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

Course of Hepatitis A

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.