Prolonged intrahepatic cholestasis secondary to acute hepatitis A

Pediatric acute viral hepatitis with atypical variants: Clinical dilemmas and natural history

Classical acute viral hepatitis (AVH) has an uncomplicated outcome. Acute liver failure has a grave prognosis. Atypical manifestations of AVH are a group of disorders that causes significant morbidity and dilemmas in children. These include prolonged cholestasis, relapsing hepatitis, ascitic form of AVH, late-onset hepatic failure (LOHF), intravascular hemolysis, and provoking an autoimmune trigger leading to autoimmune hepatitis. These entities cause significant liver dysfunction or worsening and are often difficult to differentiate from chronic liver disease (CLD). Ascitic form of AVH, LOHF, decompensated CLD and acute-on-chronic liver failure have significant overlapping features that need to be carefully dissected out. In many cases, only on long-term follow-up, these clinical entities can be separately identified. Intravascular hemolysis is usually caused by associated glucose-6-phosphate dehydrogenase deficiency. Rarely CLD such as Wilson disease and autoimmune hepatitis can also present with hemolysis in the initial presentation, which can mimic AVH with hemolysis. Identifying deviations from typical manifestations aid in avoiding unnecessary investigations, allowing focused therapy and alleviating anxiety.

Hepatitis A: Epidemiology, High-Risk Groups, Prevention and Research on Antiviral Treatment

The hepatitis A virus (HAV) is a leading cause of acute viral hepatitis worldwide. It is transmitted mainly by direct contact with patients who have been infected or by ingesting contaminated water or food. The virus is endemic in low-income countries where sanitary and sociodemographic conditions are poor. Paradoxically, improving sanitary conditions in these countries, which reduces the incidence of HAV infections, can lead to more severe disease in susceptible adults. The populations of developed countries are highly susceptible to HAV, and large outbreaks can occur when the virus is spread by globalization and by increased travel and movement of foodstuffs. Most of these outbreaks occur among high-risk groups: travellers, men who have sex with men, people who use substances, and people facing homelessness. Hepatitis A infections can be prevented by vaccination; safe and effective vaccines have been available for decades. Several countries have successfully introduced universal mass vaccination for children, but high-risk groups in high-income countries remain insufficiently protected. The development of HAV antivirals may be important to control HAV outbreaks in developed countries where a universal vaccination programme is not recommended.

Mechanisms of Hepatocellular Injury in Hepatitis A

Hepatitis A virus (HAV) infection is a common cause of acute viral hepatitis worldwide. Despite decades of research, the pathogenic mechanisms of hepatitis A remain incompletely understood. As the replication of HAV is noncytopathic in vitro, a widely accepted concept has been that virus-specific cytotoxic T cells are responsible for liver injury. However, accumulating evidence suggests that natural killer (NK) cells, NKT cells, and even non-HAV-specific CD8⁺ T cells contribute to liver damage during HAV infection. In addition, intrinsic death of virus-infected hepatocytes has been implicated as a cause of liver injury in a murine model of hepatitis A. Furthermore, genetic variations in host factors such as T cell immunoglobulin-1 (TIM1) and IL-18 binding protein (IL-18BP) have been linked to hepatitis A severity. This review summarizes the current knowledge of the mechanisms of hepatocellular injury in hepatitis A. Different mechanisms may be involved under different conditions and they are not necessarily mutually exclusive. A better understanding of these mechanisms would aid in diagnosis and treatment of diseases associated with HAV infection.

From hepatitis A to E: A critical review of viral hepatitis

Viral infections affecting the liver have had an important impact on humanity, as they have led to significant morbidity and mortality in patients with acute and chronic infections. Once an unknown etiology, the discovery of the viral agents triggered interest of the scientific community to establish the pathogenesis and diagnostic modalities to identify the affected population. With the rapid scientific and technological advances in the last centuries, controlling and even curing the infections became a possibility, with a large focus on preventive medicine through vaccination. Hence, a comprehensive understanding of hepatitis A, B, C, D and E is required by primary care physicians and gastroenterologists to provide care to these patients. The review article describes the epidemiology, pathogenesis, clinical presentation, diagnostic tools and current medication regimens, with a focus on upcoming treatment options and the role of liver transplantation.

