Clinical scenario:
A 32-year-old female presented with a history of high-grade fever and jaundice of 2 weeks duration following a lower section cesarean section in a local hospital. The patient had started icterus 1-week prior to the lower section cesarean section without any viral prodrome or offending drug intake. She denied any fever, pruritus or clay colored stools before surgery.
There was no history of intake of any herbal medication. She underwent lower section caesarean section due to intrauterine death at 37 weeks of gestation. Apart from bilirubin levels of 3 mg/dl, all her investigations were normal before surgery. She had delivered her first baby uneventfully 2 years earlier and had no other significant history.
Examination in our hospital revealed an averagely built lady, conscious, and hemodynamically stable with no signs of chronic liver disease. She was icteric and had a temperature of 38°C. The scar of surgery was healthy with no local discharge. Her systemic examination was unremarkable.
Evaluation: she had hemoglobin of 10.6 g/dl with a total leukocytic count of 7000/cu mm,
a platelet count of 515 × 103 blood urea nitrogen, and serum creatinine were normal.
Liver function test showed bilirubin levels of 8 mg/dl (direct fraction of 6.8 mg/dl). Her serum (SGOT), (SGPT) levels were 43 and 24 IU respectively. Her alkaline phosphatase and gamma-glutamyltransferase were 117 and 55 respectively.
The ultrasound showed gallstones with no intrahepatic biliary dilatation. In view of the gall stones, magnetic resonance cholangiopancreatography (MRCP) was done and biliary obstruction ruled out.
All viral markers were negative .On further evaluation, her antinuclear antibody and anti-smooth muscle antibody levels were also negative. Her serum ceruloplasmin and serum ferritin levels were normal. Computed tomographic study of the abdomen and pelvic organs showed no abnormality and there was no collection to explain pyrexia.
Her leukocytic counts on multiple occasions in the hospital course continued to be normal and all cultures were sterile. She was initially started on broad spectrum antibiotics which
were stopped as there was no objective evidence of sepsis. During her hospital stay Bilirubin levels increased to 10 mg/dl, and liver enzymes SGOT/SGPT were 52 and
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Fig 1 Liver biopsy showing acute fatty liver of pregnancy
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48 IU respectively. Coagulation parameters continued to be normal and fibrinogen degradation product levels were normal as well. Serum protein and serum albumin levels were normal. A liver biopsy was done (Fig 1) which showed microvesicular steatosis and an oil red O staining the cytoplasmic vesiculation were seen as a result of microvesicular fat. The overall histological features were consistent with acute fatty liver of pregnancy (AFLP).She was managed conservatively and
was discharged home in a stable condition after 12 days of hospitalization. She has been attending our clinic regularly for the past 1-year.
Teaching message : Fever and Jaundice rule out obstructive jaundice but look beyond obvious.
This case was submitted by
Dr Abed Al- Lahibi
Consultant Gastroenterologist
King Fahad Medical city Riyadh KSA
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