18-Year-Old Woman With Fever, Abdominal Pain, and Elevated Liver Enzymes

Abstract

A n 18-year-old woman from rural Minnesota was admitted to the hospital after presenting to a local emergency department with a 3-day history of severe right upper quadrant abdominal pain and a 2-week history of headaches, fever, nausea, and vomiting. A review of systems was otherwise unrevealing. Her only medication was trimethoprim-sulfamethoxazole for a recent urinary tract infection. She had no other notable medical history. She reported rare alcohol use 3 years previously and no recent use of over-the-counter medications or dietary supplements, smoking, illegal drug use, or sexual activity. Physical examination findings and vital signs were unremarkable aside from a temperature of 39.0°C and right upper quadrant tenderness without rebound or guarding. There was no hepatosplenomegaly or flank dullness.Laboratory studies revealed the following (reference ranges shown parenthetically): alkaline phosphatase, 738 U/L (52-144 U/L); aspartate aminotransferase (AST), 285 U/L (8-43 U/L); alanine aminotransferase (ALT), 417 U/L (7-45 U/L); total bilirubin, 2.3 mg/dL (0.1-1.0 mg/dL); direct bilirubin, 1.2 mg/dL (0.0-0.3 mg/dL); and platelet count, 101 ϫ 10 9 /L (150-450 ϫ 10 9 /L). Her hemoglobin level, leukocyte count, urinalysis results, and amylase, lipase, lactate, electrolyte, and serum creatinine levels were all within normal limits. Results of serologies for acute hepatitis A, B, and C, a heterophile antibody test, and a pregnancy test were negative, and salicylate and acetaminophen levels were unremarkable.