Case Report
Austin J Clin Med. 2016; 3(1): 1025.
Influenza B Infection Causing Acute Hepatitis, Anemia and Thrombocytopenia
Valiere Alcena
Clinical Professor, Department of Medicine, Albert Einstein College of Medicine Bronx, Adjunct Professor of Medicine New York Medical College Valhalla, NY, USA
*Corresponding author: Valiere Alcena, Clinical Professor, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, Adjunct Professor of Medicine New York Medical College Valhalla, NY, USA
Received: March 07, 2016; Accepted: March 28, 2016; Published: March 29, 2016
Abstract
An interesting case of Influenza B infection with acute viral hepatitis, diffuse skin rash, fever, leukocytosis, eosinophilia, anemia, thrombocytopenia and very high liver function tests.
Keywords: Influenza B infection; Acute hepatitis; Fever; Anemia; Thrombocytopenia
Case Presentation
A 57-year-old Black female became sick with flu like symptoms with general weakness, muscles ache; pain in lower back, legs, shoulders with headaches, and low-grade fever 3 weeks before presenting to the emergency room on February 15, 2016 extremely. Patient works as a transporter of patients at a hospital.
At the ER she was very weak, had a temperature of 102.5 F, Pulse 114, Blood pressure of 107/87, respiratory rate of 22 and O2 SAT of 100% room air. Physical examination was remarkable for a diffuse erythematous rash, HEENT was remarkable for 1+ scleral icterus, lungs were clear, cardiac examination was remarkable only for a heart rate 114 per minutes abdominal examination was negative, neurological examination was negative and patient remained alert and oriented all time, extremities were negative. Recto-pelvic examinations refused by patient.
An IV fluid of D5/normal saline was started at 125cc per hour. CBC with diff, complete metabolic profile, urinalysis, urine culture, blood culture x2, PT, UNR. PTT, blood for Influenza A&B antibodies were sent to the lab, VDRL Lyme disease, monospot, CMV, Rickettsia antibodies, Rocky Mountain Spotted fever antibodies, Coxsackie antibodies, Dengue fever antibodies, VDRL, HIV 1 & 2, Malarial smear, Babesia, hepatitis A, B. C, D and E were done [1,2].
Chest ray, Abdominal CT, Abdominal ultrasound, CT angio, Ultrasound of the legs, Brain MRI and EKG were done.
The patient was admitted to the hospital. In the hospital, she was empirically started on Doxycycline 100mg PO BID and hydrocortisone cream QID for the skin rash, Tylenol 650mg Q4h PRN for fever. On the fourth hospital 2/19/16, her HCT dropped to 23.9% and platelets count dropped to 17,000 and her eosinophil went up to 27%. She was transfused with 2 units of packed red blood cells and 1uint of platelets [3].
In addition, she was treated with Venofer 100mg IV daily and Procrit 10,000 units SC daily. She was also given Folic acid 1mg IV BID because her HGB electrophoresis shows Sickle cell trait SA.
On 2/28/16 her WBC went up to 17.300 ad her LFTs were very high.
Her Influenza B IGM < 1:10.
Her Influenza B IgG came back 1: 640, indicating that her viral illness was due to Influenza B.
The viral syndrome she experienced three weeks before admission was the result of Influenza B, which resulted in the high Influenza B IgG of 1: 640 [4,5].
Influenza A PCR is negative.
The Abnormal Blood Tests Results Found Include
Markedly elevated LFTs,
Severe anemia,
Severe Thrombocytopenia,
Very high eosinophil level,
Sickle cell trait SA (not known to the patient before),
High PT/INR,
Factor VII deficiency (not known to the patient before),
Influenza B IgG 1:640.
The patient got better and went home on 2/23/16 with a WBC of 10.600 and an HCT of 32.4%, Platelets count of 83,000 and LFTs that were almost back to normal. The skin rash much improved and overall clinically much improved.
See tables for hospital course and lab tests results: (Table 1,2,3,4,5,6,7)
Patient was seen in the office on 3/2/16 she was feeling much better and her physical examination was completely normal. She is almost back to normal except for lingering weakness (Table 8).
2/15/2016
2/16/16
2/17/16
2/18/16
2/19/16
2/20/16
2/21/16
2/22/16
2/23/16
Temperature
102.5 H
97.5
101.6
99.0
100.1
99.3
98.4
98.6
97.6
Pulse
114 H
78
98
97
118 H
96
92
85
83
Respiratory Rate
22
17
20
18
18
17
18
18
18
Blood Pressure
107/87(94)
104/64(77)
99/60(73)
107/67(80)
149/83(105) H
128/80(96)
123/77(92)
127/81(96)
143/87(105) H
Pulse Oximetry
100
96
97
98
96
99
100
98
99
Table 1: Vital signs.
