ACUTE VIRAL HEPATITIS A, E

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Introduction:

                    Hepatitis is inflammation of the liver. Acute viral hepatitis is a public health problem globally. The causative viruses may be Hepatitis A virus(HAV), Hepatitis B virus(HBV), Hepatitis E virus(HEV).and several other hepatic viruses that are not easy to test in most laboratories but have similar clinical presentations. Hepatitis C virus may be the cause of acute hepatitis. 

  • HAV and HEV are transmitted by the fetal-oral route through the consumption of contaminated food and water.
  • HBV is transmitted through contaminated blood or blood products, or maternal transmission.
  • HCV is transmitted through contaminated blood or blood products.
  • HAV is more common in children, is mild to moderate, and full recovery is expected.
  • HAV may be anicteric and may only be recognized by the deranged liver enzyme.
  • HEV is more common in adults and is more severe than HAV. HEV is especially unsafe in pregnant women with a case fatality of as high as 20-25 percent.
  • It is ordinarily not necessary to test for HAV or HEV as confirmation with tests does not dictate management. However, in doubtful or complicated cases it may be needed.

Case no.1 Uncomplicated acute viral hepatitis:

                                                                               A previously healthy 30-year-old male complained of feeling easily tired and had a poor appetite for one week. 2 days later, he felt nauseous, and then started vomiting 4 to 6 times a day. Yesterday he noticed his urine is dark and his wife noticed his eyes appeared yellow. On further questioning, he denied taking any medicine before the symptoms.

On examination he is afebrile, but the sclerae are yellow-tinged. The abdomen is soft and there is mild tenderness over the liver. The most effective test required to confirm the diagnosis is the liver function test. His total bilirubin is 12.5 mg, ALT 2050, alkaline phosphatase is normal.

Clinical features:

     1. Patients may present with fatigue, nausea, vomiting, and decreased appetite.                       2. Jaundice is present and patients often complain of dark-colored urine and itching.             3. Low-grade fever may be present along with right upper abdominal pain, myalgia, and arthralgia.                                                                                                                                         4. On examination, patients have jaundice and may have tenderness over the liver.                 5. The clinical symptoms may range from anicteric and very mild to moderate and severe manifestations.                                                                                                                                 6. The 2 most common physical findings are jaundice and tender hepatomegaly.

            Differential Diagnosis:

            1. P.Falciparum Malaria
            2. Liver abscess
            3. Leptospirosis
            4. Autoimmune hepatitis
            5. Acute viral infections( Ebstein Barr virus, Cytomegalovirus, Yellow fever)
            6. Drugs( Anti TB drugs, antiepileptics, paracetamol overdose)
            7. Wilson's disease
            8. Acute fatty liver of pregnancy
            9. Consumption of poisonous mushrooms.
            The above-written diseases should be ruled out by proper history taking, examination, and appropriate tests.

            Diagnosis:

                          Obtain detailed history, including duration and chronology of symptoms, occupation, drug history, prior history of jaundice, and status of hepatitis B vaccine. The following tests are recommended for diagnosis and prognosis.
            1. Liver function tests: ALT(SGPT) and AST(SGOT) are more than 10 times normal. Bilirubin and alkaline phosphatase rise later and may remain elevated even after ALT normalizes.
            2. If fever is present then check malaria parasite smear or rapid diagnostic test for malaria.
            3. PT/INR: If prolonged is a poor prognostic marker.
            4. Hepatitis serology: Anti HAV IgM, anti-HEV IgM, anti-HBc IgM are reactive in the acute stage of the disease and remain positive for months. IgG reactivity shows past infection. These tests are optimal as the results do not dictate management.

            Management:

            1. HAV and HEV are almost always self-limiting and only rarely lead to fulminant hepatic failure.
            2. There is no specific treatment, but patients often need symptomatic and supportive care.
            3. It is most important to control vomiting and keep and keep the patient well hydrated and nourished.
            4. Antiemetics and antipyretics may be used if needed.
            5. Oral fluids and a soft diet may be recommended, but if it is severe and persistent vomiting, IV fluids such as dextrose in water 1-2 liters over 24 hours may be given. 
            6. ALT may be repeated every 1-2 weeks or as the clinical condition demands. In exceptional cases such as pregnancy, alcoholism, or other co-existing conditions, the patient should liaise with the physician frequently to report the clinical condition and take necessary measures.

