An Unusual Case of Hepatitis Associated With Early Disseminated Lyme Disease

Abstract

Lyme disease is a tick borne infection caused by Borrelia burgdorferi, a spirochete. Abnormal liver function tests have been occasionally associated with Lyme disease, but a case of hepatitis directly related to the infection has rarely been described in the literature. We present a case of a 28-year-old male who presented with one-week history of subjective fever, chills associated with progressive weakness, headache, nausea and vomiting. Physical examination showed scleral icterus and hepatomegaly. Laboratory studies were significant for thrombocytopenia 106, elevated liver function tests (LFT) with Alkaline phosphatase (ALP) 343, aspartate aminotransferase (AST) 160, alanine aminotransferase (ALT) 182, Total Bilirubin 5.06. Ultrasound of right upper quadrant showed enlarged porta-hepatic lymph node measuring 1.4 cm. CT abdomen showed mild hepatosplenomegaly with borderline sized retroperitoneal nodes, unremarkable pancreas and gall bladder sludge. Gastroenterology was consulted. Workup was negative for all infectious and immune causes of hepatitis, Human Immunodeficiency virus, Cytomegalovirus, Epstein-Barr virus, Babesia, Anaplasma and Erhlichia. Magnetic resonance cholangiopancreatography showed gallbladder edema with mild pericholecystic edema and trace amount of free fluid along the inferior liver edge with no gallstones ad intra or extra duct dilation. LFTs continued to trend up with Total Bilirubin 6.9, direct bilirubin 5.0, ALP 566, AST 368 and ALT 329. Patient continued to have worsening headache so CT head was done which was normal. Lumbar puncture was remarkable for elevated opening pressure of 42 cm, lymphocytic pleocytosis with Glucose 59, Protein 86. Serum Lyme immunoblot was positive with 2/3 bands so patient was started on Ceftriaxone and Doxycycline pending Cerebrospinal fluid analysis which was later negative for Cryptococcal antigen, bacterial or viral serology including Lyme. LFTs trended down significantly with Total Bilirubin 2.2, Direct Bilirubin 1.4, ALP 488, AST 81, and ALT 215. Ceftriaxone was discontinued and patient was discharged with Doxycycline for total of 14 days. Patient presented with obstructive jaundice and all autoimmune and infectious causes of hepatitis were ruled out. Following the diagnosis of Lyme disease, antibiotics were started and patient showed clinical improvement along with significant improvement in LFTs which raises high suspicion of hepatitis associated with Lyme disease as seen in our patient.