Clinical Factors and Viral Load Influencing Severity of Acute Hepatitis A

Multiplexed electrical detection of whole viruses from plasma in a microfluidic platform

The advancement of point-of-care diagnostics is crucial to improving patient outcomes, especially in areas with low access to hospitals or specialized laboratories. In particular, rapid, sensitive, and multiplexed detection of disease biomarkers has great potential to achieve accurate diagnosis and inform high quality care for patients. Our Coulter counting and immunocapture based detection system has previously shown its broad applicability in the detection of cells, proteins, and nucleic acids. This paper expands the capability of the platform by demonstrating multiplexed detection of whole-virus particles using electrically distinguishable hydrogel beads by demonstrating the capability of our platform to achieve simultaneous detection at clinically relevant concentrations of hepatitis A virus (>2 × 103 IU mL-1) and human parvovirus B19 virus like particles (>106 IU mL-1) from plasma samples. The expanded versatility of the differential electrical counting platform allows for more robust and diverse testing capabilities.

Hepatitis A virus infection

Hepatitis A is a vaccine-preventable infection caused by the hepatitis A virus (HAV). Over 150 million new infections of hepatitis A occur annually. HAV causes an acute inflammatory reaction in the liver that usually resolves spontaneously without chronic sequelae. However, up to 20% of patients experience a prolonged or relapsed course and <1% experience acute liver failure. Host factors, such as immunological status, age, pregnancy and underlying hepatic diseases, can affect the severity of disease. Anti-HAV IgG antibodies produced in response to HAV infection persist for life and protect against re-infection; vaccine-induced antibodies against hepatitis A confer long-term protection. The WHO recommends vaccination for individuals at higher risk of infection and/or severe disease in countries with very low and low hepatitis A virus endemicity, and universal childhood vaccination in intermediate endemicity countries. To date, >25 countries worldwide have implemented such programmes, resulting in a reduction in the incidence of HAV infection. Improving hygiene and sanitation, rapid identification of outbreaks and fast and accurate intervention in outbreak control are essential to reducing HAV transmission.

HEPATITIS A. THE FEATURES OF DISEASE COURSE IN ADULTS

OBJECTIVE

The aim: To analyze the incidence of Hepatitis A in Ukraine and Poltava region and to study the clinical and epidemiological features of the course of Hepatitis A in adult patients.

PATIENTS AND METHODS

Materials and methods: The course of HA in 96 hospitalized patients was analyzed. The diagnosis of HA was established on the basis of clinical and epide¬miological data and confirmed by the results of laboratory studies (serological and molecular biological).

RESULTS

Results: In 2019, in the Poltava region, there was an increase in the incidence of Hepatitis A with a predominance among sick people of working age, among the urban population. This part of people aged from 60 to 75 years old constitutes 9.4%. This study showed that the waterway was the dominant way of HA transmission. The course of the disease in most hospitalized patients was typical and cyclic, with a predominance of a mixed variant of the pre-jaundice period and jaundice. One third of patients survey that they had fever, which persisted with jaundice.

CONCLUSION

Conclusions: The findings of this study indicates that the patients older than 40 years were more likely to have concomitant chronic pathology than younger patients, and Hepatitis A was more severe with the development of prolonged cholestasis, wave-like course and recurrence. In most patients under the age of 40, the course of Hepatitis A was mild, but splenomegaly and severe cytolytic syndrome were more common.

Development and Evaluation of a Molecular Hepatitis A Virus Assay for Serum and Stool Specimens

Hepatitis A virus (HAV) is an emerging public health concern and there is an urgent need for ways to rapidly identify cases so that outbreaks can be managed effectively. Conventional testing for HAV relies on anti-HAV IgM seropositivity. However, studies estimate that 10–30% of patients may not be diagnosed by serology. Molecular assays that can directly detect viral nucleic acids have the potential to improve diagnosis, which is key to prevent the spread of infections. In this study, we developed a real-time PCR (RT-PCR) assay to detect HAV RNA for the identification of acute HAV infection. Primers were designed to target the conserved 5′-untranslated region (5′-UTR) of HAV, and the assay was optimized on both the Qiagen Rotor-Gene and the BD MAX. We successfully detected HAV from patient serum and stool samples with moderate differences in sensitivity and specificity depending on the platform used. Our results highlight the clinical utility of using a molecular assay to detect HAV from various specimen types that can be implemented in hospitals to assist with diagnostics, treatment and prevention.

