An Intricate Interplay

A CLINICAL PROBLEM-SOLVING article by Richard Moseley, from the Veterans Affairs Ann Arbor Healthcare System, Michigan
A 55-year-old man presented with sinus congestion, headaches, chills, mild nausea, fatigue, and a “foggy” sensation that had lasted approximately 1 week. He reported darker urine than usual and had noticed that his eyes were turning yellow. The patient's medical history was notable for hypertension and hyperlipidemia. He consumed one to two alcoholic drinks per night. His medications included baby aspirin, atenolol, hydrochlorothiazide, lovastatin, fexofenadine, fish oil, acidophilus, vitamin D, and calcium carbonate. Three and a half years previously, at routine physical examination, the patient was noted to have mildly elevated liver-enzyme levels. At the time of the patient's current presentation, the examination was notable for scleral icterus and a soft, nontender abdomen with the liver edge palpable less than one finger breadth below the costal margin. Laboratory results which were returned late on a Friday afternoon showed markedly elevated aminotransferase levels, with more modest elevations of the alkaline phosphatase and bilirubin levels. The patient was advised to come to the emergency department that evening for further evaluation. In contrast to the broad differential diagnosis for elevations in serum aminotransferase levels that are less than 5 times the upper limit of the normal range, the causes of severe aminotransferase elevations (>20 times the upper limit of the normal range) are more limited. [Original Article]