Marked hyperbilirubinemia—silent no more!

A 25-year-old male of Eastern European descent presented to the emergency department with two days of worsening abdominal pain and nausea. He was afebrile with normal vital signs. Exam was notable for diffuse abdominal tenderness and marked jaundice. His white blood cell count was 9.4 × 109/L, hemoglobin 7.8 g/dL, platelets 128 × 109/L, total bilirubin > 20 mg/dL, direct bilirubin 0.5 mg/dL, and lactate dehydrogenase 679 U/L. Transaminase and alkaline phosphatase levels were normal. Peripheral blood smear revealed multiple bite cells and reticulocytes (Figure 1).