A case of COVID 19 with concomitant infection with hepatitis A

Symptoms of COVID-19 range from mild to severe with pulmonary manifestations being predominate, however, liver injury is not rare. There might be a reciprocal influence between COVID-19 and hepatic disease. While high levels of liver enzyme is associated with an increased prevalence of severe complications, search for other etiologies of hepatic disease should be not be ignored. We report a case of COVID-19 presented with acute fulminant hepatitis A (HAV) without previous history.

Need for hepatitis A prevention in patients with chronic liver disease in the changing epidemiological setting of India

The burden of chronic liver disease (CLD) in India is high, particularly among middle-aged men, with nearly 220,000 deaths due to cirrhosis in 2017. CLD increases the risk of infection, severe disease (e.g. hepatitis A virus or HAV superinfection, acute-on-chronic liver failure, fulminant hepatic failure), and mortality. Hence, various countries recommend HAV vaccination for CLD patients. While historic Indian studies showed high seroprevalences of protective HAV antibodies among Indian adults with CLD, the most recent ones found that nearly 7% of CLD patients were susceptible to HAV infection. Studies in healthy individuals have shown that HAV infection in childhood is decreasing in India, resulting in an increasing population of adults susceptible to HAV infection. As patients with CLD are at increased risk of severe HAV infection, now may be the time to recommend HAV vaccination among people with CLD in India.

Is COVID-19-induced liver injury different from other RNA viruses?‎

Coronavirus disease 2019 is a pandemic disease caused by a novel RNA coronavirus, SARS coronavirus 2 (SARS-CoV-2), which is implicated in the respiratory system. SARS-CoV-2 also targets extrapulmonary systems, including the gastrointestinal tract, liver, central nervous system and others. SARS-CoV-2, like other RNA viruses, targets the liver and produces liver injury. This literature review showed that SARS-CoV-2-induced liver injury is different from other RNA viruses by a transient elevation of hepatic enzymes and does not progress to liver fibrosis or other unfavorable events. Moreover, SARS-CoV-2-induced liver injury usually occurs in the presence of risk factors, such as nonalcoholic liver fatty disease. This review highlights the important differences between RNA viruses inducing liver injury taking into consideration the clinical, biochemical, histopathological, postmortem findings and the chronicity of liver injury that ultimately leads to liver fibrosis and hepatocellular carcinoma.

RNA testing for the diagnosis of acute hepatitis A during the 2017 outbreak in France

Diagnostic of acute hepatitis A virus (HAV) infection is based on the detection of anti-HAV IgM without testing for the pathogen itself. We evaluated the usefulness of HAV RNA testing for confirmation of acute hepatitis A and to provide indications about the level of HAV replication in HIV-positive and HIV-negative subjects during an unprecedented outbreak of HAV observed in France in 2017. HAV RNA was detected in 38 out of 41 (92.6%) subjects with a clinical diagnosis of acute hepatitis A, whereas nine cases tested positive for anti-HAV IgM in whom the diagnosis of acute hepatitis A was not retained were found negative for HAV RNA. All subjects in the control group were also tested negative for HAV RNA. HAV viremia was correlated to ALT peak (r = .64; P < .0001). HIV-infected patients have similar HAV RNA levels but were less likely to have prolonged international normalized ratio of prothrombin time when compared to the HIV-uninfected group (P = .016), suggesting a less severe course of acute hepatitis. HAV RNA was detected in the serum of most of the patients with acute hepatitis A, indicating that the direct detection of HAV can be used to confirm hepatitis A in patients tested positive for anti-HAV IgM antibodies. Nucleic acid tests should serve more broadly during the diagnosis workup of acute hepatitis A to improve the predictive values of HAV in vitro diagnostic tests and to confirm acute hepatitis A in patients tested positive with IgM with moderate or low S/CO values.

Fatal hepatitis A virus infection in an adolescent

Acute hepatitis A infection is largely self-limiting illness, rarely resulting in fulminant course with consequent hepatic failure and death. We present a 13-year old previously healthy Omani with fatal hepatitis A virus infection. This case highlights the critical role of hepatitis A vaccination and argues for consideration of its inclusion in national vaccination programs in order to avert similar devastating consequences of yet another vaccine preventable disease.

