Detailed Treatment Process
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Gender: Female Age: 18 years Discharge summary Department: Gastroenterology Admission date: November 8, 13:23 Discharge date: November 17, 08:30 Outpatient diagnosis: Liver damage Admission diagnosis: Liver damage Discharge diagnosis: 1. EBV infectious mononucleosis; 2. EBV hepatitis; 3. Infectious hemophagocytic syndrome; 4. Tonsillitis; Main symptoms and signs on admission: Chief complaint: Eyelid swelling accompanied by cough and sore throat for 2 weeks, abnormal liver function discovered 1 day ago. Physical examination: Clear consciousness, stable breathing, cooperative for examination, appropriate responses. No jaundice, rash, or petechiae on the skin or mucous membranes. Bilateral eyelid edema, enlarged lymph nodes in the neck and behind the ears. Pupils equal and round, reactive to light. No lip cyanosis. Supple neck, trachea midline, no jugular venous distension, no thyroid enlargement. Clear breath sounds in both lungs, no dry or moist rales. No abnormal precordial bulge, heart rate 82 beats/min, regular rhythm, normal heart sounds, no extra heart sounds or pathological murmurs, no pericardial friction rub. Abdomen soft and flat, no tenderness, rebound tenderness or muscle tension, liver and spleen not palpable below the costal margin, no shifting dullness, normal bowel sounds. No edema in the lower limbs. Neurological examination negative. BP 112/62 mmHg.
Main laboratory results: (November 7) Blood routine (five-classification): White blood cell count 20.1 × 10⁹/L↑, monocytes 7.0%, lymphocytes 73.0%↑, eosinophils (data missing) %, basophils (data missing) %, red blood cell count 4.57 × 10¹²/L, hemoglobin 129 g/L, hematocrit 39.0%, mean corpuscular volume 85.3 fl, mean corpuscular hemoglobin 28.2 pg, mean corpuscular hemoglobin concentration 330 g/L, red cell distribution width (CV) 14.5%, platelet count 196 × 10⁹/L, mean platelet volume 8.70 fl, neutrophils 11.0%↓, atypical lymphocytes 9.00% (November 7) Creatinine + BUN (urgent): Creatinine (dry slide method) 71.5 umol/L, urea nitrogen (dry slide method) 3.0 mmol/L (November 7) Liver function (urgent): Bile acids 68.2 umol/L↑, alanine aminotransferase (dry slide method) 559.0 U/L↑, total bilirubin (dry slide method) 33.7 umol/L↑, aspartate aminotransferase (dry slide method) 558.0 U/L↑, direct bilirubin (dry slide method) 0.60 umol/L, albumin (dry slide method) 38.1 g/L, alkaline phosphatase (dry slide method) 537 U/L↑, GGT (dry slide method) 188 U/L↑, total protein (dry slide method) 84.3 g/L↑, albumin/globulin ratio 0.82↓ (November 7) UF100 urine sediment: Yeast-like fungi 0.00, red blood cells 58.20 /uL↑, casts 0.43 /uL, epithelial cells 49.60 /uL↑, pathological casts 0.24 /uL, small round epithelial cells 0.00 /uL, crystals 0.00 /uL, red blood cell information mixed type, bacteria 1799.10 /uL↑, conductivity 12.20 ms/cm, white blood cell count 176.70 /uL↑ (November 7) Urinalysis: Clarity clear, urine bilirubin 3 mg/dL↑, color yellow, red blood cell hemoglobin negative /uL, urine glucose normal mg/dL, crystals (microscopy) not found/HP, urine ketones 5 mg/dL↑, granular casts not found/LP, leukocyte esterase negative /uL, urine nitrite negative, yeast-like fungi not found, urine pH 5.00↓, urine protein negative mg/dL, red blood cells (microscopy) not found/HP, specific gravity 1.020, epithelial cells (microscopy) not found/HP, hyaline casts not found/LP, urobilinogen 4.00 mg/dL↑, white blood cells (microscopy) not found/HP, cellular casts not found/LP (November 16) Renal function (inpatient) + liver function (inpatient): Fibronectin 264.00 mg/L, glycocholic acid 11.8 mg/L↑, prealbumin 218.0 mg/L, uric acid 2.9 umol/L, alanine aminotransferase 63 U/L, aspartate aminotransferase 45 U/L↑, mitochondrial AST 16 U/L, alkaline phosphatase 223 U/L↑, gamma-glutamyl transpeptidase 122.0 U/L↑, total bilirubin 7.7 umol/L, direct bilirubin 3.8 umol/L, total protein 69.3 g/L, albumin 28.9 g/L↓, globulin 40.4 g/L↑, albumin/globulin ratio 0.72↓, AST:ALT 0.71, BUN:CREA 0.07, urea nitrogen 3.31 mmol/L, creatinine 46 umol/L, uric acid 221 umol/L, glomerular filtration rate (MDRD) 153.46 mL/min per 1.75 m² (November 16) Ferritin: 276.00 ug/L↑ (November 16) Interleukin-2 receptor: 2521.0 U/mL↑ (November 16) Full DIC panel: Prothrombin time 11.50 s, PT INR 1.00, activated partial thromboplastin time 32.2 s, fibrinogen 2.66 g/L, thrombin time 15.90 s, D-dimer 1.83 mg/L FEU↑, antithrombin activity 98%, fibrin(ogen) degradation products 4.58 mg/L (November 16) Blood routine (five-classification) + CRP: CRP 8 mg/L↑, white blood cell count 5.93 × 10⁹/L, neutrophils 13.2%↓, lymphocytes 77.9%↑, monocytes 7.7%, eosinophils 0.8%, basophils 0.4%, neutrophil absolute count 0.78 × 10⁹/L↓, monocyte absolute count 0.46 × 10⁹/L, lymphocyte absolute count 4.61 × 10⁹/L↑, eosinophil absolute count 0.05 × 10⁹/L, basophil absolute count 0.03 × 10⁹/L, red blood cell count 3.76 × 10¹²/L, hemoglobin 103 g/L↓, hematocrit 31.20%↓, mean corpuscular volume 83.1 fl, mean corpuscular hemoglobin 27.4 pg, mean corpuscular hemoglobin concentration 330 g/L, red cell distribution width (CV) 14.3%, platelet count 334 × 10⁹/L↑, plateletcrit 0.31%↑, platelet distribution width 15.90 fl, mean platelet volume 9.40 fl (November 9) SARS-CoV-2 nucleic acid test (inpatient): Negative (November 15) EBV-DNA amplification: Positive↑ (November 14) T-SPOT: Negative for tuberculosis infection (November 14) Anti-HAV-IgM: Negative (November 14) Autoimmune liver disease panel: All markers negative or within normal range (November 14) Digestive autoimmune panel: ANA speckled pattern positive, ANA (1:40) positive, otherwise negative (November 14) Herpes simplex virus IgM: 3.09 Index↑ (November 14) Blood culture (bottle 1): Negative after 3 days, extended to 7 days (November 14) Blood culture (bottle 2): Negative after 3 days, extended to 7 days (November 14) T-cell subsets + absolute counts: CD3 89.71%↑, CD4 12.18%↓, CD8 65.17%↑, CD4/CD8 ratio 0.19↓ (November 14) Interleukin-2 receptor: 3617.0 U/mL↑ (November 14) Blood routine + CRP: CRP 31 mg/L↑ (November 14) Full DIC panel: D-dimer 1.94 mg/L FEU↑ (November 14) Liver function (inpatient): Several parameters still elevated, albumin 29.7 g/L↓ (November 14) Ferritin: 329.00 ug/L↑ (November 13) Fecal occult blood + routine: Normal, negative (November 12) Heterophile agglutination test: Negative (November 12) Full DIC panel: D-dimer 2.30 mg/L FEU↑, fibrin(ogen) degradation products 6.14 mg/L↑ (November 12) Interleukin-2 receptor: 5230.0 U/mL↑ (November 12) Blood routine + CRP: CRP >160 mg/L↑ (November 12) Blood lipids: Several values low or elevated as noted (November 12) Ferritin: 765.00 ug/L↑ (November 11) EBV-DNA: Positive (November 11) Electrolytes + liver function: Multiple abnormalities including hyponatremia and elevated enzymes (November 11) Blood routine + CRP: CRP 44 mg/L↑, leukocytosis with lymphocytosis (November 10) Liver function: Still markedly abnormal (November 9) Various viral serologies: EBV-CA-IgM and IgG markedly positive, HSV-IgM and IgG positive, others as documented (November 9) Urinalysis + hemosiderin: Positive for ketones, bilirubin, etc. (November 9) Thyroid panel: Mostly