Hepatitis A and Hepatitis E: Clinical and Epidemiological Features, Diagnosis, Treatment, and Prevention

Hepatitis A and E are both ancient diseases but have only been properly recognized as being caused by distinct pathogens in modern times. Despite significantly different genomic structures, both viruses employ remarkably similar strategies to avoid host detection and increase environmental transmission. There are millions of cases of acute viral hepatitis due to hepatitis A virus (HAV) and hepatitis E virus (HEV) each year, resulting in tens of thousands of deaths. The presentations can be clinically indistinguishable, but each virus also has a range of less common but more specific phenotypes. The epidemiology of HAV is complex, and is shifting in countries that are making improvements to public health and sanitation. HEV presents a significant public health challenge in resource-limited settings but has historically been incorrectly regarded as having little clinical relevance in industrialized countries.

Comparative Pathology of Hepatitis A Virus and Hepatitis E Virus Infection

Hepatitis A virus (HAV) and hepatitis E virus (HEV) cause acute, self-limiting hepatic infections that are usually spread by the fecal-oral route in humans. Naturally occurring and experimental infections are possible in a variety of nonhuman primates and, in the case of HEV, a number of other species. Many advances in understanding the pathogenesis of these viruses have come from studies in experimental animals. In general, animals infected with these viruses recapitulate the histologic lesions seen in infected humans, but typically with less severe clinical and histopathological manifestations. This review describes the histopathologic changes associated with HAV and HEV infection in humans and experimental animals.

Atypical manifestations of hepatitis A virus infection

Acute hepatitis due to the hepatitis A virus usually has a short, benign and self-limited course, without causing chronic hepatitis. However, some cases have an atypical presentation, such as relapsing hepatitis, prolonged or persistent cholestasis, fulminant hepatic failure, or liver failure associated with autoimmune hepatitis. The typical clinical course of acute hepatitis A virus infection is spontaneous remission in 90% of the cases, but atypical cases have a prevalence that varies from less than 1 to 20%, depending on the manifestation (overall prevalence ∼7%). There is little information on the atypical clinical courses of hepatitis A virus infection and the lack of recognizing those presentations in clinical practice often results in carrying out numerous studies and treatments that not only are unnecessary, but can also be harmful. The aim of the present article was to describe 3 clinical cases of atypical hepatitis A infection and provide a literature review of such cases.

Hepatitis A Virus: Essential Knowledge and a Novel Identify-Isolate-Inform Tool for Frontline Healthcare Providers

Infection with hepatitis A virus (HAV) causes a highly contagious illness that can lead to serious morbidity and occasional mortality. Although the overall incidence of HAV has been declining since the introduction of the HAV vaccine, there have been an increasing number of outbreaks within the United States and elsewhere between 2016 and 2017. These outbreaks have had far-reaching consequences, with a large number of patients requiring hospitalization and several deaths. Accordingly, HAV is proving to present a renewed public health challenge. Through use of the "Identify-Isolate-Inform" tool as adapted for HAV, emergency physicians can become more familiar with the identification and management of patients presenting to the emergency department (ED) with exposure, infection, or risk of contracting disease. While it can be asymptomatic, HAV typically presents with a prodrome of fever, nausea/vomiting, and abdominal pain followed by jaundice. Healthcare providers should maintain strict standard precautions for all patients suspected of having HAV infection as well as contact precautions in special cases. Hand hygiene with soap and warm water should be emphasized, and affected patients should be counseled to avoid food preparation and close contact with vulnerable populations. Additionally, ED providers should offer post-exposure prophylaxis to exposed contacts and encourage vaccination as well as other preventive measures for at-risk individuals. ED personnel should inform local public health departments of any suspected case.

