Question

a 39-year-old male patient complains of sudden onset of gi symptoms, fever, chills, and malaise. you run some lab tests and find leukopenia with atypical lymphocytes with elevated ast, alt 10x the upper reference limit. there is also elevated alp, ldh, and serum bilirubin. what is your working diagnosis? a) gallstones b) acute viral hepatitis c) cirrhosis d) cholecystitis e) acute pancreatitis

Explanation:

• Gallstones: Usually present with right - upper - quadrant pain (often colicky), may have normal or only slightly elevated liver enzymes (AST, ALT) unless there is obstruction. Leukopenia is not a typical major feature.
• Acute viral hepatitis: Presents with sudden - onset GI symptoms (nausea, vomiting, anorexia), fever, chills, malaise. Lab findings include leukopenia (especially in some viral infections like EBV - related hepatitis, but also in others), atypical lymphocytes (seen in viral infections), and highly elevated AST and ALT (often > 10 times the upper reference limit). Elevated ALP (though usually not as high as in biliary obstruction), LDH, and serum bilirubin (due to liver cell damage and impaired bilirubin metabolism) are also common.
• Cirrhosis: Usually a chronic condition. Symptoms are more related to chronic liver failure (ascites, jaundice, portal hypertension - related symptoms like varices). AST and ALT may be elevated but not typically 10 times the upper limit in uncomplicated cirrhosis. Leukopenia can be due to hypersplenism (a chronic finding in cirrhosis), but the sudden - onset symptoms described are not typical.
• Cholecystitis: Presents with right - upper - quadrant pain (often persistent, with Murphy's sign), fever. Leukocytosis (not leukopenia) is more common. AST and ALT may be slightly elevated if there is common bile duct involvement, but not usually 10 times the upper limit.
• Acute pancreatitis: Presents with severe epigastric pain radiating to the back, nausea, vomiting. Amylase and lipase are the key enzymes (markedly elevated). AST and ALT may be slightly elevated, but not 10 times the upper limit. Leukocytosis is more common than leukopenia.

Answer:

B. Acute viral hepatitis