Best Dx/Best Rx: Acute Viral Hepatitis

Acute Viral Hepatitis

Emmet B. Keeffe, M. D.
Stanford University School of Medicine

Definition/Key Clinical Features
Differential Diagnosis
Best Tests
Best Therapy
Best References

Definition

Acute inflammatory disease of the liver caused by infection with hepatitis A, B, C, D, or E virus or other viral agent

Key Clinical Features

Fatigue
Anorexia
Flulike symptoms
Jaundice
Hepatic tenderness
Rash

Differential Diagnosis

Alcoholic hepatitis
Drug-induced hepatitis
Autoimmune hepatitis
Acute cholelithiasis/cholecystitis
Other viral infections
- Coxsackievirus
- Herpes simplex
- Cytomegalovirus
- Epstein-Barr virus
Toxoplasmosis
Leptospirosis
Brucellosis
Severe, acute congestive heart failure
Cancer metastatic to the liver

Best Tests

General Lab Findings

Serum bilirubin generally < 15–20 mg/dl
Elevated AST and ALT, often > 1,000 U/L
Mild anemia

Serologic and Virologic Assays

Hepatitis A Virus

IgM anti-HAV appears early and is specific
Persists for 3 mo, then replaced by IgG anti-HAV

Hepatitis B Virus

HBsAg present as early as 1–2 wk after infection
IgM anti-HBc appears promptly after infection, persists for 3–6 mo, then replaced by IgG anti-HBc
Anti-HBs appears by 2–6 mo after loss of HBsAg
HBeAg correlates with presence of HBV DNA (highly infectious) in wild-type HBV infection
Patients with precore or core promoter mutant HBV have HBeAg-negative chronic hepatitis B with negative HBeAg but high-titer HBV DNA

Hepatitis C Virus

Anti-HCV used to diagnose both acute and chronic HCV infection
Serum HCV RNA useful to establish viremia and follow treatment

Hepatitis D and E Viruses

Detection of anti-HDV with HBsAg indicates infection

In acute infection, HBsAg with IgM anti-HBc + anti-HDV

In chronic infection, negative IgM anti-HBc

Liver Biopsy

Usually not performed

Best Therapy

Supportive

Reduce physical activity

Patients should eat whatever they can

No evidence that low-fat diet is beneficial

Abstain from alcohol

Encephalopathic Patients

Evaluate for liver transplantation

Treat bacterial infections with appropriate antibiotics

Administer clotting factors for bleeding

Administer laculose (30 ml p.o. q. 4 hr) if patient obtunded with high serum ammonia level

Prevention

Immunization

Administration Schedules and Dosing of Hepatitis A Vaccine

Children (2–18 yrs)

0, 6–12 mo
- Havrix, 720 ELU/0.5 ml
- VAQTA, 25 U/0.5 ml
Residents of AK, AZ, CA, ID, NV, NM, OK, OR, SD, UT, WA, and high-risk areas of AR, CO, MO, MT, TX, WY
Contraindicated in those with previous allergic reaction to HAV vaccine

Adults (>18 yr)

0, 6–12 mo;
- Havrix, 1,440 ELU/1.0 ml
- VAQTA, 50 U/1.0 ml
Travelers
Those with chronic liver disease, hemophilia or other clotting factor disorders
Other high-risk persons
Contraindicated in pregnancy

Administration Schedules and Dosing of Hepatitis B Vaccine

Infants of HBsAg-negative mother

0–2, 1–4, 6–12 mo

Engerix-B, 10 µg/0.5 ml
Recombivax HB, 2.5 µg/0.5 ml

Infants of HBsAg-positive mother

Birth (within 12 hr with hepatitis B immune globulin and HBV vaccine), 1–2, 6 mo

Engerix-B, 10 µg/0.5 ml

Recombivax HB, 5.0 µg/0.5 ml

Catch-up Schedule of Hepatitis B Vaccine for Patients Who Start Late or Who Are >1 Month Behind (no need to restart series regardless of time elapsed between doses)

Children and adolescents (4 mo–19 yr):

0, at least 4 wk, at least 8 wk (16 wk after first dose)
- Engerix-B, 10 µg/0.5 ml
- Recombivax HB, 5.0 µg/0.5 ml

Alternative series for adolescents (11–15 yr)

0, 4–6 mo
- Recombivax HB, 10 µg/0.5 ml only

Adults (≥ 20 yrs)

0, 1–2 mo, 4–6 mo
- Engerix-B, 20 µg/0.5 ml
- Recombivax HB, 10 µg/0.5 ml

Immunocompromised adults

0, 1 mo, 6 mo
- Engerix-B, 40 µg/0.5 ml
- Recombivax HB, 40 µg/0.5 ml

Best References

Krawczynski, et al: Infect Dis Clin North Am 14:669, 2000

Lok, et al: Hepatology 34:1225, 2001

NIH Consensus Statement: Hepatology 36(suppl 1):S3, 2002

Ryder, et al: BMJ 322:151, 2001

July 2004