Clinical characteristics and outcomes of acute hepatitis a in Korea: a nationwide multicenter study

The aim of this study was to investigate the clinical characteristics of acute hepatitis A during a recent outbreak in Korea. Data of patients diagnosed with acute hepatitis A from 2007 to 2009 were collected from 21 tertiary hospitals retrospectively. Their demographic, clinical, and serological characteristics and their clinical outcomes were analyzed. A total of 4,218 patients (mean age 33.3 yr) were included. The median duration of admission was 9 days. The mean of the highest ALT level was 2,963 IU/L, total bilirubin was 7.3 mg/dL, prothrombin time INR was 1.3. HBsAg was positive in 3.7%, and anti-HCV positive in 0.7%. Renal insufficiency occurred in 2.7%, hepatic failure in 0.9%, relapsing hepatitis in 0.7%, and cholestatic hepatitis in 1.9% of the patients. Nineteen patients (0.45%) died or were transplanted. Complications of renal failure or prolonged cholestasis were more frequent in patients older than 30 yr. In conclusion, most patients with acute hepatitis A recover uneventfully, however, complication rates are higher in patients older than 30 yr than younger patients. Preventive strategies including universal vaccination in infants and active immunization of hepatitis A to adult population should be considered for prevention of community-wide outbreaks of hepatitis A in Korea.

[A case of sustained cholestasis caused by acute A viral hepatitis in Dubin-Johnson syndrome]

Dubin-Johnson syndrome is a rare clinical entity. It shows intermittent symptoms such as chronic or intermittent jaundice, abdominal pain, weakness, nausea, vomiting, anorexia and diarrhea. Symptoms are precipitated or aggravated by pregnancy, alcoholism, surgical procedures and intercurrent disease. Chronic idiopathic jaundice is typical of Dubin-Johnson syndrome and its prognosis is good. We describe a case of prolonged cholestasis for more than 10 months caused by acute A viral hepatitis in a patient with Dubin-Johnson syndrome. It is a first report of cholestasis complicated by acute A viral hepatitis in a patient with Dubin-Johnson syndrome.

Graves' disease presenting with severe cholestasis

BACKGROUND

Hyperthyroidism has been associated with liver function abnormalities; however, cholestasis as the presenting feature of adolescent Graves' disease has not been previously reported.

PATIENT SUMMARY

The patient was a 17-year-old girl who presented with severe cholestasis and was found to have Graves' disease. She also had a positive hepatitis A immunoglobulin M antibody but her clinical course, the liver histopathology, and her mildly elevated transaminases indicated that the acute hepatitis A infection was not dominant at the time of presentation with severe cholestasis. Other causes of cholestasis, including congestive heart failure, autoimmune hepatitis, and viral infection, were excluded. Treatment with methimazole resolved the hyperthyroidism, and the cholestasis improved, as well.

CONCLUSION

Severe cholestasis is a rare presenting feature of Graves' disease. With careful monitoring, methimazole can be used to treat the hyperthyroidism in the setting of cholestasis.

Drug rash with eosinophilia and systemic symptoms syndrome following cholestatic hepatitis A: a case report

Hepatitis A virus (HAV) infections occur predominantly in children, and are usually self-limiting. However, 75-95% of the infections in adults are symptomatic (mostly with jaundice), with the illness symptoms usually persisting for a few weeks. Atypical manifestations include relapsing hepatitis, prolonged cholestasis, and complications involving renal injury. Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome is a severe, drug-induced hypersensitivity reaction characterized by skin rash, fever, lymph-node enlargement, and internal organ involvement. We describe a 22-year-old male who presented with acute kidney injury and was diagnosed with prolonged cholestatic hepatitis A. The patient also developed DRESS syndrome due to antibiotic and/or antiviral treatment. To our knowledge, this is the first report of histopathologically confirmed DRESS syndrome due to antibiotic and/or antiviral treatment following HAV infection with cholestatic features and renal injury.