2/15/16
2/16/16
2/17/16
2/18/16
2/19/16
2/20/16
2/21/16
2/22/16
2/23/16
WBC
10.9 H
15.0 H
16.9 H
17.2 H
16.7 H
15.6 H
12.6 H
10.5 H
10.6 H
RBC
4.02
3.57 L
3.52 L
3.52 L
3.09 L
3.22 L
3.64 L
3.70 L
3.86
Hgb
11.2 L
9.9 L
9.8 L
9.8 L
8.5 L
9.1 L
10.3 L
10.4 L
11.0 L
Hct
32.2 L
27.7 L
28.3 L
28.7 L
23.9 *L
25.5 L
29.5 L
29.7 L
32.4 L
MCV
80.1
77.6 L
80.4
81.5
77.3 L
79.2 L
81.0
80.3
83.9
MCH
27.9
27.7
27.8
27.8
27.5
28.3
28.3
28.1
28.5
MCHC
34.8
35.7
34.6
34.1
35.6
35.7
34.9
35.0
34.0
RDW
13.2
12.3
13.5
13.9
13.1
13.5
14.1
14.2
15.5 H
Plt Count
164
135 L
28 *L
17 *L
42 *L
44 *L
69 L
83 L
MPV
11.8
12.3
12.6
14.2 H
14.3 H
13.7 H
12.6
12.8
Total Counted
100
100
100
100
100
100
100
100
Seg Neutrophils%
54
56
43
51
51
68
61
56
Band Neutrophils%
30 H
13 H
17 H
15 H
11 H
1
2
5
Lymphocytes%
7 L
10 L
6 L
10 L
10 L
14 L
9 L
13 L
Atypical Lymphs%
2
4 H
1
1
1
1
Monocytes%
4
4
5
3
5
5
8
9
Eosinophils%
2
10 H
27 H
19 H
21 H
12 H
20 H
16 H
Basophils%
Myelocytes%
1 H
2 H
2 H
1H
Reticulocytes count
1.09
Hemoglobin A
55.7 L
Hemoglobin A2
2.5
Hemoglobin F Percent
0.5
Hemoglobin S
41.2 H
Vitamin B12
1437 H
Folate
>24.0
Ferritin
1160.0 H
ESR
51
Urine Analysis
Normal
Blood Cultures
Negative
Urine Culture
Negative
Table 2: Hematology lab results.
2/15/16
2/16/16
2/17/16
2/18/16
2/19/16
2/20/16
2/21/16
2/22/16
2/23/16
Sodium
127 L
133 L
135 L
135 L
137
138
138
139
137
Potassium
3.6
3.6
3.3 L
3.4 L
3.6
4.0
4.4
4.0
4.0
Chloride
91 L
98
100
101
105
104
102
103
101
Carbon Dioxide
27
28
28
27
27
30 H
31 H
30 H
28
Anion Gap
13
10
11
10
8
8
10
10
12
BUN
12
14
8
6
5 L
5 L
6
7
8
Creatinine
1.2 H
0.9
0.8
0.9
0.8
0.7
0.7
0.7
0.7
BUN/Creatinine Ratio
9.8
15.2
9.5
7.0
6.6
7.1
8.7
10.1
10.8
Random Glucose
102
159 H
81
106
109 H
102
108 H
100
101
Calcium
7.8 L
8.1 L
7.4 L
7.6 L
7.7 L
8.1 L
8.2 L
8.4
8.6
Total Bilirubin
3.8 H
2.3 H
1.4 H
1.5 H
1.3 H
1.3 H
1.3 H
1.3 H
1.2
AST
259 H
155 H
102 H
115 H
69 H
79 H
58 H
39
28
ALT
223 H
201 H
161 H
153 H
117 H
117 H
100 H
80 H
64 H
Alkiline Phosphate
244 H
225 H
195 H
186 H
183 H
194 H
189 H
183 H
191 H
Troponin
0.01
B-Natriuretic Peptide
12.5
Total Protein
7.0
6.7
5.6
5.8
5.7
6.2
6.6
6.6
7.1
Albumin
3.3 L
3.2 L
2.8 L
2.7 L
2.7 L
2.8 L
3.0 L
3.0 L
3.2 L
Albumin/Globulin Ratio
0.9 L
0.9 L
1.0
0.9 L
0.9 L
0.8 L
0.8 L
0.8 L
0.8 L
Table 3: Blood chemistry lab results.
2/15/16
Triglycerides
192 H
Cholesterol
172
LDL Cholesterol Direct
108
VLDL Cholesterol, Calc
38
Total HDL Cholesterol
24 L
Cholesterol/HDL Ratio
7.3 H
Amylase
52
Lipase
54 H
Vitamin D 25-Hydroxy
48.4
TSH
1683
Table 4: Lipid profile, vitamin D and TSH.
