Review Topic
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  • A 28-year-old man presents to his primary care physician for fatigue, malaise, and abdominal pain. He reports his symptoms began a few days ago and have progressively worsened. His symptoms are associated with nausea, 2 episodes of emesis, and generalized pruritus. Social history is significant for recent travel to India. He is currently sexually active with multiple men and does not use condoms. Physical examination is notable for scleral icterus, generalized jaundice, and hepatomegaly. Serologic testing is remarkable for anti-HAV IgM antibodies.
  • Classification
    • a Hepatovirus in the Picornaviridae family
      • single-stranded positive-sense RNA virus with an icosahedral capsid
  • Epidemiology
    • risk factors
      • sexual contact
      • working in a daycare
      • serving in the military
      • eating raw or undercooked shellfish and vegetables
  • Transmission
    • via the fecal-oral route 
  • Pathogenesis
    • within the cytoplasm of a hepatocyte, the virus replicates
      • CD8+ T-cells and natural killer cells destroy the infected hepatocytes, leading to hepatocellular damage
        • when the immune response to the infected hepatocytes is severe, it can result in severe hepatitis
  • Prognosis
    • typically a self-limited illness
    • does not become a chronic condition
  • Symptoms
    • nausea and vomiting
    • anorexia
    • abdominal pain
    • dark urine
    • pale stools
  • Physical exam
    • hepatomegaly
    • jaundice and scleral icterus
  • Serologic testing
    • anti-HAV IgM 
      • active infection is present
    • anti-HAV IgG
      • a previous infection was present
      • no active disease
      • the patient is protected against infection
    • elevated aminotransferases
  • Hepatitis B infection 
    • differentiating factors
      • presence of anti-hepatitis B antibodies in serological testing
  • Hepatitis C infection
    • differentiating factor
      • presence of anti-hepatitis C antibodies in serological testing
  • Medical
    • hepatitis A virus (HAV) vaccine
      • indication
        • all children at 1 year of age
        • all children between ages 2 and 18 who live in an area with a high disease incidence
        • people who travel or work in countries with a high disease incidence
        • men who have sex with men
        • illicit drug users
        • patients with chronic liver disease
      • comments
        • used to protect against exposure to the HAV
    • immune globulin
      • indication
        • in infants < 6 months of age
        • in travelers who have a contraindication to the vaccine (e.g., allergy)
      • comments
        • this provides passive immunization against the HAV
    • hepatitis A virus vaccine and immune globulin
      • indication
        • patients with chronic liver disease
        • immunocompromised patients who are not able to mount an adequate immune response to the hepatitis A vaccine
  • Cholestatic hepatitis
  • Fulminant hepatitis (< 1% of cases)

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Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2

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(M1.MC.15.16) A 35-year-old male comes to clinic with a 1 week history of diarrhea, fatigue, fever, and nausea. He states that he recently returned from a trip to India and that his wife also has similar symptoms. They did not receive any immunizations prior to embarking on this trip. He admits to recent unprotected sexual encounters, frequent alcohol use, and a distant history of IV drug use. Furthermore, he reports receiving a blood transfusion after a motor vehicle accident 5 years ago. On exam, he is noted to have a fever of 101.8 and his eyes are as seen in Figure A. Which of the following risk factors is most likely responsible for his condition? Review Topic | Tested Concept

QID: 104807

Unprotected sex




History of IV drug use




Recent international travel




History of blood transfusions




Alcohol consumption



L 2 E

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