Clinical features of re-emerging hepatitis A: an analysis of patients hospitalized during an urban epidemic in Korea

From April 2008 to November 2008, many cases of hepatitis A were reported in Seoul and Gyeonggi Province in Korea. Furthermore, the rate of severe or fulminant hepatitis have significantly increased during the latest epidemic (13.4% vs. 5.2%, p=0.044). Therefore, widespread use of vaccine is warranted to reduce the burden of hepatitis A in Korea.

[A case of pleural effusion associated with acute hepatitis A]

Hepatitis A virus (HAV) infection is common in developing countries, including Korea. It can be accompanied by extrahepatic complications such as renal failure, arthritis, and vasculitis. Pleural effusion is a very rare complication of HAV infection, which has been reported usually in children, and has benign clinical courses. Here we report a case of pleural effusion with ascites which occurred in an adult hepatitis A patient. A 26-year-old-woman presented generalized myalgia and fever and was diagnosed as acute hepatitis A. Despite of the improvement of laboratory findings, fever and cough persisted. Pleural effusion newly appeared on the serial chest radiologic images. After the fever settled down, the pleural effusion resolved spontaneously at 13th day of admission.

Hepatitis A virus: serology and molecular diagnostics

The diagnosis of hepatitis A virus (HAV) infection is based on the detection of anti-HAV IgM. Shortcomings of this serological approach include the persistence of IgM after normalization of liver enzymes or its detection during polyclonal activation of the immune system due to unrelated viral infection or autoimmune diseases. Molecular diagnosis of HAV along with anti-HAV IgG avidity measurement are helpful in case of positive IgM where laboratory evidence of acute hepatitis is absent and there is no epidemiologic link to other cases. Molecular epidemiology allows us to determine whether viruses from different locations are related to each other and provides further understanding of viral epidemiology by identifying sources and transmission modes. It has been demonstrated that the rapid turnover of HAV strains in low-endemicity countries is caused by their introduction by travelers. Growing sequence databases allow for the identification of geographic origin of viral strains. Collaboration between surveillance laboratories, including database sharing, should be promoted for deeper investigation of outbreaks and improved prevention approaches.

Nasobiliary drainage in acute cholestatic hepatitis with pruritus

BACKGROUND/AIM

Cholestatic acute viral hepatitis may have prolonged course. Pruritus is often a prominent feature and difficult to control. Sometimes it may be accompanied by severe cough. There are no reports of endoscopic nasobiliary drainage in these patients.

METHODS

We prospectively evaluated the role of nasobiliary drainage in six patients with cholestatic acute viral hepatitis with intractable pruritus and accompanying severe cough in one patient in an uncontrolled study.

RESULTS

There were five male and one female patient with cholestatic acute viral hepatitis with intractable pruritus. One patient also had severe cough. Nasobiliary drainage relieved pruritus in all patients and patient with cough also showed marked improvement within 24h. Nasobiliary drainage also hastened the recovery in these patients.

CONCLUSIONS

Short-term nasobiliary drainage should be considered in patients with cholestatic acute viral hepatitis with intractable pruritus and cough for symptomatic relief. It may help in faster recovery in these patients. However, a larger randomized controlled study is warranted.

Initial thrombocytopenia as a simple, valuable predictor for clinical manifestation in acute hepatitis A

OBJECTIVE

Although acute hepatitis A (AH-A) is usually self-limited, the clinical manifestations can vary from mild to severe liver dysfunction. However, little is known about the simple, valuable predictors for clinical manifestation in AH-A. The objective of this study was to identify the simple clinical predictors for severe liver dysfunction and its clinical course.

MATERIAL AND METHODS

A total of 162 IgM anti-hepatitis A virus (HAV) positive patients were enrolled in the study. Severe AH-A was defined as a prothrombin time <40% of control activity. Various liver-unrelated and liver-related parameters at presentation were compared separately between the severe AH-A group and the non-severe group.

