REGISTRAR: DR GS HURTER CONSULTANT: DR JCJ VAN VUURENFIRM: 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

Bilirubin158 192 67

Conjugated Bilirubin

96 109 29

AST 1513 62 59ALT 2518 56 40ALP 290 526 286GGT 521 280 179

Abdominal Ultrasound: HepatomegalyNo biliary obstruction noted

Patient L: Follow Up Consultation

1 MONTH AFTER DISCHARGE

History: Severe Back pain, Unable to sitAbdominal pain, less severe than previouslyDenies any history of alcohol useMinimal use of paracetamol

Examination: No Jaundice, Severe tenderness over lumbar spine Right Upper Quadrant TendernessHepatomegaly 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: ResultsLAB

TESTS02/02/10

(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 398ALT 2518 56 40 533ALP 290 526 286 205GGT 521 280 179 189

Patient L: Diagnosis ?

Patient presenting with new onset sacro-iliitisCholestatic hepatitis A infection 6 weeks

previouslyNewly 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 ResultsLAB

TESTS02/02/10 (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 114ALT 2518 56 40 533 243ALP 290 526 286 205 169GGT 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.