Dear Editors:

Would appreciate your insight into an interesting case. The pt. is a 65 yr. old female in prior good health who has had a 2 week hx of low-grade fever, malaise and anorexia (no wt. loss). No routine meds, no chronic illnesses, no correlating signs per source of infection. Symptoms are stable. Had been in China 2 weeks prior to onset. Remarkable lab results include elevations in Alk Phos (170), AST (60), ALT (90), WBC of 12.8, which has been slowly increasing. Differential shows 30% segs, 62% lymphocytes. Alk phos isoenzymes show 65% liver, 17% bone, 0% intestine and 18% macrohepatic. Plain chest film read out as small opacity on lateral view in the posterior sulcus. Pending diagnostics include CT of the chest, abdomen, pelvis. Cultures of blood, stool, and sputum also are pending as is malaria smear, febrile agglutinins, and hepatitis panel. Am I justified in my concern that this could be from non-infectious sources i.e. metastatic liver CA or am I missing something? Pt. empirically started on Tequin and Zithromax. Could you expound on the significance of the elevated macrohepatic Alk Phos plus other possibilities you would entertain in this situation.

Thank you.

BH, MD

Dear BH:

I can only comment in a general sense regarding your case. An elevated alkaline phosphatase of a hepatic nature could be from intrahepatic liver disease or biliary tract disease, obstructing either small or large bile ducts. The recent trip to China, systemic symptoms, and lymphocytosis suggests an infectious illness. I would continue your work-up, taking these points into consideration.

Emmet Keeffe, MD

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