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Infectious Diseases

A Patient With Jaundice and Malaise

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.

1 Credit CME

JAMA

Published Online: June 13, 2022

JAMA Clinical Challenge

Article Information and Disclosures

Brian L. Pearlman, MD^1,2,3

Author Affiliations

¹Wellstar Atlanta Medical Center, Atlanta, Georgia
²Emory School of Medicine, Atlanta, Georgia
³Medical College of Georgia, Augusta

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A 58-year-old woman with a history of intravenous heroin use and chronic inactive hepatitis B virus (HBV) infection with a low serum HBV DNA value, normal liver enzyme values, and no evidence of cirrhosis presented to the emergency department with sudden onset of painless jaundice and 8 days of malaise. Her last intravenous heroin use occurred 9 days prior to presentation. She was not taking any prescription or herbal medications and had not been prescribed suppressive antiviral medication for chronic HBV infection. She reported no history of travel outside the US and no raw meat ingestion. Her vital signs, mentation, and physical examination were normal except for scleral icterus (Figure). Results of blood testing were negative for hepatitis C virus RNA, anti–hepatitis A IgM, and HIV antibody. Other selected laboratory values are shown in the Table. A liver ultrasound performed 6 months prior to presentation and a repeat liver ultrasound with Doppler revealed no abnormalities.

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A 58-year-old woman with a history of intravenous heroin use and chronic inactive hepatitis B virus (HBV) infection with a low serum HBV DNA value, normal liver enzyme values, and no evidence of cirrhosis presented to the emergency department with sudden onset of painless jaundice and 8 days of malaise. Her last intravenous heroin use occurred 9 days prior to presentation. She was not taking any prescription or herbal medications and had not been prescribed suppressive antiviral medication for chronic HBV infection. She reported no history of travel outside the US and no raw meat ingestion. Her vital signs, mentation, and physical examination were normal except for scleral icterus (Figure). Results of blood testing were negative for hepatitis C virus RNA, anti–hepatitis A IgM, and HIV antibody. Other selected laboratory values are shown in the Table. A liver ultrasound performed 6 months prior to presentation and a repeat liver ultrasound with Doppler revealed no abnormalities.

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Article Information

Corresponding Author: Brian L. Pearlman, MD, Wellstar Atlanta Medical Center, Center for Hepatitis C, 285 Boulevard NE, Ste 525, Atlanta, GA 30312 (Brianpearlman3@hotmail.com).

Published Online: June 13, 2022. doi:10.1001/jama.2022.8384

Conflict of Interest Disclosures: Dr Pearlman reported serving on the speakers bureau and an advisory board of Gilead Sciences for viral hepatitis–related topics. Gilead has a nonapproved medication in clinical trials for delta hepatitis.

Additional Contributions: We thank the patient for providing permission to share her information.

References

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Lok AS , Negro F , Asselah T , Farci P , Rizzetto M . Endpoints and new options for treatment of chronic hepatitis D. Hepatology. 2021;74(6):3479-3485. doi:10.1002/hep.32082 PubMed Google Scholar Crossref

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.