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A 32-year-old woman is evaluated for arthralgia and jaundice. Three months earlier, she traveled to Mexico for a 2-week vacation and developed nausea, vomiting, abdominal pain, fever, and jaundice approximately 3 weeks after returning to the United States. Testing for hepatitis A virus IgM was positive, and she was treated with supportive measures. Her symptoms and jaundice resolved within 3 weeks. A few weeks later, jaundice reappeared along with arthralgia. The patient's medical history is otherwise unremarkable, and she takes no medication. On physical examination, vital signs are normal; BMI is 27. Jaundice is noted. The remainder of the examination is unremarkable.

Laboratory studies:
- Alkaline phosphatase: 272 U/L
- Alanine aminotransferase: 775 U/L
- Aspartate aminotransferase: 672 U/L
- Total bilirubin: 5.8 mg/dL (99.2 mmol/L)

The results of other studies, including a complete blood count, INR, serum creatinine level, antinuclear antibody, anti-smooth muscle antibody, and total IgG level, are within normal limits. Ultrasonography of the liver is normal.

Which of the following is the most likely diagnosis?

1) Autoimmune hepatitis
2) Leptospirosis
3) Malaria
4) Relapsing, remitting hepatitis A viral infection

Answer :

Final answer:

The most likely diagnosis for the patient is a relapsing, remitting hepatitis A viral infection, given her symptoms, positive hepatitis A virus IgM test, and elevated liver function test results.

Explanation:

Given the available information, the likely diagnosis is a relapsing, remitting hepatitis A viral infection. Hepatitis A is typically characterized by symptoms such as jaundice, nausea, vomiting, joint pain, gray stool, and loss of appetite, all of which this patient has exhibited. Improvements in her symptoms upon initial treatment and a later resurgence of symptoms suggest a relapse of the infection.

A key factor supporting this diagnosis is the fact that the patient's hepatitis A virus IgM was positive. IgM antibodies are the first antibodies to be made by the body to fight a new infection, thereby indicating an active hepatitis A infection. Additionally, the patient's increased levels of alkaline phosphatase, alanine aminotransferase (ALT), aspartate aminotransferase (AST), and total bilirubin point towards a liver disease such as hepatitis.

While the other presumed conditions (autoimmune hepatitis, leptospirosis, malaria) could present with similar symptoms, the positive test for hepatitis A virus IgM as well as a prior history of hepatitis A infection makes a relapsing, remitting hepatitis A viral infection the most likely prognosis.

Learn more about Hepatitis A here:

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