Hepatitis

Algemeen Medisch Laboratorium – Antwerpen

Dr. Johan Beert

Acute hepatitis

Man, 66 jaar (collega)

Bloedafname op 29/1/2018

Acute hepatitis

Man, 66 jaar

Bloedafname op 29/1/2018

Acute hepatitis

Differential diagnosis — Marked elevations in serum aminotransferase levels

may be seen with:

• Alcoholic hepatitis

• Autoimmune hepatitis

• Acetaminophen (paracetamol) toxicity

• Idiosyncratic drug reactions

• Toxin exposure, including mushroom poisoning

• Acute viral hepatitis (hepatitis A, B, C, D, E; herpes simplex virus; varicella zoster virus; Epstein-Barr

virus; cytomegalovirus [CMV]); other viral infections; or an acute exacerbation of chronic viral hepatitis

(hepatitis B)

• Wilson disease

• Ischemic hepatitis

• Budd-Chiari syndrome

• Sinusoidal obstruction syndrome (veno-occlusive disease)

• HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome and occasionally acute fatty liver

of pregnancy

• Malignant infiltration (most often breast cancer, small cell lung cancer, lymphoma, melanoma, or

myeloma)

• Partial hepatectomy

• Sepsis

• Heat stroke

• Muscle disorders (acquired muscle disorders [eg, polymyositis], seizures, and heavy exercise [eg,

long distance running])

UptoDate, accessed 8/1/2018

Acute hepatitis

Man, 66 jaar

Bloedafname op 6/11/2017

• Analyse(s) bijgevoegd na telefonisch overleg:

• Serologie voor EBV, CMV, Hep A en B immuunstatus, Hep E

• Auto-immune oorzaken.

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• Auto-immune oorzaak?

• ANA (HEp-2, 1/80) Positief

• ANA patroon Nucleolair kernfluorescentiepatroon

• ANA titer 80

• C R P slechts licht verhoogd : 28,9 (< 5,0 mg/L)

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WEEFSELANTISTOFFEN (IgG tegen:)

• Mitochondriën (1/20) Negatief

• LKM (1/20) Negatief

Lever autoimmuun immunoblot

• AMA-M2 Negatief

• M2-3E (BPO) Negatief

• LKM-1 Negatief

• Liver Cytosol Antigen 1 Negatief

• Soluble Liver Antigen/LP Negatief

• Sp100 Negatief

• gp210 Negatief

• PML Negatief

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• Virale serologie:

• Hep A IgG pos

• Hep B – géén detecteerbare antistoffen

• CMV en EBV doorgemaakt

• Hep E IgM duidelijk pos en IgG neg – vals + ?

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= Acute hepatitis E

4100 4100

1579

447179

0,00

2,00

4,00

6,00

8,00

10,00

12,00

14,00

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

28/01 30/01 1/02 3/02 5/02 7/02 9/02

Bili

rub

ine

(m

g/d

l)

AST

/ALT

(U

/ml)

ALT AST BilirubineHepatitis E: IgM +++

Confirmatietest:

Hep. E: RNA +++

• Hepatitis E

• Meestal na reis naar ontwikkelingslanden – maar niet altijd

• 4 genotypes

• Genotype 1 en 2 Azie, India, Noord Afrika Waterborne

• Genotype 2 Mexico en West Afrika Waterborne

• Genotype 3 Westerse landen, N-Amerika, Azie Zoonotic

• Genotype 4 Europa en Azie Zoonotic

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Acute hepatitis E – globale distributie

Marano G et al. Blood transfusion. 2015;13(1):6-17.

Acute hepatitis E

Waterborne infection – HEV genotype 1 and 2 infections are spread by fecally

contaminated water in endemic areas.

Zoonotic transmission – HEV genotypes 3 and 4 usually cause infections due

to consumption of contaminated food. Most cases are sporadic and unidentified

as an acute viral hepatitis…,

Swine are most frequently implicated in transmission, followed by consumption

of filter feeder shellfish [48-51]. However, many animal species (including

rodents in some regions), have been identified as part of the viral reservoir of

disease [52]. HEV transmission has been reported from consumption of

undercooked deer meat, wild boar meat, pig liver sausage, and internal organs

of animals in Japan, Germany, and France [53-56].

There are limited data regarding food preparation to reduce/eliminate HEV

transmission. In one study, cooking liver at 191°F for five minutes or boiling liver

for five minutes reduced the risk of transmission by inactivating HEV [58].

UptoDate, accessed 8/1/2018

Typisch symptomen Hepatitis E

• Icterus

• Malaise

• Anorexie

• Nausea, braken, buikpijn

• Koorts

• Hepatomegalie

• Soms: diarree, arthralgie, pruritus, urticariele rash

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Verloop Hepatitis E

• Incubatietijd 15 tot 60 dagen

• Meestal mild en zelflimiterend – normalisatie levertesten na 1 a 6 w.

• Regelmatig verlengde cholestase

• Supportieve therapie volstaat meestal

• Soms chronische vormen (vnl. genotype 3) – bij immunodeficit

• Zelden ernstige vormen waarvoor antivirale R/ (Ribavirine)

• Voorkomen: hygiëne , voedselkeuze, vaccinatie (China)

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Einde