Management of Jaundice with Fever and Cough in an Indian Middle-Aged Woman
The management of a patient with jaundice, fever, cough, and icterus requires prompt diagnostic evaluation to identify the underlying cause, with immediate consideration of infectious etiologies such as viral hepatitis, leptospirosis, or other systemic infections that can cause hepatic dysfunction. 1
Initial Diagnostic Approach
- Obtain comprehensive laboratory tests including complete blood count, liver function tests (ALT, AST, alkaline phosphatase, GGT, total and direct bilirubin), prothrombin time/INR, renal function tests, and arterial blood gases 1
- Collect blood cultures, urine cultures, and sputum cultures to identify potential bacterial infections 1
- Test for viral hepatitis with Anti-HAV IgM, HBsAg, anti-HBc IgM, anti-HEV IgM 1
- Consider leptospirosis testing (CSF + blood cultures) as it commonly presents with jaundice and fever 1
- Perform chest X-ray to evaluate for pulmonary involvement 1
- Conduct abdominal ultrasonography to assess liver size, biliary tract, and rule out obstruction 2, 3
Differential Diagnosis
Infectious causes:
- Viral hepatitis (A, B, E) - common cause of jaundice with fever 1
- Leptospirosis - presents with jaundice, fever, and sometimes pulmonary symptoms 1
- Enteric fever (typhoid/paratyphoid) - can present with jaundice and fever 1
- Yellow fever - if travel history to endemic areas 1
- Malaria - should be excluded in endemic regions 1
Non-infectious causes:
Immediate Management
- Hospitalize the patient for close monitoring and management 1
- Provide supportive care with intravenous fluids to maintain hydration 1
- Monitor vital signs, mental status, and liver function tests regularly 1
- Avoid hepatotoxic medications and nephrotoxic drugs 1
- Ensure adequate nutrition with 1-1.5g protein/kg and 30-40 kcal/kg body weight 1
Specific Treatment Based on Etiology
- For viral hepatitis: Primarily supportive care; specific antivirals for hepatitis B in selected cases 1
- For leptospirosis: Doxycycline (100mg twice daily) or penicillin (1.5 million units IV every 6 hours), though treatment may be less effective after jaundice has developed 1
- For enteric fever: Ceftriaxone (2g IV daily) if clinically unstable; switch to ciprofloxacin or azithromycin based on sensitivity 1
- For alcoholic hepatitis: Consider methylprednisolone 32mg daily if severe (Maddrey discriminant function >32 or MELD score >20) 1
- For drug-induced liver injury: Discontinue the offending agent 1
Monitoring and Follow-up
- Monitor liver function tests daily in severe cases 1
- Assess for complications such as hepatic encephalopathy, coagulopathy, or renal dysfunction 1
- Watch for signs of multi-organ failure which indicates poor prognosis 1
- Evaluate response to therapy with clinical improvement and laboratory parameters 1
Important Considerations
- The combination of jaundice, fever, and cough suggests possible systemic infection with hepatic involvement 1
- In India, viral hepatitis (particularly hepatitis A and E) and leptospirosis are common causes of acute jaundice with fever 1
- Respiratory symptoms may indicate pulmonary involvement in leptospirosis or a concurrent respiratory infection 1
- Alcoholic hepatitis should be considered if there is history of heavy alcohol consumption 1
Common Pitfalls to Avoid
- Delaying diagnostic workup - jaundice with fever requires urgent evaluation 1
- Missing concurrent infections - patients with liver dysfunction are susceptible to secondary infections 1
- Administering hepatotoxic medications - can worsen liver injury 1
- Overlooking renal function - acute kidney injury commonly accompanies severe liver disease 1
- Failing to consider endemic infections based on geographical location 1