Beyond the pale

Hepatitis A can cause fulminant liver failure up to 1% of infected patients. I once saw a young patient who was at the brink (AST was 12,000 at one point) before her liver started to get better. After she came out of the ICU, all my team could really do was watch and offer supportive care.

We tracked her numbers as she healed. As expected, even as other liver markers start to decline, bilirubin levels show a mild, delayed increase. My patient became a little jaundiced.

Then, during morning rounds on the day of her planned discharge, her skin appeared bronze! The labs indicated her AST was now below 1000, and her total bilirubin was only 5.4, up a few notches the day prior.

I ran these trends by her, but added, cautiously, that I couldn't explain why she looked so much more jaundiced today.

She laughed and revealed, "I just put on my tanning cream."

Of course. Something to add to one's differential of painless jaundice: Nosocomial spread of tanning cream.

UPDATE: Tanning is apparently a common side effect of the phototherapy used to relieve neonatal jaundice. Who's an expert on this? Dr. Tan, naturally.