Differential Diagnosis for Transaminitis, Elevated Alk Phosphate, Bili, and Neck Stiffness

Single Most Likely Diagnosis

• Viral hepatitis: This condition is a common cause of transaminitis (elevated liver enzymes) and can also lead to elevated alkaline phosphatase and bilirubin levels. Neck stiffness could be indicative of a systemic infection or inflammation affecting the meninges, which can be seen in some cases of viral hepatitis, particularly in the initial stages.

Other Likely Diagnoses

• Autoimmune hepatitis: This condition can cause transaminitis, elevated alkaline phosphatase, and bilirubin levels. While less common than viral hepatitis, it is a plausible diagnosis, especially if there are other signs of autoimmunity.
• Drug-induced liver injury (DILI): Many drugs can cause liver injury, leading to elevated liver enzymes, alkaline phosphatase, and bilirubin. DILI can sometimes present with systemic symptoms, including those that might mimic neck stiffness.
• Primary biliary cholangitis (PBC): Although more commonly associated with cholestasis (elevated alkaline phosphatase and bilirubin), PBC can also cause transaminitis. However, neck stiffness is not a typical presenting symptom.

Do Not Miss Diagnoses

• Viral meningitis: Although the primary symptoms suggest liver dysfunction, the presence of neck stiffness is a red flag for meningitis, which can be deadly if not promptly treated. Some viral infections can cause both meningitis and liver enzyme elevations.
• Weil's disease (Leptospirosis): This bacterial infection can cause a wide range of symptoms, including liver dysfunction (transaminitis, elevated alkaline phosphatase, and bilirubin) and meningitis (leading to neck stiffness). It is crucial to consider this diagnosis, especially in individuals with exposure to contaminated water.

Rare Diagnoses

• Wilson's disease: A genetic disorder leading to copper accumulation in the liver, which can cause liver dysfunction (including transaminitis and elevated alkaline phosphatase) and, in rare cases, neurological symptoms that might mimic neck stiffness.
• Budd-Chiari syndrome: A condition caused by thrombosis of the hepatic veins, leading to liver dysfunction. While it can cause elevated liver enzymes and bilirubin, neck stiffness would be an unusual presenting symptom unless there was associated thrombosis or infection affecting the central nervous system.