Sudden hearing loss following acute hepatitis

A 35-year-old previously healthy physician was admitted to the emergency room with a fever up to 40°C, extreme weakness and dark urine. The physical examination was remarkable for right upper quadrant abdominal tenderness and mild splenomegaly. He denied sore throat or direct contact with blood products. Laboratory studies disclosed elevated liver enzymes, hyperbilirubinaemia and bilirubinuria. A diagnosis of acute hepatitis was established. Initially, all serologic viral studies were negative. However, a late seroconversion for IgM to the early antigen (EA) of Epstein-Barr virus (EBV) in the presence of negative antibodies to Epstein-Barr nuclear antigen (EBNA), followed by a rise in the IgG titres to EA and EBNA were observed, indicating EBV to be the causative agent of the hepatitis. During follow-up examinations in our out-patient clinic, a gradual convalescence and normalisation of the abnormal liver function tests were observed. Four weeks later the patient complained of a sudden hearing loss in his right ear which he had noticed subsequent to an examination of his patients with a stethoscope and after using a telephone handset with his right ear. He did not complain of tinnitus, nausea, vomiting or vertigo. The physical examination was normal, with a negative Romberg test and without nystagmus. A comprehensive audiologic assessment revealed a bilateral normal ear-drum with a normal pure-tone air and bone conduction (Weber and Rinne tests). The pure tone threshold analysis results are presented in figure 1. Treatment was initiated and the audiogram was repeated 10 days later (figure2). Figure 1 Audiogram performed on admission Figure 2 Audiogram performed 10 days after initiation of therapy 1 : What abnormality is demonstrated on the admission audiogram (figure 1) ? 2 : What is the diagnosis and its cause ? 3 : What are the possible additional common aetiologies of the presented disorder ? 4 : Describe the changes in the audiogram presented in figure2 compared to that in figure 1. ### QUESTION 1 The audiogram performed on admission demonstrates a decrease of 20–35 dB hearing level at low to intermediate frequencies (250–1000 Hz) …