RESULTS

Mean age (+/-SD) was 27.5 (+/-7.1) years and the proportion of males was 54% (88/162). Fourteen patients (8.7%) experienced severe AH-A. Of the liver-unrelated parameters, leukopenia (<4000/microl), thrombocytopenia (<150,000/microl), and high serum C-reactive protein levels (>8 mg/l) at presentation were significant predictors for severe AH-A in a univariate analysis (p<0.05). On multivariate analysis, only thrombocytopenia was an independent predictor for severe AH-A (odds ratio (OR) 5.562, 95% confidence interval (CI) 1.153-26.834, p=0.033). Of the liver-related parameters, there were no independent predictors, as shown by multivariate analysis. The thrombocytopenia group (33%, 54/162) not only had a longer recovery time (28 days (range, 14-140) versus 37 days (20-128), p<0.001), but also more frequent complications (OR 4.632, 95% CI 1.886-11.372, p=0.001) than the non-thrombocytopenia group.

CONCLUSIONS

Initial thrombocytopenia may be a simple, valuable predictor for severity and clinical course in AH-A.

Does co-infection with multiple viruses adversely influence the course and outcome of sporadic acute viral hepatitis in children?

BACKGROUND

This study looked at the frequency of co-infection with multiple hepatotropic viruses and the effect of such infection on the course and outcome of acute sporadic viral hepatitis (AVH) and fulminant hepatic failure (FHF) in children.

METHODS

Consecutive children up to 15 years of age presenting with AVH or FHF between January 1998 and July 2002 were evaluated prospectively. The following viral markers were assessed in all children: immunoglobulin M (IgM) anti-hepatitis A virus (HAV), IgM anti-hepatitis E virus (HEV), hepatitis B surface antigen (HBsAg), IgM anti-hepatitis B core (HBc), and anti-hepatitis C virus (HCV).

RESULTS

A total of 149 children were included in the study, 122 with AVH and 27 with FHF. Co-infection with multiple viruses was detected in 30 (24.6%) AVH patients (A+E in 24, A+B in three, and E+B, A+C and A+E+B in one each) and seven (26%) FHF patients (A+E in five, and A+B and E+B in one each). The majority of single infections were due to HAV (AVH 70/92, FHF 14/20) followed by HEV (AVH 9/92, and FHF 5/20). HEV infection was associated with infection with another agent in 88% of patients with AVH (odds ratio 53, 95% confidence interval 15-186, P<0.0001). Frequency of anicteric state, prolonged cholestasis, relapsing hepatitis, ascites, hemolysis and mortality rates were similar in the single and multiple infection groups for both AVH and FHF patients.

CONCLUSIONS

Co-infection with multiple viruses is observed in one-quarter of patients with sporadic AVH in childhood. Such infection does not produce a more severe disease. HEV positivity is a strong marker for multiple infections.

[Hepatitis A]

Hepatitis A infection is known since the ancient Chinese, Greek and Roman civilizations but the first documented report was published in the eighteenth century. The hepatovirus belongs to the Picornaviridae family, and carries a single strand RNA. There are 7 genotypes. Antibodies of the IgM and IgA classes, during natural infections, appear early in the serum, together with the first clinical manifestations of the disease, but they may also appear at the end of the first week of infection. There is a spectrum of clinical presentation: asymptomatic infection, symptomatic without jaundice and symptomatic jaundiced. A rare fatal form of hepatitis has been described. Diagnosis of the hepatitis A infection is confirmed by the finding of IgM anti-HAV antibodies, routinely performed using an ELISA test. Treatment is supportive. Intramuscular anti-A gamma globulin is used for passive immune prophylaxis, and there is an efficient vaccine for active immune prophylaxis.

Hepatitis

Hepatitis is a common disorder with diverse etiology. Hepatitis can be classified as acute when duration is short and as chronic when it lasts more than 6 months. It can also be suspected to be chronic because of its cause. When evaluating a patient with hepatitis, investigation for viral etiologies is usually the first step, however it is important not to forget the other possibilities of drug- or chemical-related injury, as well as the multiple immune, metabolic and toxic causes of hepatitis. In this article, we have dedicated the larger part of our discussion to viral etiologies. There has been enormous progress over the past few years in the management of viral hepatitis, especially of viral hepatitis B and C. In this article, we discussed current therapeutic options in the management of these relatively common disorders and provided some recommendations in preventing transmission of these infections.

