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Agency for Toxic Substances and Disease Registry
Polychlorinated Biphenyls (PCB) Toxicity
Case Study and Pretest
A 48-year-old handyman has progressive cystic acne and abnormal liver function.
A 48-year-old man that you are treating for acne vulgaris returns to your office for a follow-up appointment. You first saw this patient about 3 weeks ago. At that time, he had multiple acneform lesions in the malar and periorbital areas. Both cystic and comedonal lesions were present; most ranged between 3 and 6 millimeters (mm) in diameter, and some were edematous. The patient noted that he was surprised about the development of acne at his age: he never suffered from this condition during adolescence. He used over-the-counter astringents and antiacne medications, but they did not affect the lesions.
A review of the patients medical history indicates that he has Gilbert syndrome and occasionally had elevated bilirubin levels in the past. However, the patient has no history of hepatitis, contact with hepatitis patients, other liver difficulties, or blood transfusion. There is no family history of cardiovascular disease or cancer. The patient does not smoke; he drinks 2 to 3 bottles of beer each evening, and sometimes more on weekends. He is taking no medications other than over-the-counter dermatologic medications.
The patient is married with three teenaged children; his wife and children are in good health. They live in a high-rise apartment building where the patient has been a handyman and part-time building manager for the last year. He spends a lot of time in the basement area, which includes a workshop, recreation room with pool table, and laundry and heating facilities. An avid fisherman, he spends most weekends fishing in Lake Michigan and eating his catch with his two sons.
At the end of the patients previous visit, you prescribed a topical antibiotic and instructed the patient on its use. After reassuring the patient that stronger prescription medications are available for the treatment of acne, you ordered a serum biochemical and hematologic profile to document baseline values in the event that a course of Accutane (isotretinoin) therapy is warranted.
During todays physical examination, you note little or no improvement in the patients acne. The ratio of cystic to comedome lesions seems to have increased, and many lesions appear to have become more edematous and erythematous. The patient has several new comedones on his chin, and he points out what appear to be developing areas of folliculitis on his chest and forearms.
In addition to this worsening of the patients symptoms of acne, physical examination reveals mild, nontender hepatomegaly without jaundice. This finding causes you to review the results of the biochemical panel, and you are surprised to note the following abnormalities:
- total bilirubin 2.8 milligrams per deciliter (mg/dL) (normal 01.5), direct bilirubin 0.4 mg/dL (normal 00.4),
- serum glutamic-pyruvic transaminase (SGPT) (alanine aminotransferase [ALT]) 74 international units per liter (IU/L) (normal 050),
- serum glutamic-oxaloacetic transaminase (SGOT) (aspartate aminotransferase [AST]) 88 IU/L (normal 050),
- glutamyl transpeptidase (GGTP or GGT) 190 IU/L (normal 1585), and
- lactate dehydrogenase 230 IU/L (normal 50225).
The results of all other tests, including the complete blood count, alkaline phosphatase, blood urea nitrogen, creatinine, and urinalysis are within normal limits.
- What should be included in the patients problem list?
- What is a differential diagnosis for the patients altered liver enzymes?
- What tests would be useful in helping you arrive at a diagnosis?
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