Comparison of the Clinical Features of Hepatitis A in People Living with HIV between Pandemics in 1999-2000 and 2017-2018 in the Metropolitan Area of Japan

Since 2017, hepatitis A virus (HAV) infection has been an epidemic among men who have sex with men (MSM) in Japan. We have come across 11 MSM patients with hepatitis A who were also infected with HIV. In 1999-2000, we came across 5 HIV-infected patients with hepatitis A. Since the conditions of current HIV-infected patients have changed owing to the recent progress in anti-HIV therapies, we compared clinical features of hepatitis A between patients in 2017-2018 and those in 1999-2000. By comparing the background characteristics of the patients, we found that the CD4/CD8 ratio was significantly higher in the 2017-2018 group. After the onset of hepatitis, peak levels of hepatic transaminases were found to be higher in the 2017-2018 group, suggesting severe hepatocellular damage. In contrast, neither the peak level of total bilirubin nor the nadir of prothrombin time was significantly different among the 2 groups. We also analyzed the HAV genome derived from some of the recently infected patients, and found that the HAV strains were almost the same among these patients; slight differences were observed from the previously identified strain. Thus, we concluded that the recovery of immunity by recent anti-HIV therapies may result in more severe hepatocellular damages and differences in clinical features.

Deteriorated outcome of recent patients with acute liver failure and late-onset hepatic failure caused by infection with hepatitis A virus: A subanalysis of patients seen between 1998 and 2015 and enrolled in nationwide surveys in Japan

AIM

A nationwide survey of acute liver failure (ALF) and late-onset hepatic failure (LOHF) has revealed that the outcomes of recent patients whose diseases were caused by infection with hepatitis A virus (HAV) have worsened, compared with those of previously reported patients. The factors associated with this deterioration were evaluated.

METHODS

A total of 83 patients with HAV infection seen between 1998 and 2015 were enrolled. All the patients had a prothrombin time-international normalized ratio of 1.5 or more and hepatic encephalopathy of grade 2 or more severe. The demographic and clinical features of 45 patients seen prior to 2003 (cohort 1) and 38 patients seen during 2004 and thereafter (cohort 2) were compared.

RESULTS

Three and four patients in cohort 1 and cohort 2, respectively, received liver transplantations; the survival rates among the remaining patients were 56% for cohort 2 and 79% for cohort 1 (P < 0.05). The mean age (±standard deviation) of the patients was higher in cohort 2 than in cohort 1 (58 ± 11 vs. 48 ± 13 years; P < 0.01). The percentages of patients with underlying metabolic diseases were 22% in cohort 1 and 61% in cohort 2 (P < 0.01). Diabetic mellitus was more common among deceased patients than among rescued patients (29% vs. 8%; P < 0.05) among patients who did not receive liver transplantations, and a multivariate analysis revealed that patient age and disease type were significantly and independently associated with the outcome.

CONCLUSION

The outcomes of recent patients with ALF or LOHF caused by HAV infection have recently worsened mainly because of an increase in underlying metabolic diseases as a consequence of aging.

Gender Impacts on the Disease Severity of Overt Acute Hepatitis A: Different from Overt Acute Hepatitis B

BACKGROUND

Acute hepatitis A (AH-A) and acute hepatitis B (AH-B) were found more severe in males and females, respectively, while impacts from underlying liver disease on severity were not excluded in the AH-A study.

AIM

The precise gender-specific impact on the severity of AH-A was investigated and compared with that of AH-B.

METHODS

A case-control study of overt AH-A (n = 118) and AH-B (n = 118) patients without any underlying liver disease was conducted. Overt hepatitis was defined as serum bilirubin ≥ 2 mg/dL and alanine transaminase (ALT) ≥ 10 × upper limit of normal.

RESULTS

Of the AH-A patients, age (95% confidence interval of odds ratio 1.051-1.147) and ALT (1.001-1.002) were associated with hepatic decompensation. Indifferent rates of hepatic decompensation, hepatic failure, and mortality were found between male and female patients. Compared with the AH-B patients, AH-A patients showed lower bilirubin levels (p < 0.001), hepatic decompensation (p = 0.004), and mortality rates (p = 0.013). Among patients < 40 years, the AH-A patients had higher hepatic decompensation rates than AH-B in the male subgroup (15% vs. 2.8%, p = 0.045), while the situation is reverse in the female subgroup (7.7% vs. 48.1%, p = 0.001).

