We have a 21yo woman from Guatemala who presented with 6 months of worsening abdominal pain with 5 days of fevers and nausea, found to have thrombocytopenia to 20K (MPV 9.5) on admission with elevated ferritin to 20,985 and elevated LFTs. Her HIV, and hepatitis serologies are negative, undetectable acetaminophen and ethanol levels, and no splenomegaly or evidence of cirrhosis on imaging. Her LFTs are: AST 436, ALT 315, AlkP 390, Tbili 5.1, Dbili 4.5. Her peripheral smear with some stomatocytes and atypical appearing lymphocytes (potentially large granular lymphocytes) and some dysplastic neutrophils. We recommended checking B12, folate, copper, H. pylori, NK cell activity, CD25, CXCL9, EBV PCR, CMV PCR, autoimmune work-up though wanted to reach out if you had any additional work-up recommendations for her thrombocytopenia, elevated ferritin, and elevated liver enzymes?
I'd check EBV, the elevated ferritin looks like it is probably from acute liver injury and that could be due to a virus. I agree with the workup for HLH and if she is clinically declining I would just start empiric therapy with Dexamethasone, the initial dose is 10mg/m2. If the liver injury is just post viral then it should start to get better in a week or so.
