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 < 1520 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 12 wk after infection
- IgM anti-HBc appears promptly after infection, persists for 36 mo, then replaced by IgG anti-HBc
- Anti-HBs appears by 26 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
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 (218 yrs)
- 0, 612 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, 612 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
- 02, 14, 612 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), 12, 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 mo19 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 (1115 yr)
- 0, 46 mo
- Recombivax HB, 10 µg/0.5 ml only
- Adults (≥ 20 yrs)
- 0, 12 mo, 46 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
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