case_images: PMC6582860_01
case_images: Liver enzymes and temperature trend.
case_images: CRIHEP2019-4808143.001.jpg
case_images: PMC6582860_01_CRIHEP2019-4808143.001.jpg
case_images: fig1
case_images: However, she continued to spike fever through the third day of hospitalization prompting expansion of antibiotic coverage to Vancomycin and Zosyn (Figure 1). One week into her hospitalization, her AST and ALT kept trending up reaching a peak of 1712 U/L and 845 U/L, respectively (Figure 1), mildly elevated alkaline phosphatase 140, INR 1.6, normal total bilirubin, absolute lymphocyte count of 0.11 K/uL, persistently negative blood cultures, and serum creatinine increased to 2.9 mg/dL, all concerning for a disseminated process. Within the first 24 hours of starting acyclovir, AST and ALT began to downtrend while fever and diarrhea improved (Figure 1).