Evaluation of mixed LFT abnormalities

Todays case presented a patient with mixed LFT abnormalities and painless jaundice without evidence of extrahepatic biliary obstruction.  AST/ALT elevated >400, AlkPhos >500, bili >18.

Differentials discussed included drug induced liver disease, ? recent antibiotic exposure,

This page from NIH has a good breakdown of the varying patterns of drug induced liver disease, including the predominantly cholestatic pattern and the  mixed pattern.

The clinical/pathological syndrome of "granulomatous hepatitis" - expanded upon in this presentation - was also discussed, though does not usually lead to the degree of bilirubin elevations noted in this case.  The linked presentation walks through a good differential of this condition based on pathological or epidemiological risk factors present in the case.

Lastly, acute hepatitis C is a possibility to be considered.  Interestingly - a robust immune response is generally required to trigger symptomatic disease and jaundice, and this subset of patients (presenting with jaundice) have a lower rate of development of chronic hepatitis C infection.

And from noon conference - the noon conference on Sjogren's syndrom brought to mind this image from NEJM, which made an appearance in a prior Quiz Bowl and is likely to make an appearance at a future showing,