Differential Diagnosis

The patient presents with significantly elevated AST/ALT levels, jaundice for an extended period, positive IgM Hepatitis A, splenomegaly, and lymph nodes in the porta hepatis on ultrasound. Here's a structured approach to the differential diagnosis:

• Single Most Likely Diagnosis

  • Acute Hepatitis A: The presence of IgM antibodies against Hepatitis A virus is a strong indicator of an acute Hepatitis A infection. The elevated liver enzymes (AST/ALT) and jaundice are consistent with this diagnosis. Hepatitis A typically causes a self-limiting illness, but the prolonged duration of jaundice (90 days) might suggest a more severe or complicated course.

• Other Likely Diagnoses

  • Chronic Hepatitis: Although the IgM Hepatitis A suggests an acute infection, the prolonged jaundice and significant elevation of liver enzymes could also be seen in chronic hepatitis, especially if the patient has a co-existing condition like chronic hepatitis B or C, which could have been reactivated or exacerbated.
  • Autoimmune Hepatitis: This condition can present with elevated liver enzymes and jaundice. The presence of lymph nodes in the porta hepatis could suggest an autoimmune or inflammatory process.
  • Drug-Induced Liver Injury (DILI): Certain medications can cause significant liver enzyme elevation and jaundice. The history of medication use should be thoroughly investigated.

• Do Not Miss Diagnoses

  • Wilson's Disease: A genetic disorder that leads to copper accumulation in the liver, which can cause liver dysfunction, elevated liver enzymes, and jaundice. It's crucial to consider this diagnosis due to its potential for severe liver damage and the availability of specific treatments.
  • Budd-Chiari Syndrome: Thrombosis of the hepatic veins can cause liver enlargement, ascites, and abdominal pain. The presence of splenomegaly and lymph nodes in the porta hepatis could be indicative of portal hypertension, which might be seen in Budd-Chiari syndrome.
  • Lymphoma: Although less common, lymphoma involving the liver and spleen could explain the splenomegaly, lymphadenopathy in the porta hepatis, and elevated liver enzymes.

• Rare Diagnoses

  • Primary Biliary Cholangitis (PBC): An autoimmune disease of the liver characterized by a progressive destruction of the bile ducts within the liver. It typically presents with cholestatic liver enzyme elevation rather than the hepatocellular pattern seen here, but it's a consideration in the differential diagnosis of chronic liver disease.
  • Primary Sclerosing Cholangitis (PSC): A chronic liver disease characterized by inflammation and fibrosis of the bile ducts. It could present with elevated liver enzymes, jaundice, and lymphadenopathy, although it's less common than other diagnoses listed here.