Lab case 372 interpretation

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**** For more details about individual liver enzymes, please look at Lab case 367 interpretation.

Answers:

Bilirubin = 26 umol/L. that is slightly elevated. Normal range: 6-24 umol/L. At this level patients usually don’t show jaundice. (Usually, clinical jaundice starts to appear at level of 35 umol/L).

Bilirubin level increase due to increase production of bilirubin, that is usually due to RBC haemolysis or reduction in liver ability to clear the bilirubin, this can be due to intrahepatic or extrahepatic causes.

Alkaline phosphatases = 127 U/L. That is within the normal range (44 to 147 U/L). ALP are a group of isoenzymes, located on the outer layer of the cell membrane, these enzymes get elevated in the presence of obstruction, usually in post-hepatic diseases.

GGT = 311 U/L. That is elevated. Normal range is 9-48 U/L.  GGT is found throughout the body, but mostly in the liver. When there is damage to the liver, GGT leaks into the bloodstream. High levels of GGT in the blood is a sign of liver disease or damage to the bile ducts. So that tells us that the problem of hyperbilirubiaemia in this patient is due to a pathological process affecting the liver.

 ALT = 159 U/L, that is elevated. Normal range = 4 – 36 U/L.

 AST = 383 U/L, that is also elevated, normal range = 8 – 33 U/L.

Both ALT and AST are intracellular enzymes, they get released in larger quantities with cellular damage.

 Albumin = 37 g/L, that is within normal range (34 – 54 g/L)

Globulin = 36 g/L, that is slightly toward the high side (normal range = 20 – 35 g/L).

Total protein = 73 g/L, that is the combination of the two proteins above. That is within normal range (60 – 83 g/L).

This patient has transaminitis or hepatitic picture. The inflamed hepatocytes tend to swell and obstruct bile canaliculi and interfere with bile flow. This will lead to high bilirubin level.

This patient has returned from overseas with fever, she has an infection of some kind. There are multiple infections that can cause deranged liver enzymes.

These can be divided into hepatitis viruses (A to E) and non-hepatitis viruses. It is known that severe influenza infection can be associated with abnormalities in liver enzymes **. The liver can be affected as part of a generalized host infection with viruses that primarily target other tissues, particularly the upper respiratory tract. Examples of this include the herpes viruses (Epstein-Barr virus, cytomegalovirus and herpes simplex virus), parvovirus, adenovirus and coronaviruses also Dengue.

This patient had low platelets count. This can happen either due to increase platelets destruction or reduced platelets production.

Increased platelets destruction with infection is usually due to:

  • ITP (HCV, HIV, CMV, EBV, hantavirus, varicella zoster virus, herpes viruses, and corona viruses including COVID-19)
  • Dengue haemorrhagic fever
  • Influenza induced thrombocytopenia (Increased hepatic clearance of virus-containing platelets)
  • Malaria
  • DIC with severe sepsis.

Reduced platelets production with infection is caused by:

  • Viral infections (Rubella, Mumps, Varicella, Parvovirus, Hep-C, CMV, EBV and HIV)

From the 2 lists above we can see that there are multiple infective causes that can cause thrombocytopenia and deranged liver enzymes.

This patient was a returned traveler with fever. Important causes of fever to consider in a returned traveler are:

  • Malaria
  • Dengue
  • Mononucleosis (EBV or CMV)
  • Salmonella (Typhi and Paratyphi)
  • Rickettsial infections
  • TB
  • Don’t forget common infections including Influenza and COVID-19.

This patient had Dengue fever.

Dengue virus causes thrombocytopaenia *** through decreased in bone marrow production and/or increased peripheral destruction and clearance of platelets.

Thrombocytopenia in dengue is a marker of disease severity, it rarely happens with first infection (Usually preset as a flue like illness). Those who become infected with the virus a second time are at a significantly greater risk of developing severe disease and haemorrhagic complications.

 

 

** Systemic Viral Infections and Collateral Damage in the Liver. David H. Adams and Stefan G. Hubscher

*** Thrombocytopenia in Dengue: Interrelationship between Virus and the Imbalance between Coagulation and Fibrinolysis and Inflammatory Mediators. Elzinandes Leal de Azeredo, Robson Q. Monteiro and Luzia Maria de-Oliveira Pinto.

 

Special thanks to Dr Prathibha Shenoy for providing the details of this case