            Clinical course:

            1. Ill appearing patients should be monitored with regular clinic follows ups with signs of fulminant hepatic failure usually within a few weeks of severe acute hepatitis.
            2. Approximately 85% of HAV infected patients have full clinical and biochemical recovery within 3 months and nearly all have a complete resolution by 6 months.
            3. Patients should be counseled regarding the prevention of transmission to other individuals, such as washing hands after using the toilet and not sharing soap bars, towels, toothbrushes, or toothpicks.
            4. Dietary restrictions are unnecessary. The patient may take all hygienically prepared food items that he/she can tolerate. Even though family members insist on dietary restrictions, this has not only been shown to not improve symptoms or outcomes but actually slows recovery.
            5. Restriction of physical activity is unnecessary, Let the patient decide.

            Case no. 2 Acute Fulminant Hepatic Failure:                                                                                                             A pregnant women in her 2nd trimester presents with a drowsy state. She is disoriented, dehydrated, and jaundiced. She has deepening jaundice for the last 7 days and persistent vomiting and has now become drowsy and confused. There has been no bleeding from any site but she has had bruises on her arms over the last 2 days. She has not taken any medications in the recent past except for pre-natal vitamins.

            1. Fulminant hepatic failure occurs more commonly in patients with underlying liver disease and is more common during pregnancy, 
            2. Severe P.Falciparum malaria may mimic acute fulminant hepatic failure and a test for malaria must be done
            3. A careful history should be taken for any hepatotoxic drugs that were used by the patient such as Alcohol, Dilantin, INH, rifampicin, or PZA for T.B, or overdose of paracetamol.
            4. This is a medical emergency.
            5. There is no specific therapy for HAV or HEV.
            6. Check blood sugar, maintain IV line with dextrose and refer to a hospital for further management and urgent, intensive care.
            7. Blood glucose should be monitored frequently as hypoglycemia may occur in liver failure.
            8. HEV can also be transmitted vertically to babies of HEV-infected mothers.

            Warning signs of worsening condition:

            1. Excessive vomiting and inability to tolerate oral uptake.
            2. Excessive drowsiness and altered mental state.
            3. Seizures.
            4. Bleeding from any site.
            Refer to a hospital if:
            1. Worsening signs.
            2. Pregnant.
            3. Hisory of paracetamol overdose.

            Prevention:

                               Infected individuals are contagious during the incubation period(2-6 weeks) and until a week after jaundice appears. The most important prevention is through improvement of sanitary conditions in towns and cities. Personel hygiene is important for the individual at all times:

            1. Wash hands after using the toilet, changing diapers, Toilet utensils or taps can be contaminated. Hand washing with soap and water is highly effective in preventing transmission of the virus. HAV may survive for up to 4 hours on fomities and fingers.
            2. Avoid unhygienic food and drinks.
            3. Was meat, poultry, vegetables and fruits thoroughly before cooking or eating. 
            4. Vaccination: Inactivated Hepatitis A virus: 2 doses I/M. 1ml for adults and 0.5 ml for children.
            The vaccine is safe and may be given to any suspectible person. Most children and adults in endemic areas over age 12 are immune as they have had sub clinical or overt hepatitis and need not receive HAV vaccine.

            1. Patients with chronic liver disease 
            2. Travelers from low risk areas to areas with high prevalence of Hepatitis A( e.g.From US or UK to Pakistan), should be given HAV vaccine at least 4 weeks prior to travel.
            3. Vaccine for HBV should be given universally, especially to the newborn and school age children.
            4. Vaccine for HEV is undergoing trials.

            Pearls of wisdoms:

            1. Acute viral hepatitis is usually self limiting.
            2. It requires supportive care for adequate hydration and nutrition
            3. There is no specific therapy despite claims to liver tonics and multivitamins
            4. Once symptoms begin to improve , normal diet and activity should be encouraged.
            5. Fever and transaminitis may be non-specific, in association with other infections as with sepsis, typhoid, severe malaria, cytomegalovirus, Epstein Barr virus.
            6. Transaminitis without fever may occur as reaction to hepatotoxic drugs, liver steatosis   
                                                                                                                                                     

                         
                                                              

             

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