A Red Herring in a College Track and Field Thrower

Abstract

HISTORY: 18 year old male track and field thrower, who was previously healthy, presented to the training room clinic 2 months after being diagnosed with mono by his PCP. The symptoms at the time of presentation to his PCP were fatigue and palpitations, and his labs showed elevated liver enzymes. The patient continued to have the same symptoms at the time of presentation to us. He had been on long term (>1 yr) Bactrim for acne, denied taking Tylenol regularly, but did occasionally drink ETOH. At the time of presentation to the training room, he had been scheduled for a stress treadmill and cardiac evaluation for work up of the palpitations. PHYSICAL EXAMINATION: Constitutional: Well developed. Eyes: B/L No injection. Neck: Inspection reveals symmetry. Respiratory: Lungs clear to auscultation. Normal effort Cardiovascular: No murmurs RRR No edema is present. Vascular: Pulses Capillary refill less than 2 sec. Abd: Symmetric - no distention. BS +, no bruits. NT, no RRG. No hepatic enlargement. Integumentary: No impressive skin lesions present. Ext: No edema. Neurological: Memory: Intact . Psychiatric: OA x 3 demonstrates the appropriate mood and affect. DIFFERENTIAL DIAGNOSIS: - Drug-induced hepatitis from multiple years of Bactrim use -ETOH abuse - Viral hepatitis - Gallbladder polyp/stones - Hemochromatosis - Mono TEST AND RESULTS: Hepatitis panel negative, CMP- Normal except for ALT 211 AST 87 Negative treadmill stress test FU lab 9 m later showed- Negative mono test, but ferritin was 5172, Total iron binding capacity 317, % of iron sat 91 %, iron 289, genetic testing for hemochromatosis was negative. FINAL WORKING DIAGNOSIS: Hemochromatosis TREATMENT AND OUTCOMES: Patient is doing much better at this time. Patient started out getting phlebotomies every 2 weeks and then was increased to twice weekly. His last ferritin was 750 and he continues now with once weekly phlebotomies. He is currently participating without restrictions in track and field at the NCAA level.