Elevated Bilirubin with No Reason - Gilbert’s Syndrome?

82 yo AAM with a PMH of Afib on Coumadin for the last 3 years is admitted to the hospital with CC: Neck pain x 7 days.

He had a similar episode of neck pain 5 months ago and was treated with antibiotics.

Physical examination:
Afebrile
Furunculosis and cellulitis of the back of the neck
CVS: Irregularly irregular rhythm


CBC, CMP over the last 6 months; LFT, direct and indirect bilirubin (click to enlarge)

CMP showed an increase in total bilirubin mostly due to the indirect bilirubin. Patient was not visibly jaundiced which is not surprising since the jaundice is usually seen with total bilirubin level > 3.

The rest of the LFT were WNL.

What do you think is the reason for the elevated bilirubin?
Gilbert’s syndrome which represents an asymptomatic increase in indirect bilirubin in a fasting patient or during an intercurrent infection. In this patient the infection was neck furunculosis.

Notice that there was a bump in the bilirubin level during the previous hospitalization for neck skin infection 5 months ago.

How do you treat Gilbert’s syndrome?
There is no treatment and there is no need for one.

Final diagnosis:
Gilbert’s syndrome

What did we learn from this case?
Not all lab changes are due to dangerous causes.
Gilbert’s syndrome is a relatively common and benign entity.

References:
Gilbert's Syndrome - eMedicine