324 The Korean Journal of Hepatology Vol. 17. No. 4, December 2011 CASE REPORT A 37-year-old male visited the emergency room on December 28, 2008 for treatment of fever (40℃), chills, and jaundice lasting for 2 days. He was a nonsmoking social drinker, and denied recent overseas travel, contact with hepatitis cases, or taking any medications. His past medical history revealed an episode of pneumonia and bronchiectasis that occurred 20 years earlier. Physical examination showed a temperature of 40℃and mild icterus without hepatosplenomegly. Results from chest and throat examination were normal without cervical lymphadenopathy. His initial level of aspartate transaminase (AST) was 12,000 IU/L, alanine aminotransferase (ALT) 8,129 IU/L, total bilirubin 4.5 mg/dL, prothrombin time 23.6 second (international normalized ratio 2.06) and hemoglobin (Hb) 14.3 g/dL. IgM anti-HAV (Microparticle Enzyme immunoassay, Abbott, Wiesbaden, Germany) and IgG anti-HAV (Radio-immunoassay kit, General Biologicals corp., Taiwan) were both positive. Hepatitis B virus surface antigen, IgM anti-HBc, hepatitis C virus (HCV) RNA, and anti-HCV were all negative. IgM anti-HEV (Genelabs Diganostics, Singapore) was negative. Chest X ray and CT scan of the abdomen and chest showed no remarkable findings. Under diagnosis of acute hepatitis A, the patient received supportive care showing gradual recovery, and AST/ALT levels decreased to 285/919 IU/L, with a stable hemoglobin level of 14.4 g/dL, while his total bilirubin level progressively increased up to 21.8 mg/dL at hospital discharge (January 6, 2009) suggesting a prolonged cholestatic feature. On January 12, 2009, he was readmitted for recurrent fever, general weakness, and aggravated jaundice. At this time, IgM anti-HEV was positive with persistently positive IgM anti-HAV. Total and direct bilirubin levels were 39 mg/dL and 29 mg/dL, respectively, with an alkaline phosphatase level of 374 IU/L, and Hb level was 13.4 g/dL. Until January 24, total bilirubin level increased rapidly, up to 64.1 mg/dL (direct bilirubin level of 41 mg/dL), and Hb level fell rapidly to 5.5 g/dL, despite decreasing levels of transaminase. Serial laboratory results are summarized in Table 1. Haptoglobin level was 27.3 mg/dL and direct Coombs' test was positive (anti-IgG type) with polychromasia and anisocytosis on a blood film (Fig. 1A), which was compatible with autoimmune hemolytic anemia (AIHA). IgM anti-parvovirus B19 was negative. Oral prednisolone therapy (1 mg/kg) was started on January 22, however, his reticulocyte count remained low (0.13%), and he received 17 units of red blood cell transfusion for 11 days. To exclude the possibility of pure red cell aplasia, bone marrow aspiration and biopsy were performed, and it showed increased erythropoiesis compatible with AIHA without evidence of pure red cell aplasia (Fig. 1B). The dosage of oral prednisolone therapy was incremented to 1.5 mg/kg/day, and after 8 days of the Table 1. Hematologic and biochemical findings of the case 2009/1/24* 2009/2/12† 2009/2/20‡ 2008/12/28 2009/1/6 2009/1/12 2009/1/19 2009/4/22 Hemoglobin, g/dL 14.3 14.4 11.2 7.6 5.5 10 12.1 14.3 Reticulocyte, % 0.13 0.31 7.49 2.22 Total bilirubin, mg/dL 4.5 21.8 34.2 37.8 39.3 10 5.4 0.7 AST, IU/L >12000 285 79 76 154 90 22 21 ALT, IU/L 8129 919 138 88 130 380 136 49 γ-GT, IU/L 349 448 350 325 552 1482 897 Albumin, g/dL 3.7 3.2 3.6 3.0 3.1 3.8 3.8 3.8 Prothrombin time, INR 1.69 1.06 1.04 1.03 1.08 0.90 0.90 HAV RNA in plasma IA IA ND IIIA in stool IA IA ND ND HEV RNA in plasma ND ND in stool ND ND ND, not detected. * Prednisolone 75 mg per day started on this day, † Liver biopsy was performed during therapy with prednisolone 105 mg per day, ‡ Discharge day on prednisolone 75 mg per day administration. AST, aspartate aminotransferase; ALT, alanine aminotransferase; HAV, Hepatitis A virus; HEV, Hepatitis E virus; ND, not detected.