REGISTRAR: DR GS HURTER CONSULTANT: DR JCJ VAN VUUREN
FIRM: 3 MILITARY HOSPITAL
ATYPICAL MANIFESTATION OF HEPATITIS A
Patient L: Case Discussion
35 year old female from Bloemfontein referred by
local sickbay on 15/02/10: History: Nausea and vomiting last 2
weeks, Abdominal tenderness, Yellow discoloration
of eyes, fatigue, Anorexia Medical History: No chronic diseases, No chronic
medication Examination: General: Severe Jaundice
Abdominal: Right upper quadrant tenderness, Hepatomegaly
Laboratory Investigations: Hepatitis A IgM antibodies present
Patient L: Special Investigations
LAB TESTS 02/02/10(OUT PATIENT)
15/02/10 (IN PATIENT)
22/02/10 (ON
DISCHARGE)
Total Bilirubin
158 192 67
Conjugated Bilirubin
96 109 29
AST 1513 62 59
ALT 2518 56 40
ALP 290 526 286
GGT 521 280 179
Abdominal Ultrasound: Hepatomegaly
No biliary obstruction noted
Patient L: Follow Up Consultation
1 MONTH AFTER DISCHARGE
History: Severe Back pain, Unable to sit
Abdominal pain, less severe than previously
Denies any history of alcohol use
Minimal use of paracetamol
Examination: No Jaundice, Severe tenderness over lumbar spine
Right Upper Quadrant Tenderness
Hepatomegaly still present
Patient L: Follow Up Consultation
Differential Diagnosis: 1) Infection - Septic diskitis 2) Inflammatory arthritis 3) Mechanical back pain
Further investigations: - Lumbar/Thoracic spine X-ray
- Skeletal scintigram
- Follow up LFT
Patient L: Results
Lumbar/Thoracic X-rays: Normal, No signs no diskitis
Skeletal Scintigram: Increased uptake in SI joints
Patient L: Results
LAB TESTS
02/02/10 (OUT
PATIENT)
15/02/10 (IN
PATIENT)
22/02/10(ON
DISCHARGE)
16/03/10(FOLLOW UP
VISIT)
Total Bilirubin
158 192 67 25
Conjugated Bilirubin
96 109 29 11
AST 1513 62 59 398
ALT 2518 56 40 533
ALP 290 526 286 205
GGT 521 280 179 189
Patient L: Diagnosis ?
Patient presenting with new onset sacro-iliitis
Cholestatic hepatitis A infection 6 weeks previously
Newly elevated hepatic cellular enzymes ALT > AST
Diagnosis:
Relapsing Hepatitis A with extra hepatic manifestation of
arthritis
Hepatitis A in Adults
Acute hepatitis A incidence has declined by 92 % between 1995 and 2007 due to vaccination
Vaccination has cause a proportion increase of cases among adults
HAV infection is usually silent or subclinical in children. In contrast, infection in adults can vary in severity from a mild flu-like illness to fulminant hepatitis
Atypical manifestations of hepatitis A include:- Cholestatic hepatitis- Autoimmune hepatitis- Extrahepatic manifestations- Relapsing Hepatitis
Overview Relapsing Hepatitis A
Relapsing form of hepatitis is observed in 3-20% of patients with a Hepatitis A infection
Patients initially shows a full recovery from a Hepatitis A infection with near normalization of AST levels
Within 4 to 15 weeks patients can present with a biochemical and/or a clinical relapse of symptoms
Relapse is usually milder than the initial episode
Hepatitis A virus is usually present in stool samples thus patients remain infectious !!
IgM HAV antibodies persists during the course of disease
Overview Relapsing Hepatitis A
A cholestatic from can also be seen Multiple relapses can occur 50% of patients are asymptomatic during
relapses Symptomatic patients can develop extra
hepatic disease during relapses such as arthritis, vasculitis, nephritis and cryoglobulinemia
Cause of relapsing Hepatitis A is unknown No predisposing factors have been
identified Treatment is supportive, use of oral cortico-
steroids has been suggested in some articles to improve arthritis symptoms
Overview Relapsing Hepatitis A
Recognition of this entity is important to prevent unnecessary, expensive and potentially invasive tests
Abdominal ultrasound should be done to exclude extra hepatic obstruction in patients with severe jaundice
Prognosis is good, complete recovery is expected
Relapses can occur up to 12 months since initial infection
Only one fatality has been reported in association with relapsing hepatitis A in a pregnant patient
Patient L: Further Management
Patient started on NSAID’s and Prednisone 20mg daily po
Patients follow up IgM for Hepatitis A was still positive at readmission, confirmed diagnosis of Relapsing Hepatitis A
Patient slowly responded to steroid therapy
Patient L: Final Results
LAB TESTS
02/02/10 (OUT
PATIENT)
15/02/10
(IN PATIENT)
22/02/10
(ON DISCHARGE)
16/03/10
(READMISSION)
30/03/10
(ON DISCHARGE)
Total Bilirubin 158 192 67 25 12
Conjugated
Bilirubin96 109 29 11 8
AST 1513 62 59 398 114
ALT 2518 56 40 533 243
ALP 290 526 286 205 169
GGT 521 280 179 189 315
References:
Schiraldi, O, Modugno, A, Miglietta, A, et al. Prolonged viral hepatitis type A with cholestasis: Case report. Ital J Gastroenterol 1991; 23:364
Glikson, M, Galun, E, Oren, R, et al. Relapsing hepatitis A: Review of 14 cases and literature survey. Medicine (Baltimore) 1992; 71:14
Rachima, CM, Cohen, E, Garty, M. Acute hepatitis A: Combination of the relapsing and the cholestatic forms, two rare variants. Am J Med Sci 2000; 319:417
Schiff, ER. Atypical clinical manifestations of hepatitis A. Vaccine 1992; 10 (Suppl 1):S18.
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