Acute Hepatitis – Differential Diagnosis

Acute hepatitis DDx

Viral:  hepatitis A, B, C, EBV, CMV
– AST & ALT 2-3x ULN, AlkP elevated.
Drug/Toxin:  acetaminophen, alcohol, nitrofurantoin, minocycline, phenytoin, sulfasalazine, INH, antifungals, TZDs, MAOIs, SSRIs and NSAIDs.  Poisonous mushrooms, cocaine, ecstasy, PCP, ephedra, jin bu huan, germander, chaparral, pennyroyal, skullcap, kava, Herbalife, Hydroxycut.
Wilson’s disease:  consider in the young pt with hepatitis!
 – normal ceruloplasmin does NOT rule out Wilson’s
 – Kayser-Fleischer rings absent in ~50%.
 – Fulminant Wilson’s hepatitis:  lowish (<1500) AST & ALT elevation
low or normal AlkP for age (Zn cofactor displaced by Cu)
AST:ALT >2.2
AlkP:TB < 4
Cholelithiasis (AST/ALT elevations usu followed by AlkP elev)
Budd-Chiari syndrome (hepatic vein thrombosis) (RUQ pain, ascites)
Ischemic hepatitis (marked AST/ALT > 5000, elev LDH)
Lymphomatous or metastatic infiltration
Pregnancy-associated:  HELLP syndrome, intrahepatic cholestasis of pregnancy, preeclampsia, AFLP.
Autoimmune hepatitis:  (+) Ab, hypergammaglobulinemia
Czaja scoring system (ANA, anti-Sm, liver-kidney microsome Ab, soluble liver antigen Ab, liver biopsy findings) >7 definite Dx.

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