By Lenore Jarvis, Children’s National
with Jamil Madadti, Children’s National

The Case
This is a case of a 14 yo M with hx of hepatitis who recently moved from El Salvador presenting as a referral from the PMD for hyperbilirubinemia, fever, hemorrhagic conjunctivitis, hand desquamation, and sore throat. The challenge in this case is how to approach this patient with fever and recent travel history. For a complete case presentation with audience and Hot Seat Attending comments, please click here.

Here’s How You Answered Our Questions

Fellows and attendings were split about what labs/imaging to order. During the Debrief, it seemed that “all of the above” seemed appropriate. Everyone wanted to make sure that the patient wasn’t coagulopathic or in liver failure.

In terms of dispo, Dave made a great comment “if truly afebrile and no potential risky (communicable) exposures AND there is not a significant change in labs to suggest acute blood loss or coagulopathy/DIC AND his tachycardia is improved with hydration AND he doesn’t have signs of cardiomegaly on CXR…discharge with close follow-up with PCP/ID.” Mentioned below, the patient is an undocumented child, so one also has to weigh the concern of poor follow-up with the costs of admission. Pavan also made a great observation that it can be difficult to get a patient immediate ID or GI follow-up.

Denouement
Patient was strep positive 5 days ago at PCP, but amoxicillin never filled.

In the ED, labs came back: CBC 13/13.3/38.7/272 (left shift, 3.5% Eos), ESR 59/CRP 3.9. BMP negative. Total bili 1.6 (0.1 direct), ALT 98/AST 118. Coags normal. UA negative. GAS negative. CXR negative. Abdominal US: thickened gallbladder, nodule on pancreas and splenomegaly. Attending not comfortable with discharge and admitted for observation and repeat labs. The patient was admitted to the Hospitalist Service.

ID consulted and suspected GAS or Adenovirus. Kawasaki Disease unlikely as only two days of fever. Stated typically a viral infection will have an ESR less than 50. ID recommended 10 day course of amoxicillin. Etiology of elevated LFTs unclear (repeat during admission ALT 75/AST 32, total bili 1.1), but may be related to previous hepatitis or recent infection. Recommend repeat LFTs with PCP and follow up with GI as an outpatient if not normal on repeat testing.

SW consulted due to child immigrant from El Salvador ~1 month ago. Family was apprehended by Immigration during their journey. (See recent Article of the Week on Undocumented Children if interested.)

Discharged home about 1.5 days later. On discharge, was afebrile for 24hrs, clinically well and tolerating PO diet and antibiotics. Plan for follow-up with PCP for repeat LFTs as an outpatient.

ID labs, many of which resulted after discharge home:
• Negative: BCx, HAV IgM, GAS ASO, Adenovirus PCR
• CMV: IgM negative, IgG positive (past infection)
• EBV: viral capsid IgM positive, viral capsid IgG positive, nuclear Ag IgG positive, early (D) Ag IgG negative (convalescent phase and his IgM didn’t yet go away, so likely to be still symptomatic for Mono)

Unknown if patient followed up with PCP. Has not followed up with GI or ID as an outpatient.

Debrief Teaching Points – from Thursday Conference
1. “Review travel history.” “Consider isolation.”
• This recent traveler was in a curtained room. A detailed travel history can tell you what PPE is needed and whether a negative pressure isolation room is required.

2. “Reinforces the use of the CDC website.”
• Helps to guide the differential and possible laboratory testing.

3. “Hemorrhagic conjunctivitis is usually benign.”
• Most frequently caused by enterovirus, coxsackievirus and adenovirus, and it typically resolves in 5-7 days. Do not use steroids in treatment.

4. “Think about what labs will change your management.” “How to guide treatment with LFTs.” “To think more about GGT.”
• ALT (liver), AST (liver, heart, skeletal muscle, kidneys, brain, RBC), GGT (liver, biliary system, pancreas, renal tubules, intestine), ALP (biliary, bone)
• Bilirubin, albumin, PT (INR) – liver synthetic function
• Acute hepatic injury typically will have ALT >10x baseline (viral, drugs, ischemia, autoimmune, etc.) vs. chronic injury where ALT/AST 2-5x baseline (drug, chronic viral hepatitis, autoimmune, etc.).
• Elevated GGT helps to indicate a hepatic source for elevated ALP
• Thrombocytopenia – liver fibrosis

5. Bonus: from the Denouement
• EBV: viral capsid antigen (VCA) IgM positive, viral capsid antigen (VCA) IgG positive, Epstein-Barr nuclear Ag (EBNA) IgG positive, early (D) Ag (EA) IgG negative = Convalescent Phase