ANSWER 8
The diagnosis is likely to be acute viral hepatitis. The biochemical results show abnormal
liver function tests with a predominant change in the transaminases, indicating a hepato-
cellular rather than an obstructive problem in the liver. This might be caused by hepatitis A,
B or C. The raised white count is compatible with acute hepatitis. Homosexuality and intra-
venous drug abuse are risk factors for hepatitis B and C. Other viral infections such as
cytomegalovirus and herpes simplex virus are possible.
Since the drug ingestion history is unclear, there is a possibility of a drug-induced hepatitis.
The prodromal joint symptoms suggest a viral infection as the cause, and this is more com-
mon with hepatitis B. Serological tests can be used to see whether there are immunoglobu-
lin M (IgM) antibodies indicating acute infection with one of these viruses, to confirm the
diagnosis. The reported negative HIV test 6 months earlier makes an HIV-associated condi-
tion unlikely although patients are not always reliable in their accounts of HIV tests, and
HIV seroconversion should also be considered.
Treatment is basically supportive in the acute phase. The prothrombin time in this patient
is raised slightly but not enough to be an anxiety or an indicator of very severe disease.
Liver function will need to be measured to monitor enzyme levels as a guide to progress.
Alcohol and any other hepatotoxic drug intake should be avoided until liver function tests
are back to normal. If hepatitis B or C is confirmed by serology then liver function tests
and serological tests should be monitored for chronic disease, and antiviral therapy then
considered. Rare complications of the acute illness are fulminant hepatic failure, aplastic
anaemia, myocarditis and vasculitis. The opportunity should be taken to advise him about
the potential dangers of his intake of cigarettes, drugs and alcohol, and to offer him
appropriate support in these areas.
- Viral hepatitis is often associated with a prodrome of arthralgia and flu-like symptoms.
- Confirmatory evidence should be sought for patients’ reports of HIV test results.