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Real Doctors (Life Makers)  |  Basic Science  |  Microbiology, Virology , Parasitology and Immunology  |  CASES « previous next »
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cleo_md
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CASES
« on: /October/ 20, 2005, 07:15:50 PM »

Complaint
A 41-year-old woman complains of nausea and vomiting. She also reports that her eyes have "turned yellow," her abdomen is sore, and her urine has turned dark. The patient first felt ill 3 to 4 days ago. She mentions that she went to a seafood restaurant 3 weeks ago. Apparently, all her dinner partners from that night also are experiencing fatigue and nausea and vomiting.


History
The woman is usually healthy. She takes no regular medications; is monogamous; and does not smoke, drink alcohol, or use illicit drugs.
Physical Exam
A low-grade fever is present, and the patient is jaundiced. Abdominal exam reveals right upper quadrant tenderness and mild hepatomegaly.

Tests

Hemoglobin: 14 g/dL (normal 12-16 g/dL)
Alanine aminotransferase (ALT): 100 IU/L (normal 1-21 IU/L)
Aspartate aminotransferase (AST): 98 IU/L (normal 7-27 IU/L)
Bilirubin, total: 3.2 mg/dL (normal 0.1-1.0 mg/dL)
Bilirubin, direct: 1.6 mg/dL (normal 0.1-0.4 IU/L)
Alkaline phosphatase: 42 IU/L (normal 13-39 IU/L)
Urinalysis: elevated urobilinogen; negative for glucose, protein, and bacteria
Hepatitis A IgM: positive
Hepatitis B panel: negative
Hepatitis C IgM antibody: negative
Hepatitis D IgM antibody: negative

Questions
Given her history and lifestyle, how many of the four hepatitis viruses listed would the woman be unlikely to contract?
What is the route of spread of hepatitis A? Is there a chronic carrier state for this virus?
How is hepatitis E transmitted? What is the link between hepatitis E and pregnancy? Is there a chronic carrier state for this virus?
 


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Condition

Hepatitis A

Pathophysiology/Epidemiology
Acute viral hepatitis is most often due to one of the named hepatitis viruses (A-E), which all can cause similar acute illnesses. Only hepatitis B, C, and D can cause chronic hepatitis, however, which can lead to cirrhosis and hepatocellular carcinoma.
 
Physical Findings
The viral causes of acute hepatitis all can present in a similar fashion and generally can be distinguished only by history and serology. Some cases are asymptomatic. Classic acute hepatitis symptoms and signs vary from mild to fulminant and include anorexia, nausea, vomiting, lethargy, dark-colored urine, jaundice, low-grade fever, and tender hepatomegaly/abdominal discomfort or pain.

Histology/Tests
The urine is often dark because of the presence of bilirubin products (only direct bilirubin is filtered into the urine). Hepatic transaminases (AST and ALT) are usually elevated and alkaline phosphatase normal or mildly elevated when acute symptoms occur. Hyperbilirubinemia (direct and indirect elevated) occurs with more severe inflammation. Donated blood is screened for hepatitis.
Hepatitis A virus infection most often causes symptoms after a latent period of 3 to 4 weeks. Detection of the hepatitis A IgM antibody is usually possible at the time of clinical presentation. Tests for the hepatitis E virus (uncommon in the United States) are not readily available for clinical use.

Prevention & Treatment
No antiviral therapy is available for hepatitis A or E. Hepatitis A (common) and E (rare) are transmitted via the fecal-oral route, so are most likely in persons in institutions (e.g., day care) and if seafood (especially undercooked) is mentioned.
Common-source outbreaks (e.g., restaurants, food distributors) are classic. Individuals who are promiscuous, use intravenous drugs, or have received blood transfusions in the past are at risk for hepatitis B, C, or D, which are transmitted parenterally.

More High-Yield Facts
Women who acquire hepatitis E during pregnancy have a high mortality rate.
Other causes of infectious (e.g., cytomegalovirus, Epstein-Barr virus) and noninfectious hepatitis (e.g., alcoholic or drug-induced hepatitis, autoimmune hepatitis) also must be considered in the appropriate setting.

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