Clin Med
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Observational Study
Blood alanine aminotransferase levels >1,000 IU/l - causes and outcomes.
Standard medical education dictates that the vast majority of cases of an alanine aminotransferase (ALT) level >1,000 IU/l will be due to acute ischaemia, acute drug-induced liver injury (DILI) (usually paracetamol) or acute viral hepatitis. There are very few references in the literature to other potential causes of an ALT >1,000 IU/l nor to the prognosis ascribed to each aetiology. ⋯ Common bile duct stones and hepatitis E are two causes for which there needs to be a high index of suspicion as the necessary tests may not be in the clinician's first-line investigation panel. Failing to find a cause and determining that the cause was ischaemic both have poor prognostic implications.
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The systemic autoinflammatory syndromes often present with recurrent fevers. They have proved exceptionally informative about the innate immune system. Although extremely rare, they are important to recognise, as many can now be completely controlled by long-term drug therapies. Diagnosis relies on clinical suspicion followed by genetic testing.
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The Royal College of Physicians' Acute care toolkit 10 has recommended the use of the AMB score as an aid to determining patients suitable for ambulatory care. As this score has only been previously validated in one centre, the present study calculated the score of 200 patients referred to the medical take to see if it successfully identified patients who had a length of stay of less than 12 hours. In our test centre, the score was found to have a reduced sensitivity compared with the original centre (88 vs 96%) and a positive predictive value of 39%. Therefore in our hospital this was not a useful scoring system, and other trusts need to be aware that the AMB score may not be as effective as the original study suggested.
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Fevers are relatively common in rheumatic disease, largely due to the fact that the inflammatory process is driven by inflammatory mediators that function as endogenous pyrogens. Since the immune system's sensors cannot accurately distinguish between endogenous and exogenous (pathogen-derived) pyrogens a major challenge for physicians and rheumatologists has been to decipher patterns of clinical signs and symptoms to inform clinical decision making. Here we describe some of the common pitfalls and clinical challenges, and highlight the importance of a systematic approach to investigating the rheumatic disease patient presenting with fever.