetic Neuralgia
  • Topical capsaicin cream (Zostrix)

Merck Manual Recommended Reading for Question 4:

• HERPES ZOSTER
• ACUTE CHOLECYSTITIS
• ABDOMINAL PAIN;Diagnosis
• THE MERCK MANUAL - PEPTIC ULCER;Diagnosis and Differential Diagnosis
• THE MERCK MANUAL - ACUTE PANCREATITIS;Laboratory Findings and

Following other appropriate studies, the most appropriate management would be to

a) administer oral folate therapy
b) administer parenteral iron therapy
c) administer parenteral vitamin B12 (cyanocobalamin) therapy
d) begin transfusion with packed erythrocytes
e) begin transfusion with whole blood

View Answer D: Begin transfusion with packed erythrocytes