This case presentation describes a 25-year-old female patient who presented with jaundice and itching for 2 months. Her symptoms included diarrhea, fever, and a skin rash. Lab work showed elevated liver enzymes and bilirubin levels. An ultrasound found her gallbladder to be distended with thick walls and fluid around it. She was diagnosed with hepatitis based on her clinical presentation and investigation results. Her liver function tests gradually improved over time with treatment.

1. Case Presentation
By
Mustafa Abdelhalim Fathy
Resident of Tropical Medicine
Minia University Hospital

2. Personal History
Female patient,B. A.A,25 years old,from
Abu Kurkas-Al Minia,housewife,married
and has one sibling 2 years old,has no
special habits of medical importance

3. Complaint
Yellowish discolouration of the eye for 2
months.

4. History of present Illness
The condition has started by jaundice,of
insidious onset ,very progressive course,of
2 months duration,associated with dark
urine ,generalized itching all over the
body,with appearance of red skin papules
scattered all over the body which are
characterized by scaling and peeling of
the skin.

5. The condition is associated with diarrhea,
watery in consistency mixed with
mucus,yellowish in color of normal
odour,of gradual onset, progressive
course,not related to meals,more than 10
motions per day, affecting general
condition of the patient as patient became
bed ridden.

6. History of intermittent fever,low grade,of 1
month duration.

7. Patient sought dermatological advice,
various topical treatment and advised for
internist consultation then patient referred
for admission in our department.

8. • No history of
hematemesis,melena,epistaxis,bleeding
per gums nor purpric or ecchymotic
patches.
• No history of nausea,vomiting nor
abdominal pain.
• No history of LL edema nor abdominal
distension.

9. • No history suggestive of urinary troubles
• No history suggestive of cardiac illness in the
form of( symptoms of pulmonary venous
congestion, systemic congestion, low cardiac
output, chest pain,palpitation,cyanosis,nor
symptoms of embolizaion)
• No history suggestive of chest disease apart
from dry intermittent cough.
• No history suggestive of neurological illness.
• Patient not known to be diabetic nor
hypertensive.

10. Past History
• History of contraceptive injection,2 years
ago.
• No history of hospital admission.
• No history surgical operation.
• No history of TB nor Bilharziasis.
• No history of traveling abroad.
• No history of trauma.

11. Family History
• Positive consanguinity.
• No history of similar condition.
Menstrual history
regular,D/C:4/28,average in amount, no
intermenstrual spotting

12. Obstetric history
2.5months ago, patient discovered to be
pregnant,although she was on
contracepive injection drugs,1 week later
patient suffered form massive vaginal
bleeding,then patient sought obstetric
consultation and diagnosed as Abortion.

13. The bleeding was horrible and
uncontrolled,which made the patient
receiving prescribed and non prescribed
treatment without limitations,about 10 to
15 tablets per day,as she thought more
pills,more control on bleeding.

14. General Examination
Patient is conscious,oriented,lies comfortable in
bed.
She is not dyspnic,not orthopnic.
She looks underbuilt.
She looks pale and jaundiced.No cyanosis
Temp 37.4 C
Blood pressure 100/60 measured in supine
position
Pulse 86 bpm.regular,equal on both sides,average
volume,intact peripheral pulsations,with no
special character.

15. General Examination cont.
• No LL edema
• No palpable LN
• Generalized skin scales, areas of
hyperpigmentation,erythematous rashes.
• Chest examination: NAD.
• Cardiac examination:NAD.

16. Abdominal Examination
• Inspection:
The abdomen moves freely with respiration,
normal sub costal angle, no epigastric pulsation,
no divercation of recti,umbilicus is midway
between xiphi-sternum and symphysis pubis and
inverted,feminine hair distribution
No visible veins
No scar of previous operation
Apparent areas of scratch marks.
Intact hernial orifices.

17. Abdominal Examination cont.
• Palpation:
Superficial:
No superficial masses, no rigidity, no
tenderness.
Deep:
No palpable abdominal
organs( liver,spleen,both kidneys)

18. Abdominal Examination cont.
Percussion
the abdomen is resonant
Liver: upper boder at 5th
intercostal space
Auscultation:
Frequently auscultated intestinal sounds

19. Investigations
Lab:
CBC:(27/4/2015)
Hb 8 gm%(Normocytic normochromic)
TLC 12.200(lymphocytes 16%,staff 5%,neutrophils
72%,monocytes 3%,eosinophils 1%,myelocytes
1%,metamyelocytes 1%,promyelocytes 1%)
Nutrophils show toxic granulations as a sign of
infection
Platlets 462.000

20. CBC repeated after 3 days(30/4/2015)
Hb 7.2(Normocytic normochromic)
TLC 8200(lymph 21%,neutrophils 71%
monocytes7%)
Platlets 417000
Retics 6%
ESR 1st
hour 105,2nd
hour 136

21. Prothrombin concentration on admission
26%,INR 2.6
After 2 days 82%,INR 1.06

22. 15/4/2015
• ALT 285
• AST 157
• Alkaline phosphatase 686
• RBS 50
• Sr.albumin 2 gm/dl
• Total bilirubin 20 mg/dl
• Direct bilirubin 17 mg/dl
• Creat 0.4
• Urea 26
• Total protein 5.16

23. 18/4/2015
• ALT 49
• AST 35
• Alkaline phosphatase 540
• RBS 78
• Sr.albumin 2.2
• Total bilirubin 15
• Direct bilirubin 5
• Creat 0.53
• Urea 36
• Total protein 5.2

24. 19/4/2015
• ALT 24
• AST 20
• RBS 83
• Sr.albumin 2.5
• Total bilirubin 13
• Direct bilirubin 5
• Creat 0.5
• Urea 35
• Total protein 5.2

25. 21/4/2015outside hospital
• ALT 32
• AST 46
• Alkaline phosphatase 985
• Total bilirubin 7.5
• Direct bilirubin 6.1

26. 30/4/2015outside hospital
• ALT 38
• AST 50
• Alkaline phosphatase 295
• Sr.albumin 2.6
• Total bilirubin 3.8
• Direct bilirubin 2.1
• Indirect bilirubin 1.7

27. • HCV Ab negative
• HBsAg negative
• HIV IgG negative
• HAV IgM negative
• Sr potassium 3.0 mmol

28. Abdominal ultrasound
(16/4/2015(
• Liver:average size,regular surface,uniform
echopattern,no IHBD or venous dilatation.
• GB:distended,thick edematous walls,with
pericholecystic collection
• Both kidneys:both at Rt side(crossed
fused kidneys(with no stones or
backpressure changes
• Mild amount of free fluid collection

29. Abdominal ultrasound
(21/4/2015(
The same as previous but no free fluid
collection and no pericholecystic collection