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Atypical manifestation of hepatitis A

Atypical manifestation of hepatitis A. REGISTRAR: DR GS HURTER CONSULTANT: DR JCJ VAN VUUREN FIRM: 3 MILITARY HOSPITAL. Patient L: Case Discussion. 35 year old female from Bloemfontein referred by local sickbay on 15/02/10:

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Atypical manifestation of hepatitis A

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  1. Atypical manifestation of hepatitis A REGISTRAR: DR GS HURTER CONSULTANT: DR JCJ VAN VUUREN FIRM: 3 MILITARY HOSPITAL

  2. 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

  3. Patient L: Special Investigations • Abdominal Ultrasound:Hepatomegaly No biliary obstruction noted

  4. 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

  5. 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

  6. Patient L: Results • Lumbar/Thoracic X-rays: Normal, No signs no diskitis • Skeletal Scintigram: Increased uptake in SI joints

  7. Patient L: Results

  8. 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

  9. 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

  10. Course of Hepatitis A

  11. 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

  12. 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

  13. 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

  14. 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

  15. Patient L: Final Results

  16. 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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