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What was the cause of patient's hepatitis?

A 36-year-old man who sold antiques over the Internet developed a sore throat and persistent cough in early September. For several weeks, he put up with the cough, but in early October, his energy flagged, and he began waking up in the middle of the night, feverish and drenched in sweat.

Testing a blood sample.
Testing a blood sample.Read moreiStock

A 36-year-old man who sold antiques over the Internet developed a sore throat and persistent cough in early September.

For several weeks, he put up with the cough, but in early October, his energy flagged, and he began waking up in the middle of the night, feverish and drenched in sweat.

He went to see his physician, who prescribed Doxycyclin, an all-purpose antibiotic that is active against a broad range of bacteria.

The medicine did not work.

His fevers persisted, and he felt increasingly washed-out and weary.

When the whites of his eyes turned a mustardy yellow, he went to the emergency room,

A liver function test was done, revealing both inflammation and an inability to normally excrete bile, a type of biological soap that helps the body digest dietary fat.

An ultrasound showed a slightly enlarged spleen and liver, but no blockages, abscesses, or other worrisome features.

What was causing this patient's hepatitis?

His physicians asked him about his daily routines. He was a stay-at-home father with two small children under age 6. They were both healthy and well. So was his wife, a business executive.

Had they traveled anywhere recently?

Yes.

The family had spent a week in Hilton Head, S.C., in June. In August, they had vacationed at the Jersey Shore and then taken a brief trip to his boyhood home on Martha's Vineyard, Mass.

None of these destinations presented a cause for concern.

The list of possible causes for his illness was long, but his physician's best guess was that it had been caused by a virus.

There was a small chance it could be hepatitis A, spread from fecal material to the mouth. It is the most common cause for hepatitis in the developing world, where sanitation is poor and fecal contamination of food and water are common. But in the U.S., hep A is rare and usually occurs in an outbreak in which a number of people within a community get sick in a short period of time.

This did not fit.

Perhaps hepatitis B? This disease is on the downswing in the United States because children are now immunized against it at birth. In adults, sex and intravenous drugs are the usual sources of infection - in this well-behaved patient, not a likely diagnosis.

Solution

Could alcohol or other toxic agents such as a medication be the cause? The patient never drank more than an occasional beer and always used ibuprofen rather than acetaminophen for headaches and other aches and pains. Ibuprofen, while potentially toxic to the kidneys, is kind to the liver.

Perhaps his hepatitis was the result of an autoimmune process such as lupus? Again, no.

He had no rash, joint aches, hair loss, or any other signs of inflammation, and his blood work came back negative.

His physicians were beginning to scratch their heads.

They took a second look at the laboratory blood tests obtained when he was admitted to the hospital.

There was the clue.

The hematology lab had identified a few "variant" or "atypical" lymphocytes. This kind of white blood cell is only seen in a few diseases - acute HIV, acute cytomegalovirus infection (which is rare in adults), and, last, Epstein-Barr virus, otherwise known as infectious mononucleosis.

HIV was improbable given the patient's lifestyle, and his blood test came back negative.

His CMV blood test revealed a previous infection, probably acquired when he was a child, giving him immunity from a second infection for life.

What about Epstein-Barr?

He did not have a sore throat or big lymph glands in his neck, and no one at home had any illness recently to explain how he might have caught this virus.

Nevertheless, with all his other studies coming back negative, his doctors ordered a highly sophisticated study looking for the DNA in the blood.

Sure enough, he had 100,000 copies of Epstein-Barr virus in each cubic centimeter of blood.

In older patients, the clinical presentation of mono becomes more atypical. This patient's manifestation of mono was hepatitis.

After a few weeks, the fever resolved, the jaundice disappeared, and he regained his energy.

Where did he get this illness?

Probably from one of his children, who had become infected and was contagious but never got sick.

For all his suffering, kissing the kids good night was still totally worth it.