Learning Objective Discuss the differential diagnosis of unconjugated hyperbilirubinemia in alcoholic liver disease.
Case A 43 year-old male with history of hepatitis C, cholelithiasis and alcoholic liver disease presented with a 20-day history of fever, worsening jaundice, pain and swelling in his left leg without prior trauma. He had been admitted a month earlier for similar complaints and treated as cellulitis after a negative workup for DVT. Examination was remarkable for a temperature of 100°C, icterus, hepatomegaly and an erythematous, tender, swollen left leg. Laboratory data: Hb 8.5g/dL, WBC 6.4 k/μL, platelet 118 k/μL, MCV 115 fl, T.bil 9.4 mg/dL, C.bil 3.3 mg/dL, AST 98 U/L, ALT 40 U/L, Alkaline phosphatase 220 U/L, INR 1.7, LDH 1525 U/L, vitamin B12 > 1000 pg/mL, normal folate and potassium levels. He was started on antibiotics for presumed unresolved cellulitis. Further evaluation revealed persistently negative blood cultures, macrocytic peripheral smear, negative Coombs' test and no evidence of biliary obstruction. MRI was obtained to rule out osteomyelitis due to unresponsiveness to therapy. Imaging revealed a large hematoma extending from lower thigh into the calf as seen in Figure 1.
Discussion The main differential diagnoses for a predominantly unconjugated hyperbilirubinemia in alcoholic patients include hemolysis (spur cell anemia and Zieve's syndrome), ineffective erythropoiesis, sepsis and hepatitis. In our patient, the underlying hematoma was masked as it mimicked features of cellulitis. Hemolysis within the hematoma along with alcoholic hepatitis was most likely responsible for this presentation. This case highlights the need to suspect an underlying hematoma after excluding other etiologies of unconjugated hyperbilirubinemia. Figure 1. MRI showing extension of the hematoma collection.