Contributed by Andrew Freeman, MD and Lirong Qu, MD, PhD
A female in her 20s presented to the ED for worsening right upper quadrant abdominal pain, nausea/vomiting, malaise, fever/chills, and jaundice. She has no significant past medical history, however, was recently seen for similar symptoms a few days prior. At that time, she had bloodwork done that was diagnostic for acute infectious mononucleosis, including a positive monospot test and IgM Epstein-Barr virus (EBV) antibodies (with negative IgG EBV antibodies), and mildly elevated AST, ALT, and bilirubin.
Because of the patient's worsening symptoms and new-onset jaundice, she was admitted to the hospital for further workup. A right upper quadrant ultrasound was obtained and showed no pathologic abnormalities. The patient's initial total bilirubin was noted to be severely elevated at 32.3 mg/dL (RR: 0.3-1.5 mg/dL). Additional testing was performed with chemistry (Table 1), hematology (Table 2), Immunology (Table 3), and Blood Bank (Tables 4-7) results and their trends shown below. A peripheral blood smear was performed and is shown below in Figure 1. The patient received 2 units of red blood cells on day 3 of her hospitalization. She was otherwise managed with supportive therapy and steadily improved. She was discharged on day 5 in stable condition.
Figure 1. Peripheral Blood Smear (Medium and High Power)