normal (November 9) Fecal routine: Normal (November 9) Peripheral blood morphology: Lymphocytosis (November 9) Immunoglobulins: Polyclonal increase (November 9) Haptoglobin: Decreased (November 9) Direct antiglobulin test: Negative (November 9) Troponin I: Normal (November 9) Full DIC panel: Several abnormalities (November 9) Renal function + lipids + electrolytes + cardiac enzymes: Multiple derangements (November 8) Procalcitonin + amylase + liver function + electrolytes + glucose: Multiple elevations in liver enzymes and bile acids (November 8) Blood routine + CRP: Leukocytosis with lymphocytosis
Special examinations and important consultations: November 16 ultrasound: Enlarged cervical lymph nodes, slightly enlarged axillary and inguinal nodes, mild splenomegaly, otherwise unremarkable. November 16 ECG: Normal. November 14 chest CT: Small nodules in lower lobes, possible small bilateral pleural effusions. November 9 ultrasound: Enlarged lymph nodes, mild splenomegaly, benign thyroid nodule. November 8 ECG: Sinus tachycardia with T-wave changes. November 11 infectious diseases consultation: Recommended antiviral therapy with ganciclovir or acyclovir, supportive care, monitoring for hemophagocytic syndrome.
Course and treatment outcome: After admission, the patient underwent comprehensive investigations to determine the cause of liver damage, including viral panels, autoimmune markers, T-cell subsets, inflammatory indicators, routine tests, coagulation studies, hemolysis markers, imaging, and cultures. Treatment included magnesium isoglycyrrhizinate, polyene phosphatidylcholine for liver protection, intravenous antibiotics, and nutritional support. EBV-IgM was strongly positive and EBV-DNA was detected, confirming EBV infection. During the stay, fever developed with declining hemoglobin and platelets. After infectious diseases consultation and departmental discussion, hemophagocytic syndrome was suspected. Antiviral therapy with ganciclovir 250 mg twice daily was started on November 11, along with dexamethasone for two days to control inflammation and fever. Symptoms of sore throat and lymphadenopathy improved significantly, fever resolved after November 12, liver function improved markedly, hemoglobin and platelets rose, fibrinogen increased, and IL-2 receptor and ferritin levels declined. The patient had good appetite, no fever or discomfort, and was discharged for outpatient follow-up. Complications: None Discharge status: Stable, no fever or abdominal pain. Physical examination essentially normal. Discharge medications and advice: 1. Health education: Light, soft diet, avoid alcohol and spicy food, rest adequately, avoid fatigue, seek prompt medical attention if unwell, especially for fever.
********* Outpatient record December 1 BP 98/49 HR 106/min Cough, fever, transient syncope for 1 week, worsening for 2 days. Physical examination: Fatigue, scleral icterus, tonsils appearing narrowed, pharyngeal erythema. Impression: Tonsillitis; EBV mononucleosis Plan: Emergency visit and observation
December 1 blood routine: CRP 147 mg/L↑, WBC 3.22 × 10⁹/L, hemoglobin 108 g/L, platelets 88 × 10⁹/L (thrombocytopenia)
Bone marrow biopsy pathology report: The biopsy showed approximately 60% hematopoietic cells, visible megakaryocytes. Immunohistochemistry suggested mild increase in T lymphocytes, otherwise unremarkable lineages. Reticulin stain negative, Congo red negative, PAS focal positive. Report date: December 8
According to the medical death certificate, multiple organ failure occurred on December 1. Death is therefore presumed to have occurred on December 1.