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Learning ObjectiveDiscuss the differential diagnosis of unconjugated hyperbilirubinemia in alcoholic liver disease.CaseA 43 year-old male with history of hepatitis C, cholelithiasis and alcoholic liver disease presented with a 20-day history of fever, worsening jaundice, pain and swelling in his left leg without prior trauma. He had been admitted a month earlier for similar complaints and treated as cellulitis after a negative workup for DVT. Examination was remarkable for a temperature of 100°C, icterus, hepatomegaly and an erythematous, tender, swollen left leg. Laboratory data: Hb 8.5g/dL, WBC 6.4 k/μL, platelet 118 k/μL, MCV 115 fl, T.bil 9.4 mg/dL, C.bil 3.3 mg/dL, AST 98 U/L, ALT 40 U/L, Alkaline phosphatase 220 U/L, INR 1.7, LDH 1525 U/L, vitamin B12 > 1000 pg/mL, normal folate and potassium levels. He was started on antibiotics for presumed unresolved cellulitis. Further evaluation revealed persistently negative blood cultures, macrocytic peripheral smear, negative Coombs' test and no evidence of biliary obstruction. MRI was obtained to rule out osteomyelitis due to unresponsiveness to therapy. Imaging revealed a large hematoma extending from lower thigh into the calf as seen in Figure 1.DiscussionThe main differential diagnoses for a predominantly unconjugated hyperbilirubinemia in alcoholic patients include hemolysis (spur cell anemia and Zieve's syndrome), ineffective erythropoiesis, sepsis and hepatitis. In our patient, the underlying hematoma was masked as it mimicked features of cellulitis. Hemolysis within the hematoma along with alcoholic hepatitis was most likely responsible for this presentation. This case highlights the need to suspect an underlying hematoma after excluding other etiologies of unconjugated hyperbilirubinemia. Figure 1. MRI showing extension of the hematoma collection.

Learning ObjectiveRecognize nonspecific and delayed presentations of malignant hyperthermia (MH).CaseA 22-year-old male was admitted with drug overdose. He was found to be afebrile and drowsy with shallow respirations in the ER and was intubated for airway protection. CXR showed a right lower lobe infiltrate. Five hours later in the MICU, he was noted to be flushed and tachycardic with a temperature of 104.8°C. Cultures were obtained; Tylenol and antibiotics administered with a cooling blanket applied later. A review of medications given in the ER revealed succinylcholine. A CPK level of 37,789 U/L, elevated urine myoglobin, and high fever suggested malignant hyperthermia with rhabdomyolysis. The patient became normothermic after two doses of dantrolene. He was counseled about MH on discharge.DiscussionMH is a rare genetic disorder due to the mutations of ryanodine receptor in skeletal muscles. It usually occurs after administration of inhaled anesthetics or depolarizing muscle relaxants. Clinical features include marked fever, muscle rigidity, metabolic acidosis, rhabdomyolysis and hemodynamic instability. Hyperthermia develops within minutes to hours following exposure to disease-inducing medications. Many of the early signs are nonspecific and can mimic those of other etiologies. In our case, delayed diagnosis of MH was due to not only late-onset hyperthermia, but also initial attribution of his fever to aspiration pneumonia. Treatment includes discontinuation of triggering agents, oxygenation and use of dantrolene along with cooling measures. This case demonstrates the variability of presentation and underscores the need for continuous monitoring whether in a surgical or medical setting.

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