CONCLUSIONS

Overt AH-A was less severe than overt AH-B and, unlike AH-B, had no difference in severity between males and females. Among subgroups < 40 years, AH-A was more severe than AH-B in males, but the situation was reverse in females in terms of hepatic decompensation rates.

Seroepidemiology of Hepatitis Viruses and Hepatitis B Genotypes of Female Marriage Immigrants in Korea

PURPOSE

The Korean society has moved rapidly toward becoming a multicultural society. This study aimed to estimate the seroprevalence of hepatitis viruses and investigate hepatitis B virus (HBV) genotypic diversity in female marriage immigrants.

MATERIALS AND METHODS

Screening program was conducted at support centers for multicultural families in 21 administrative districts in Korea between July 2011 and January 2017. A total of 963 female marriage immigrants were included in this study. Blood samples were tested for hepatitis viral markers and HBV genotype.

RESULTS

Subjects' median age was 33 years (20-40 years), and they originated from nine countries including Vietnam (n=422, 43.8%), China (n=311, 32.3%), the Philippines (n=85, 8.8%), Cambodia (n=58, 6.0%), and Japan (n=39, 4.0%). About 30% (n=288) of subjects required hepatitis A vaccination. HBsAg positive rate was 5.4% (n=52). Positive HBsAg results were the highest in subjects from Southeast Asia (6.6%, n=38). Anti-HBs positive rate was 60.4% (n=582). About 34% (n=329) of subjects who were negative for anti-HBs and HBsAg required HBV vaccinations. Genotypes B and C were found in 54.6% (n=12) and 45.4% (n=10) of the 22 subjects with HBV, in whom genotypes were tested. Eight (0.8%) subjects were positive for anti-HCV. Positive anti-HCV results were the highest in subjects from Central Asia (7.9%, n=3).

CONCLUSION

Testing for hepatitis viral marker (hepatitis A virus IgG and HBsAg/anti-HBs) is needed for female marriage immigrants. Especially, HBV genotype B is different from genotype C of Koreans. Therefore, interest and attention to vaccination programs for female marriage immigrants are necessary for both clinicians and public health institutes.

Acute Liver Failure: An Update

Pediatric acute liver failure (PALF) is a dynamic, life-threatening condition of disparate etiology. Management of PALF is dependent on intensive collaborative clinical care and support. Proper recognition and treatment of common complications of liver failure are critical to optimizing outcomes. In parallel, investigations to identify underlying cause and the implementation of timely, appropriate treatment can be life-saving. Predicting patient outcome in the era of liver transplantation has been unfulfilling and better predictive models must be developed for proper stewardship of the limited resource of organ availability.

Natural History, Clinical Manifestations, and Pathogenesis of Hepatitis A

Hepatitis A virus (HAV) is transmitted by the fecal-oral route and is a major cause of acute viral hepatitis. The clinical manifestations of HAV infection range from asymptomatic infection to acute liver failure (ALF), but do not include progression to chronic hepatitis. Risk factors for severe acute hepatitis A are older age (>40 years) and preexisting liver disease. Some patients may show atypical clinical features such as relapsing hepatitis, prolonged cholestasis, or extrahepatic manifestations. Almost all hepatitis A patients spontaneously recover with supportive care. However, in the case of ALF (<1%), intensive care and urgent decision on liver transplantation are required. Liver injury during hepatitis A is not directly caused by HAV but is known to be caused by immune-mediated mechanisms. In this review, the natural history and clinical manifestations of hepatitis A are described. In addition, mechanisms of immunopathogenesis in hepatitis A are discussed.

Hepatitis A virus genotype IA-infected patient with marked elevation of aspartate aminotransferase levels

We describe a case of acute liver failure (ALF) without hepatic encephalopathy with marked elevation of aminotransferase due to hepatitis A, according to the revised Japanese criteria of ALF. This liver biopsy of the patient showed compatible to acute viral hepatitis and she immediately recovered without intensive care. She had no comorbid disorders. Of interest, phylogenetic tree analysis using almost complete genomes of hepatitis A virus (HAV) demonstrated that the HAV isolate from her belonged to the HAV subgenotype IA strain and was similar to the HAJFF-Kan12 strain (99% nucleotide identity) or FH1 strain (98% nucleotide identity), which is associated with severe or fulminant hepatitis A. Careful interpretation of the association between HAV genome variations and severity of hepatitis A is needed and the mechanism of the severe hepatitis should be explored.