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Chapter 25: Hepatitis, Viral

INTRODUCTION

  • Viral hepatitis refers to the clinically important hepatotropic viruses responsible for hepatitis A (HAV), hepatitis B (HBV), delta hepatitis, hepatitis C (HCV), and hepatitis E.

HEPATITIS A

  • HAV infection usually produces a self-limited disease and acute viral infection, with a low fatality rate, and confers lifelong immunity. Outbreaks occur each year in the United States.

  • HAV infection primarily occurs through transmission by the fecal-oral route, person-to-person, or by ingestion of contaminated food or water. The incidence of HAV correlates directly with low socioeconomic status, poor sanitary conditions, and overcrowding. Rates of HAV infection are increased among international travelers, injection drug users, the homeless population, and men who have sex with men.

  • The disease exhibits three phases: 1) incubation (averaging 28 days, range 15–50 days), 2) acute hepatitis (generally lasting 2 months), and 3) convalescence. Acute hepatitis is marked by an abrupt onset of nonspecific symptoms; some very mild. Some patients may experience symptoms for up to 9 months. Nearly all individuals have clinical resolution within 6 months of the infection, and a majority have resolution by 2 months. HAV does not lead to chronic infections.

  • The clinical presentation of HAV infection is given in Table 25-1. There are no specific symptoms unique to HAV. Children younger than 6 years of age are typically asymptomatic.

  • The diagnosis of acute HAV infection is based on clinical criteria of acute onset of fatigue, abdominal pain, loss of appetite, intermittent nausea and vomiting, jaundice or elevated serum aminotransferase levels, and serologic testing for immunoglobulin (Ig) M anti-HAV. Detection of IgG anti-HAV replaces IgM and indicates host immunity following the acute phase of the infection.

TABLE 25-1Clinical Presentation of Acute Hepatitis
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TABLE 25-1 Clinical Presentation of Acute Hepatitis

Hepatitis A (HAV)

Hepatitis B (HBV)

Hepatitis C (HCV)

Signs and symptoms

>70% of patients are symptomatic with fever, jaundice, scleral icterus, hepatomegaly. Less common: splenomegaly, skin rash, arthralgia.

Approximately 70% of patients are anicteric or subclinical. Younger patients are most likely to be asymptomatic.

If symptoms occur, jaundice, dark urine, white stool, abdominal pain, fatigue, fever, chills, loss of appetite, and pruritus are possible.

Approximately 70% of patients are asymptomatic. If symptoms occur, jaundice, dark urine, white stool, abdominal pain, fatigue, fever, chills, loss of appetite, and pruritus are possible.

Laboratory Findings

Aminotransferase (ALT, AST) elevations

>1000 IU/L (6.7 µkat/L)

ALT>AST

1000–2000 IU/L (16.7–33.3 µkat/L)

ALT>AST

Highly variable, can be approximately 1000 IU/L (16.7 µkat/L)

ALT>AST

Bilirubin

Elevated and preceded by aminotransferase elevations

Can be within normal or elevated

Elevated and preceded by aminotransferase elevations

Virus-specific tests

IgM anti-HAV

IgM anti-HBc (+), HBsAg (+)

HCV RNA (+) or quantifiable; HCV antibody reactive within 12 weeks of exposure

ALT, alanine aminotransferase; AST, aspartate aminotransferase; anti-, antibody to; HBc, hepatitis B core; HBsAg, hepatitis B surface antigen; IgM, immunoglobulin; IU, international units; L, liter; RNA, ribonucleic ...

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