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A 48 year old man presented with gradual onset of fever, anorexia, episodic nausea and vomiting, a 40 pound weight loss, and deepening jaundice over a six week period. Fever was intermittent and associated with chills and rigors. There was no history of pain in the right hypochondrium, pruritus, or clay coloured stools. The patient had a 30 pack year smoking history and consumed alcohol in moderation. He took no medications. Five years previously, he had an emergent laparotomy after a motor vehicle accident, details of which he was unable to supply. He was a native of El Salvador, but had been residing in the northeastern United States for the past four years. He was a gardener by occupation. There was no history of travel abroad during this time.
On examination, the temperature was 39°C, pulse rate 92 beats/min, blood pressure 120/60 mm Hg, and respiratory rate 18 breaths/min. There was no significant lymphadenopathy. He was markedly icteric, but there was no rash or stigmata of chronic liver disease. Cardiorespiratory examination was within normal limits. Abdominal examination revealed a midline scar. The liver was palpable 8 cm beneath the right costal margin and percussed to a liver span of 16 cm. It was tender, firm, and smooth surfaced. The spleen was not palpable, and there was no shifting dullness. Neurological examination was normal.
Laboratory values on admission are shown in table 1. Viral hepatitis profile was negative for hepatitis A, B, and C viruses. Monospot test (infectious mononucleosis) and ELISA test for HIV were negative. Urinalysis revealed large bilirubin and urobilinogen >8 EU/dl (normal <1 EU/dl). Chest radiography was normal. A computed tomogram of the abdomen showed diffuse hepatomegaly without biliary dilatation or gallstones; the spleen was not visualised. Electrocardiogram showed sinus tachycardia.
Over the next 48 hours, the patient complained of increasing lassitude and dyspnoea. He had intermittent fever with chills, but physical examination was otherwise unchanged. Laboratory findings over days 2–4 are summarised in table 2. Serum haptoglobin on day 3 was less than 0.06 g/l (normal 0.5–2.2 g/l). Multiple blood cultures and a urine culture were done, all of which showed no growth as of day 4. A peripheral blood smear was taken (see fig 1).
In this patient’s clinical context, how do you interpret the laboratory tests on admission (table 1) and those done between days 2–4 (table 2)?
What does the blood smear show (fig 1)? What is the differential diagnosis?
How would you treat this patient? What are the common complications of this condition?
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