Changes of gallbladder and gastric dynamics in patients with acute hepatitis A

Transient alterations of gallbladder morphology and dynamics have been reported in patients with during acute hepatitis A. The presence of dyspepsia also suggests involvement of gastric motility. During a 60-day follow-up, we investigated gallbladder and gastric motility in relation to dyspepsia in acute viral hepatitis A patients. Twenty patients were assessed at referral (day 0) and at days 7, 21, 42 and 60 and compared with 20 healthy volunteers. Gallbladder morphology and motility and gastric motility were assessed in the fasting and postprandial period by functional ultrasonography using a liquid test meal. Dyspeptic symptoms were scored. At day 0, fasting gallbladder volume was 5.9 +/- 1.3 mL, 32.6 +/- 4.6 mL, and 21.5 +/- 1.9 mL (mean +/- SE) in patients with gallbladder sludge (n = 7), without sludge (n = 13) and controls, respectively (P < 0.05 in sludge vs. no sludge and controls; P < 0.05 in no sludge vs. controls, ANOVA). Small fasting gallbladder volume in patients with sludge increased and sludge disappeared within 7 days. At day 0, patients with sludge also had increased thickness of fasting gallbladder wall and increased serum transaminase levels compared with patients without sludge and controls. Gallbladder contraction was similar in patients and controls. However, patients had delayed gastric emptying, which positively correlated with dyspepsia score. Gallbladder morphological changes observed in the acute phase of hepatitis A are transient and are associated with hepatocellular damage. Gastric emptying is delayed during the first week of disease and is associated with dyspeptic symptoms.

Diagnosis and monitoring of hepatic injury. II. Recommendations for use of laboratory tests in screening, diagnosis, and monitoring

Purpose: To review information on the use of laboratory tests in screening, diagnosis, and monitoring of acute and chronic hepatic injury.

Data Sources and Study Selection: A MEDLINE search was performed for key words related to hepatic diseases, including acute hepatitis, chronic hepatitis, alcoholic hepatitis, cirrhosis, hepatocellular carcinoma, and etiologic causes. Abstracts were reviewed, and articles discussing use of laboratory tests selected for review. Additional articles were selected from the references.

Guideline Preparation and Review: Drafts of the guidelines were posted on the Internet, presented at the AACC Annual Meeting in 1999, and reviewed by experts. Areas requiring further amplification or literature review were identified for further analysis. Specific recommendations were made based on analysis of published data and evaluated for strength of evidence and clinical impact.

Recommendations: Although many specific recommendations are made in the guidelines, only some summary recommendations are listed here. In acute hepatic injury, prothrombin time and, to a lesser extent, total bilirubin are the best indicators of severity of disease. Although ALT is useful for detecting acute and chronic hepatic injury, it is not related to severity of acute hepatic injury and only weakly related to severity of chronic hepatic injury. Specific tests of viral markers should be the initial differential tests in both acute and chronic hepatic injury; when positive, they are also useful for monitoring recovery from hepatitis B and C.

