different symptoms - cant get a diagnosis that fits

[rachnak]

My nephew started to feel tired about October 2003 timeframe and was out of energy, running a fever off and on (low grade)and constipatred. Around thanksgiving we noticed his eyes were yellow - took him to the doctor for a checkup. he did a lot of blood tests - his liver function tests came back very high, alt, ast, ggt..etc. they did more tests and with an ultrasound and found that he was extremely constipated. he was given a medication to flush him out. During the day he was being flushed out, it took about 6 hours and during this time he ran a fever of 105-106.
we got worried, he was very deyhdrated, took him to the hospital and he was admitted and put on an IV. this was on Sunday and on Monday we were told we should agree to a liver biopsy - which we did. his liver tests were still off the charts and they suspected AIH becuz of anti smooth muscle and ana being elevated.
his bilirubin was also high at 3.6.

his liver biopsy didnt show much scarring, very minimal, but we were told by the GI it was AIH and therefore nephew was put in Prednison at 60mg. this was brought down to 40mg within a week and started Imuran with it. he is also taking octagol and nexxium and miralax.

it has been 3 weeks since he is from the hospital (he stayed there for 1.5 weeks, left on jan 1st) and his liver function tests are mostly normal. his ggt is still high but coming down, bilirubin is 1.6 (was 1.1 last week).

problem is that in the last month or so, except for 10 days, he has a fever with abdominal pain (in the middle of the body, not right or left, smack in the upper abdomen) in the morning. this starts with the pain and becomes fever around 9-10 AM and continues till around 12-1. last about 3 hours and goes away by itself - we give him no medications to bring this down. of course, he also has days every 3 or 4 days after this where there is no fever or pain and he is fine.
Every evening, he is fine and looks healthy and feels healthy.

my nephew is 14 years old and he has not been back to school since beginning to december.

we went for a 2nd opinion to Mt. Sinai and were told that the diagnois of AIH may not be right and that it could be cholangitis or UC or something else.

newphew also had an MRCP done in the hospital as well as a CT scan - which all came out clear.

What can this pain and fever mean? why do they come and go away - it doesnt seem like a bacterial infection.

also, we could use a referral for a GI specialist in our area of Central NJ. We are having a hard time finding a specialist here.
DR. at Mt Sinai also suggested that we go to a Rheumtologist - any referrals there in central jersey?
lastly, could nexxium cause fever and pain - or is prednisone causing this?

i realize there are a lot of inherent questions here - i would really appreciate any help you can provide. we are all feeling very frustrated currently.

thanks,

Rachna

[Kevin Pho, MD]

This is a difficult case.  Certainly a lot of tests and evaluations have already been done, including liver biopsy, MRCP and CT scan.  To evaluate the upper GI pain - you may want to consider an upper endoscopy to exclude an ulcer or inflammation of the esophagus or stomach.  

I agree with the rheumatology referral.  Typically, AIH alone does not cause the fever.  It is possible that a rheumatological disorder may be considered.  

To find a rheumatologist or gastroenterologist, you can consider finding one here:
http://www.abim.org/dp/apps/physdir1.htm

Regarding the fever, here are some other tests to consider:
-Erythrocyte sedimentation rate
-Lactate dehydrogenase
-Tuberculin skin test
-HIV antibody assay and HIV viral load for patients at high risk
-Three routine blood cultures drawn from different sites over a period of at least several hours without administering antibiotics, if not already performed
-Rheumatoid factor
-Heterophile antibody test in children and young adults
-Antinuclear antibodies

It is unlikely that the Nexium or Prednisone is causing the fever.

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Thanks,
Kevin, M.D.

[Caroline5]

I love my gastro doc. It is Joel Levinson in Springfield, NJ (973-467-1313). He is very smart and is also excellent with children.

[yoshi]

just want to point out some medication coated with aluminium can cause constipation.
did the doc explain what caused his big time constipation??

[rachnak]

no, constipation was never explained. they think it was something to do with AIH...could be UC or cholangitis - but no diagnosis. thats what we're struggling with.

his symptoms were constipation, jaundice, elevated liver tests, some fever and pain in the upper abdomen.

now the jaundice and constipation is gone, but upper abdomen pain and fever are intermittent...

very strange and it doesnt fit AIH or UC..etc.

[yoshi]

if he goes to see a GI ,he will probably be asked to test for hector pylori bacteria.

[kwag]

many people suffer from constipation these days due to our American diet.  Our diet is high in processed foods and very low in raw natural fruits and vegees.  We ususally drink very minimal water.  Our colon's are often depleted of the good bacteria that it needs to function effectively due to chlorinated water consumption, antibiotics (in meat and other foods as well as medications), and poor diet as well as other things.  I suggest a good live probiotic and diet alterations.  Most health food stores have books about restoring gastrointestinal health.  Please look into natural measures that you can do to help.  I find that the closer we stick to the natural way and live the way the Bible outlines, the closer to health (in all spheres) we can be.  God Bless