A 27-year-old medical student who recently (3 weeks ago) began a 9-month treatment of isoniazid for latent tuberculosis after a positive purified protein derivative (PPD) test presents for follow-up. He has no complaints and reports refraining entirely from alcohol use. Physical examination is unremarkable and laboratory results reveal the following:
Which of the following is the next best step in management of this patient?
Continue current treatment regimen. A 9-month course of isoniazid (INH) is recommended for latent tuberculosis infection. INH is also used in active tuberculosis infection with rifampin, ethambutol, and pyrazinamide. A mild hepatotoxicity can occur in some patient on INH therapy. The risk of hepatotoxicity on INH treatment increases if the patient consumes alcohol during the treatment regimen. Nevertheless, up to 20% of patients on INH will encounter a mild hepatic injury regardless of alcohol use with mild increases in ALT and AST (usually <100 U/L). This is self-limited though and does not affect the prognosis of the patient. The recommendation is to continue the INH treatment with close follow-up and monitoring of liver function tests.
(B) A second-line anti-tuberculosis medication can be used in cases of severe hepatotoxicity (which this patient does not demonstrate). (C) A liver biopsy is important in cases of unknown etiology. The AST/ALT elevations here are known to be due to INH treatment, making it unnecessary to perform a liver biopsy. (D) Three weeks is not sufficient time to clear the latent Mycobacterium tuberculosis infection, so all anti-tuberculosis medications should not be discontinued.
A 64-year-old man is on his third postoperative day after a partial small bowel resection and is noted to have jaundice. The surgery was successful and the patient had no complications intraoperatively other than a few mild hypotensive episodes for which he received three units of packed red blood cells. The patient is afebrile and the physical examination demonstrates jaundice. Abdominal examination demonstrates a soft nontender, nondistended abdomen. Laboratory results reveal the following:
Which of the following is the most likely diagnosis?
Postoperative cholestasis. The patient in this question is showing signs, symptoms, and laboratory findings consistent with a diagnosis of postoperative cholestasis. This condition is benign and commonly occurs after surgeries with hypotension and significant blood loss. The jaundice that develops with this condition is thought to occur from decreased liver function (thought to be secondary to the hypotensive episodes) and diminished bilirubin clearance (thought to be secondary to renal tubular necrosis). Jaundice occurs by the third postoperative day and laboratory findings typically show elevated total bilirubin and alkaline phosphatase levels. (B) Acute liver failure is associated with coagulation abnormalities (not seen in this patient) and hepatic encephalopathy. (C) Unlike in the past, posttransfusion hepatitis is exceedingly rare nowadays since blood products are thoroughly screened. (D) Although this condition is benign, this is not to (and should not) be considered a normal postoperative finding. Bilirubin levels should be monitored to demonstrate improvement of the cholestasis.
A 31-year-old woman presents with anxiety that she might have contracted viral hepatitis. She is a volunteer at the local hospital and although she reports no needle stick injuries or direct exposure to blood, she is concerned because 5 months ago she was observing a paracentesis without eye protection on a patient with chronic hepatitis B infection and she reports that ascites fluid splashed into her eyes as the physician was completing the procedure. Hepatitis B panel is ordered and reveals the following:
What is the patient’s status with respect to hepatitis B infection?
Vaccination against hepatitis B infection. The patient in this question would like to know whether or not she contracted hepatitis B (HBV) infection from her ascites exposure. In this case, the patient presents with positive anti-HBsAg but negative HBsAg and other HBV serologic tests. This is consistent with vaccination against hepatitis B. Anti-HBsAg appears in the serum after HBV vaccination or elimination of HBsAg, so this is detectable for life and signifies a noninfective state and immunity. Of note, there is a period called the “window period” in which there is a period of time between the elimination of HBsAg and appearance of anti-HBsAg. See Figure below for full details. (A) Chronic HBV infection would have positive HBsAg (must be present for more than 6 months to be chronic). (C) Previous hepatitis B infection with full recovery would be positive for anti-HBsAg (as in this patient) and negative for HBsAg. However, these patients will also be positive for anti-HBcAg against the viral core antigen HBcAg. This will not be found in vaccinated individuals, as the HBV vaccine does not contain core antigen. (D) Acute hepatitis B infection would have positive HBcAb, specifically IgM. This is in contrast to a chronic carrier state in which there is positive HBcAb, but it is IgG. Other serologic markers characteristic of acute hepatitis B infection include positive HBsAg and negative HBsAb (too early to mount a response yet).
A 71-year-old man with a history of hypertension presents with cough, foul breath, a sense of having a “lump” in his neck, and subjective fevers. He reports that he has had much difficulty swallowing his meals and admits to often regurgitating undigested food particles. He has a temperature of 38.5°C, blood pressure of 132/90 mmHg, heart rate of 104 beats per minute, and a respiratory rate of 18 breaths per minute. Physical examination is significant for foul-smelling breath, but is otherwise unremarkable.
Which of the following is the best next step in the diagnostic workup of this patient?
: Esophagram barium swallow study. The patient is presenting with signs and symptoms (halitosis, cough, dysphagia, sense of throat “lump”) consistent with a presumptive diagnosis of Zenker diverticulum, a diverticulum of the mucosa of the pharynx just above the upper sphincter of the esophagus. It is a false diverticulum (not involving all layers of the esophageal wall). The halitosis results from settling of the food material in the diverticulum. Occasionally, one can palpate a Zenker diverticulum (if large) and patients are at risk for aspiration pneumonia. The best diagnostic test to order is an esophagram barium swallow study. Definitive treatment is surgical intervention. (A) Upper GI endoscopy is contraindicated when Zenker diverticulum is suspected, as it can potentially cause perforation. (C) Bronchoscopy might be indicated if this patient had presented with recurrent pneumonias consistent with an obstructing mass, but that is not the case in this scenario. (D) Gastric feeding tube placement is not indicated as Zenker diverticulum is treated with surgery and the patient will be able to resume his normal dietary habits.
A 39-year-old man with a history of alcoholism presents with 2 days of unrelenting midepigastric abdominal pain that radiates to the back. The patient reports some relief with leaning forward. He has vomited several times and is febrile. The patient reports drinking 10 to 12 beers per day for the last 15 years. Laboratory findings reveal severely elevated amylase and lipase and chest x-ray confirms left pleural effusion and an elevated hemidiaphragm.
Which of the following is the best initial treatment for this patient’s condition?
Supportive care. The patient in this question is presenting with classic symptoms and laboratory values consistent with a diagnosis of acute pancreatitis (midepigastric abdominal pain that radiates to the back, vomiting, elevated lipase and amylase, pleural effusion). The best treatment initially with acute pancreatitis is supportive management consisting of making the patient nil per os (NPO), administration of IV fluids, and pain management. (A) Broad-spectrum antibiotics are often used in the treatment of severe pancreatitis (often associated with signs of hemorrhage, i.e., Grey Turner sign of flank ecchymoses). The antibiotic of choice is typically imipenem. (B) Corticosteroids are not useful in the treatment of acute pancreatitis. (D) Administration of pancreatic enzymes and vitamin B12 is used in the treatment of chronic pancreatitis, not acute pancreatitis.
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