41. The Diamonds


        Julie came in with pruritus and jaundice. I am sure you are already thinking of a million possibilities, but let’s see if you thought of this one.

        Julie was a 33-year-old woman with a pretty benign past medical history. She had never been admitted, never had any surgery, didn’t take any medications, didn’t drink alcohol nor smoked. But she did notice that she was itching a lot 3 days before. At first, she thought it was the money, since she was a cashier, but then her husband noticed that she was turning a little yellow.

They both came to the ED and she was admitted. She looked ill, nauseated, and anxious. Her heart was tachycardic, she was fatigued and sweating. Her alanine and aspartate aminotransferase were in the 200s, just like her alkaline phosphatase and GGT. Bilirubin was 2. You got the point, her liver was inflamed. But why?

‘Peter you need to help me out with this.’ He was about to leave, but I was on call that day. He turned to me and smirked.

‘What do you need help with, nerd?’

‘I am glad you asked! Take a seat.’

He laughed and took a seat. I knew he would stay.

‘So, I am having trouble with Julie’s case, you know? The one with hepatitis.’


‘Well, I can’t figure out why she has it. It’s not cholestasis, her ultrasound was normal. And it’s not like she is getting incredibly better for me to give up on her diagnosis.’

‘Okay. You tested her for viral hepatitis, right?’

‘All of them. And antibodies for autoimmunity were negative.’

‘Humm… I have an idea.’ He went to get the whiteboard. ‘Let’s forget about her case for a moment and think only about hepatitis.’

I watched as he wrote “D-I-A-M-O-N-D-S” on the board. I had never heard of that, but I imagined it was some differential diagnosis mnemonic. People had different words for the mnemonic to work, his were apparently ‘diamonds’.

‘You know where I am going with this, right?’

‘Yes, lead the way.’ I smiled.

‘Okay, so D is for Degenerative.’

We both thought for a while.

‘I don’t know, NASH?’ I laughed referring to non-alcoholic steatohepatitis, not knowing if it was a perfect fit for this category. ‘But she is young, normal weight and normal ultrasound, so unlikely.’

‘Yeah, but that’s the idea. When in doubt go broad.’ He wrote NASH on the board in black, which meant it was a less likely cause. ‘I is more complicated. Inflammatory, infection, and ischemic slash vascular.’

‘Autoimmune possible but less likely because of her antibodies. Infections we have eliminated viral hepatitis, but theoretically, she could have other infections that affect the liver.’ I thought out loud.

‘True, she could have some other virus. I’ll put that as more likely since we have nothing to rule this out effectively, even though she doesn’t look infected overall.’ He wrote systemic infections in red, autoimmune in black. ‘What about ischemic slash vascular?’

‘She could have Budd-Chiari, but we ordered an ultrasound and it was normal. Heart failure is also unlikely since no jugular venous distension or leg edema.’

‘A is for Abrasion, meaning trauma, or Anatomic.’ He laughed. ‘I know, weird, but the mnemonic has to work. She didn’t have any trauma right?’

‘No, nothing. And her ultrasound wasn’t suggestive of obstruction.’

‘M for Metabolic. Ideas?’ He asked me.

‘Well, the usual right, alfa 1 antitrypsin deficiency, hemochromatosis, and Wilson disease. But we tested for those and no luck.’

‘Okay, but let’s try to think of something we haven’t ruled out yet.’

‘I don’t know, thyroid? You’re not giving many ideas either smartass.’ I pushed him. I was having so much fun, I missed doing differentials like this.

‘Well it’s your patient, isn’t it? I like thyroid, thyroid can cause anything, right? And there are other congenital metabolic disorders that could also do that, although extremely rare.’ He wrote both on the board.

‘O is for Others, we save that for last as a hail mary.’ I smiled at him, I loved sports references. ‘N is for neoplastic. I guess it would be an extremely unlikely presentation, and we would have other systemic symptoms.’ I nodded in agreement.

‘D for Drugs.’ I said already imagining it, and Peter nodded for me to go on. ‘She doesn’t use any drugs, not even alcohol, and no medicines. I guess we could hang on to some crazy tea, but she seemed like a coffee person to me.’ I joked.

‘Maybe you are a coffee person and that’s all you can see in people.’

‘Maybe. In fact, we should both go get one after this at the cafeteria.’ I laughed knowing he hated coffee. He rolled his eyes.

‘S is for pSych.’ He stared at me.

‘Well, if she tried suicide with acetaminophen she could have hepatitis.’ I said with a little sadness just thinking of that. ‘But she has a 3-day evolution, and her mood seems good.’

He nodded and wrote it on the board.

‘Okay so now what, Peter?’ We both stared at the board tiredly.

‘Now we figure out how to rule out the ones we haven’t yet. We have systemic infections, thyroid, and crazy tea.’ He looked at me.

‘And idiopathic. In the Others category.’

‘Yeah, but idiopathic is no fun.’ He said and I actually agreed.

‘Okay, so let’s go with fun. Systemic infections are harder to rule out because we couldn’t test for everything. So order her a thyroid test and I’ll go ask her about crazy teas.’

I was right, she was a coffee person, no teas. On the other hand, her TSH came completely suppressed, and her free T4 on the roof. Julie had an undiagnosed Graves disease. We treated her for that and her liver enzymes returned to normal. Her thyroid disease caused thyrotoxicosis hepatitis, extremely rare, and we wouldn’t have thought of that if it wasn’t for Peter’s D-I-A-M-O-N-D-S.

‘You were right.’ I said to Peter. ‘Thyroid can cause anything.’

Want to read more about Thyrotoxicosis?


Want to read a real case of Thyrotoxicosis?


Clinical Board

S/S: signs and symptoms; Tt: treatment.

Extra: Differential Diagnosis

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