Differential Diagnosis

The patient presents with normal white cell count (WCC) and C-reactive protein (CRP) levels, but significantly elevated lactate dehydrogenase (LDH), aspartate aminotransferase (AST), and alanine aminotransferase (ALT). This pattern suggests tissue damage or disease processes affecting the liver and possibly other tissues. Here is a categorized differential diagnosis:

• Single Most Likely Diagnosis

  • Viral Hepatitis: The marked elevation in AST and ALT with normal WCC and CRP suggests a hepatitis infection, possibly viral in nature. Viral hepatitis can cause significant elevations in liver enzymes without a substantial increase in inflammatory markers like CRP.

• Other Likely Diagnoses

  • Alcoholic Hepatitis: Although the patient's social history is not provided, alcoholic hepatitis could explain the elevated liver enzymes. It often presents with a more significant elevation in AST compared to ALT, but the pattern can vary.
  • Drug-Induced Liver Injury (DILI): Various medications and drugs can cause liver injury, leading to elevated liver enzymes. The pattern of enzyme elevation can help narrow down the cause but often requires a detailed medication history.
  • Non-Alcoholic Fatty Liver Disease (NAFLD) with Acute Exacerbation: NAFLD can lead to elevated liver enzymes, and an acute exacerbation could result in the levels seen in this patient.

• Do Not Miss Diagnoses

  • Wilson's Disease: An inherited disorder that leads to copper accumulation in the liver, causing liver damage. It's crucial to consider in young patients with elevated liver enzymes, as early diagnosis and treatment can prevent long-term damage.
  • Autoimmune Hepatitis: Although less common, autoimmune hepatitis can present with elevated liver enzymes and requires early recognition and treatment to prevent liver failure.
  • Budd-Chiari Syndrome: A condition caused by thrombosis of the hepatic veins, leading to liver enlargement and elevated liver enzymes. It's a medical emergency that requires prompt diagnosis and treatment.

• Rare Diagnoses

  • Hemophagocytic Lymphohistiocytosis (HLH): A rare disorder of the immune system where the body produces too many activated immune cells called macrophages and lymphocytes. It can cause elevated LDH and liver enzymes among other symptoms.
  • Lymphoma Involving the Liver: Certain types of lymphoma can infiltrate the liver, causing elevated liver enzymes and LDH.
  • Glycogen Storage Diseases: Rare genetic disorders that affect the body's ability to store glycogen, leading to elevated liver enzymes among other metabolic disturbances.

Each of these diagnoses requires careful consideration of the patient's clinical presentation, laboratory results, and additional diagnostic testing as needed.