What is the diagnosis and treatment for a young female with insomnia, fatigue, chills, anorexia, neutrophilia, and mild hyperbilirubinemia?

Diagnosis and Treatment for Young Female with Insomnia, Fatigue, Chills, Anorexia, Neutrophilia, and Mild Hyperbilirubinemia

Most Likely Diagnosis

The clinical presentation of insomnia followed by fatigue, intermittent chills, loss of appetite, neutrophilia (75%), and mild hyperbilirubinemia (1.4 mg/dL) in a 27-year-old female most likely represents acute viral hepatitis or infectious mononucleosis (EBV infection), and requires immediate evaluation for alcoholic hepatitis if there is any history of alcohol use. 1, 2

Diagnostic Approach

Essential History to Obtain

• Alcohol consumption history - any recent heavy drinking (>40-60g/day for women) is critical, as alcoholic hepatitis presents with jaundice, fever, malaise, weight loss, and neutrophilia with AST>ALT ratio >1.5-2.0 1
• Recent pharyngitis or cervical lymphadenopathy - suggests infectious mononucleosis with constitutional symptoms of fatigue and malaise 2
• Medication history - drug-induced liver injury can mimic this presentation 1
• Risk factors for viral hepatitis - sexual contacts, IV drug use, tattoos 1

Critical Laboratory Tests to Order Immediately

• Complete blood count with differential - to assess for atypical lymphocytosis (suggests EBV) or true neutrophilia (suggests bacterial infection or alcoholic hepatitis) 3, 2
• Comprehensive metabolic panel - AST, ALT, alkaline phosphatase, albumin, prothrombin time/INR to assess liver synthetic function 1
• AST/ALT ratio - if >1.5-2.0 with AST >50 IU/mL but <300 IU/mL, strongly suggests alcoholic hepatitis 1
• EBV serology (VCA-IgM, VCA-IgG, EBNA) - to diagnose infectious mononucleosis 3, 2
• Hepatitis A, B, C serologies - to rule out acute viral hepatitis 1
• Peripheral blood smear - can rapidly identify atypical lymphocytes (EBV) or abnormal cells 3

Imaging if Indicated

• Abdominal ultrasound - to assess liver echogenicity, rule out biliary obstruction, and evaluate spleen size (splenomegaly suggests EBV) 2

Treatment Based on Most Likely Diagnoses

If Alcoholic Hepatitis (Maddrey Score ≥32 or MELD ≥21)

• Prednisolone 40 mg daily for 28 days if severe disease (bilirubin >5 mg/dL with prolonged PT or encephalopathy/ascites) 1
• Nutritional support - aggressive caloric supplementation as malnutrition is common 1
• Abstinence from alcohol - monitor with urine or hair ethyl glucuronide (EtG) testing 1
• Transjugular liver biopsy if diagnostic uncertainty exists, to confirm diagnosis and rule out other causes 1

If Infectious Mononucleosis (EBV)

• Supportive care only - rest, hydration, and symptomatic treatment 4, 2
• Paracetamol for fever and malaise - avoid NSAIDs in context of potential hepatitis 4
• Avoid contact sports for 3-4 weeks due to splenomegaly and rupture risk 2
• Clinical follow-up every 6-12 months for first 2-3 years to monitor for EBV-associated lymphoma development (Burkitt lymphoma, Hodgkin lymphoma, DLBCL) 2
• Patient education about warning signs - painless progressive lymph node enlargement, B symptoms (fever, night sweats, weight loss), or persistent fatigue warrant immediate re-evaluation 2

If Acute Viral Hepatitis (HAV, HBV, HCV)

• Supportive care - rest, adequate hydration, avoid hepatotoxic medications 1
• Monitor liver function tests weekly until improvement 1
• Antiviral therapy for HBV - consider if severe acute hepatitis or evidence of liver failure 1

Management of Insomnia and Anorexia

The insomnia and loss of appetite are likely secondary to the underlying acute illness rather than primary eating or sleep disorders. 5, 6, 7

• Reassurance that sleep and appetite should normalize as the acute illness resolves 4
• Short-term symptomatic treatment - honey for cough if present, adequate hydration 4
• Avoid codeine or sedatives unless absolutely necessary, as they can worsen hepatic encephalopathy if liver dysfunction is present 4

Red Flags Requiring Immediate Hospitalization

• Coagulopathy (INR >1.5) - suggests acute liver failure 1
• Encephalopathy - confusion, altered mental status 1
• Hypotension or severe electrolyte disturbances - suggests adrenal insufficiency or severe dehydration 1
• Bilirubin >5 mg/dL with prolonged PT - indicates severe alcoholic hepatitis requiring corticosteroids 1
• Severe abdominal pain - could indicate splenic rupture if EBV with splenomegaly 2

Common Pitfalls to Avoid

• Do not dismiss as simple viral illness without checking liver enzymes and AST/ALT ratio - alcoholic hepatitis has 30-50% mortality if severe and untreated 1
• Do not attribute neutrophilia solely to viral infection - neutrophilia is characteristic of alcoholic hepatitis, not typical viral infections 1
• Do not miss EBV-associated lymphoma risk - patients with infectious mononucleosis require long-term surveillance for lymphoma development 2
• Do not start corticosteroids without ruling out infection - sepsis can mimic alcoholic hepatitis 1