Medical Case: A rare of jaundice in a farmer

62-year-old woman with fatigue, jaundice, fever, and kidney injury. Can you guess the diagnosis?

A farmer woman in the emergency room

One morning in September, S.R., a 62-year-old woman living in a rural area and engaged in agricultural activities, presented to the emergency room. The patient arrived at the hospital complaining of fatigue, general malaise for several days, nausea, fever and the appearance of jaundice. There was no abdominal pain, diarrhea, or changes in her usual diet. There was no weight loss in the preceding time.

Physical examination

The woman was 62 years old, BMI within normal limits. The physical examination performed in the emergency room gave the following findings:

• sensory examination negative, apyretic;
• pulse arrhythmic and tachycardic, remaining vital parameters within normal range;
• skin and mucous membranes jaundiced, dehydrated;
• petechiae in oral cavity.

Nothing to report on remaining objectivity.

Medical history

The patient lived in the countryside and worked in the fields and in contact with farm animals. The patient was married with a husband who was still alive and healthy and had completed two pregnancies. The patient reported that she had smoked up to 10 years earlier (about 10 cigarettes a day). She drank a glass of wine with meals.

Past medical history:

• hypertension;
• dyslipidemia;
• previous hepatitis, likely type A.

The patient was taking drug therapy including statins, beta-blockers and PPIs.

Laboratory findings

• Neutrophilic leukocytosis (WBC 19.98 x10^9/L), severe thrombocytopenia (PLT 18 x10^9/L).
• Total bilirubin 23 mg/dL, direct bilirubin 21 mg/dL.
• Acute kidney injury (creatinine 4.2 mg/dL, urea 36.2 mmol/L) and electrolyte imbalance (Na+ 122 mmol/L, K+ 3 mmol/L).
• Elevated inflammatory markers: CRP 120 mg/L, procalcitonin 2.1 µg/L.
• Muscle necrosis CPK (700 U/L).
• Coagulation: PT and aPTT normal, D-dimer 1389 ug/L
• Urinalysis: proteinuria, hemoglobinuria, and bilirubinuria.

Radiology and instrumental diagnostics

ECG: AF tachyarrhythmia, FVM 130 bpm, no changes in repolarisation.
Chest X-ray: increased background transparency; slight accentuation of perilymph pattern; free costophrenic sinuses cardiac shadow at large values.
Echo abdomen: alithiasic cholecyst, no dilatation of biliary tract, regular spleen, kidneys within limits.

Clinical and diagnostic pathway

A) Acute cholangitis: The presence of jaundice and fever could suggest biliary pathology; however, abdominal ultrasound showed no bile duct dilation or gallstones.
B) Acute viral hepatitis: Hyperbilirubinemia and the clinical context might support this diagnosis. Serological investigation needed. 
C) Leptospirosis (Weil's syndrome): Jaundice, fever, acute kidney injury and thrombocytopenia strongly suggest this infection. Additional anamnestic information needed.
D) Thrombotic microangiopathy: Petechiae, jaundice, and acute kidney injury are compatible, but the absence of anemia and schistocytes in the peripheral smear makes this less likely.
E) Severe sepsis of unknown origin: Elevated inflammatory markers support this hypothesis, but no clear infectious source was identified.

Additional information was collected. Serology for HAV, HBV and HCV was negative. Information on contact with animals was sought. The patient and her husband reported the frequent presence of rats around their home.