2/18/16
Albumin %
40.6 L
Albumin (PEP)
2.4 L
Albumin/Globulin Ratio
0.7 L
Alpha-1-Globulins
0.4
Alpha-1-Globulins (%)
6.4 H
Alpha-2-Globulins
0.8
Alpha-2-Globulins(%)
12.9
Beta Globulins
0.7
Beta Globulins (%)
11.5
Gamma Globulins
1.7 H
Gamma Globulins(%)
28.6 H
IgG
1390
IgA
479 H
IgM
238 H
AgD
<1
ANA Screen
NEGATIVE
Table 5: Immunology and ANA.
2/15/16
Hepatitis A B C D
Negative
Monospot
Negative
CMV Virus Blood Test
Negative
VDRL
Negative
Stool Culture
Negative
Stool for Ova and Parasites
Negative
Lime Disease Screen
Negative
Coxsackie Virus Antibodies
Negative
Rocky Mountain Spotted Fever
Negative
Influenza A PCR
Negative
RSV Antigen
Negative
Malarial Blood Smear
Negative
Babesia Blood Smear
Negative
HIV I and II
Negative
Dengue Virus Antibody
Negative
Strongyloides Antibody
Negative
Rickettsial Antibodies
Negative
Influenza A Antibody
Negative
Influenza B IgM
<1:10
Influenza B IgG
1:640
Typhus Fever IgG Titer
Negative
Typhus Fever IgG Ab
Negative
Typhus Fever IgM Titer
Negative
Typhus Fever IgM Ab
Negative
Flocytometry
Shows No evidence of Hematological Malegnancies
Table 6: Special lab tests.
2/15/16
Chest X Ray
Negative
Abdominal CAT Scan
Negative
CT Angio
Negative
Ultrasound of the Legs
Negative
Abdominal Ultrasound
Negative
EKG
Negative
Table 7: X-rays and EKG.
3/2/16
WBC
5.3
RBC
4.72
HGB
13.6
HCT
40.4
MCV
85.6
MCH
28.8
MCHC
33.7
RDW
15.7
PLT
132
MPV
11.5
SEGS
61
LYMPHS
24
ATYP LYMPHS
1
MONOS
6
EOS
7
BASOS
1
GLU
92
NA
139
K
3.7
CL
100
CO2
32
AGAP
10
BUN
16
CRET
0.9
BCR
17.0
CA
9.6
TP
8.5
ALB
3.9
AG
0.8
TBIL
1.1
ALKP
156
ALT
25
AST
29
Patient was seen in the office on 3/2/16 she was feeling much better and her physical examination was completely normal. She is almost back to normal except for lingering weakness.
Table 8: Post Discharge Blood Test Results.
Conclusion
This is the first case of Influenza B infection that I am aware of that causes RBC suppression, thrombocytopenia, severe eosinophilia and skin rash in a patient with sickle cell trait and factor VII deficiency. The gradual drop in her HGB to 8.5grams, HCT of 23.9% and platelets count of 17,000, and reticulocytes count of 1.09 % are evidence of acute and transient inability of the bone morrow to produce adequate red blood cells and platelets, requiring transfusion of blood and platelets. The HCT gradually dropped from 32.2% on admission to 23.9% and the platelets dropped from 164,000 to 17,000. The very LFTs are clear evidence of acute inflammation of the liver (hepatitis). The fact her serum albumin was a bit low is a reflection of the fact the patient had been sick for three weeks prior to admission to the hospital and had not been eating well, and does not preclude the evidence of acute hepatitis due to the viral infection. Abdominal ultrasound and CT of the abdomen were both normal, ruling out both gall bladder and pancreatic diseases that explained otherwise explain the very high LFTs. Note that 1 week after discharge from the hospital on 3/2/16 the patient serum albumin returned to normal at 3.9, confirming the fact it was malnutrition that caused the low serum albumin that was present on admission to the hospital. Sometimes in cases of acute illness such as what this patient presented with can also cause serum albumin.
Flow cytometry using peripheral blood rules out Hematological malignancy. Bone marrow aspiration and biopsy were not done because the risk of bleeding was too high.
References
- Gauer, Robert L, Braun, Michael M. Thrombocytopenia Influenza B virus. AM Fam Physician 2012; 85: 612-622.
- Influenza A and B 2015-2016. CDC.
- Flu season 2015-2016. Immune deficiency Foundation
- Adam and Hubscher. Systemic Viral Infections and Collateral Damage in the Liver. Am J Pathol. 2006; 186: 1057-1059.
- Shizuma T. Immune thrombocytopenia. Following influenza A virus infection and vaccine administration. Virology & Mycology. 2014; S2.
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