Hepatitis E infection.

CASE PRESENTATION A 63-year-old Indian man presented to the emergency department with fever, nausea, chills, and generalized abdominal pain that had been present for 2 weeks. Th e patient had been in India for the past 3 months and began to feel ill during the last week of his visit. He was seen by a local physician and was found to have abnormal liver function tests and was treated with sparfl oxacin and silibinin. Upon his return, the patient’s symptoms persisted, with fevers up to 102°F, and he began to have emesis. He was admitted for further workup. Th e patient had a past medical history of allergic rhinitis and gastroesophageal refl ux disease. He took omeprazole for his refl ux and had taken the sparfl oxacin and silibinin given to him while in India. He had no known drug allergies. He did have a signifi cant drinking history: in addition to having 3 to 4 drinks of brandy per day, he engaged in heavy binge drinking during his trip to India. He did not smoke or have a history of illicit drug use. Th e patient had a low-grade temperature of 100°F on admission with normal blood pressure and heart rate. On physical examination, he had signifi cant scleral icterus. His abdomen was soft and mildly distended with no appreciable ascites or hepatosplenomegaly. He had some generalized discomfort to deep palpation diff usely but no guarding or rebound tenderness. He had no spider angiomas, gynecomastia, or asterixis. His admission laboratory values were signifi cant for a total bilirubin of 9.4 mg/dL with a direct bilirubin of 6.5 mg/dL, alkaline phosphatase of 198 U/L, aspartate aminotransferase (AST) of 560 U/L, and alanine aminotransferase (ALT) of 303 U/L. His complete blood count showed a white blood cell count of 11.8 K/uL, hemoglobin of 13.1 g/dL, hematocrit of 37.1%, and platelet count of 331 K/uL. Prothrombin time was 14.4 seconds with an international normalized ratio of 1.4. Viral hepatitis serologies revealed IgG antibodies to hepatitis A virus, a positive hepatitis B surface antibody with negative From the Department of Internal Medicine, Baylor University Medical Center at Dallas.