Hepatitis A: old and new

The hepatitis A virus (HAV), a picornavirus, is a common cause of hepatitis worldwide. Spread of infection is generally person to person or by oral intake after fecal contamination of skin or mucous membranes; less commonly, there is fecal contamination of food or water. Hepatitis A is endemic in developing countries, and most residents are exposed in childhood. In contrast, the adult population in developed countries demonstrates falling rates of exposure with improvements in hygiene and sanitation. The export of food that cannot be sterilized, from countries of high endemicity to areas with low rates of infection, is a potentially important source of infection. After ingestion and uptake from the gastrointestinal tract, the virus replicates in the liver and is excreted into the bile. Cellular immune responses to the virus lead to destruction of infected hepatocytes with consequent development of symptoms and signs of disease. Humoral immune responses are the basis for diagnostic serologic assays. Acute HAV infection is clinically indistinguishable from other causes of acute viral hepatitis. In young children the disease is often asymptomatic, whereas in older children and adults there may be a range of clinical manifestations from mild, anicteric infection to fulminant hepatic failure. Clinical variants include prolonged, relapsing, and cholestatic forms. Management of the acute illness is supportive, and complete recovery without sequelae is the usual outcome. Research efforts during World War II led to the development of passive immunoprophylaxis. Pooled immune serum globulin is efficacious in the prevention and attenuation of disease in exposed individuals. More recently, active immunoprophylaxis by vaccination has been accomplished. Future eradication of this disease can now be contemplated.

Viral hepatitis. From prevention to antivirals

The challenge of viral hepatitis has been acknowledged and confronted in the last decade. Significant progress in prevention of infection with HAV and HBV may eradicate these serious infections from the United States and other parts of the world in the coming decades. Application of prophylactic strategies to children will be a major mechanism in accomplishing this task. The quest for potent antiviral medications continues. The next critically important development will be ways to prevent new HCV infections and to treat the millions of already infected individuals at risk for the serious consequences of this disease. For pediatricians, realizing these goals requires a greater understanding of perinatal HCV transmission, use of vaccines for prevention of viral hepatitis, and identification of HCV-infected children who are likely to benefit from new therapeutic strategies as they become available.

Hepatitis A

Hepatitis A remains an important cause of community-acquired hepatitis in the United States and in the world. In recent years, improvements in personal hygiene and environmental sanitation have led to declines in overall hepatitis A infection rates in developed countries, although sporadic outbreaks still occur with similar rates of hospitalization and loss of work. Therapy remains supportive and prevention holds the key to elimination of widespread infection. Acute infection can be prevented or attenuated with IG or with inactivated, highly immunogenic vaccines. Elderly persons and those with advanced liver disease are at higher risk of the consequences of acute HAV, and they represent target populations for immediate vaccination. Challenges for the future include strategies for broad-based population vaccination, including cost-effective approaches.

Acute hepatitis A: combination of the relapsing and the cholestatic forms, two rare variants

Here we present an unusual case of a 23-year-old, otherwise healthy man who had a biphasic form of viral hepatitis A with a combination of two variants, the relapsing and cholestatic forms. One month after resolution of the first phase of acute hepatitis A, he was readmitted with jaundice and intense pruritus. During hospitalization, his serum bilirubin level increased to 50.2 mg/dL, with a slight increase in the other levels of liver enzymes. He was treated with ursodeoxycholic acid and later with corticosteroid therapy, resulting in resolution of symptoms and improvement of his liver function tests after 2 weeks. Medication therapy seems to be justified in markedly symptomatic patients with relapsing hepatitis.

Viral hepatitis A, B, and C

Mankind probably has known viral hepatitis for many centuries; however, the major and most dramatic developments in our knowledge of these diseases have taken place during the second half of the 20th century. During this relatively short period of time, the infectious nature of hepatitis A, B, and C has been proven, leading to their identification and description. The advent of serologic markers has provided the means for establishing the diagnosis. Epidemiologic studies have provided important information that led to exciting achievements in detection and prevention of transmission. Molecular biology studies and cell culture techniques have established our knowledge of the viral genomes, and led to the development of specific vaccines for hepatitis A and B. Anti-viral therapy has been developed and aggressive combination therapy has emerged as a promising strategy for chronic hepatitis B and C. This article reviews some of the main fields of progress and achievement related to viral hepatitis A, B, and C in the 20th century.

Cost-effective analysis of hepatitis A prevention in Ireland

OBJECTIVE

The purpose of this study was to determine the most cost-effective prevention strategy against hepatitis A virus (HAV) infection for healthcare workers and the general population at risk in Ireland.

METHODS

Four prevention strategies were compared: active immunization with Havrix Monodose (1440E.U); screening for anti-HAV antibody and then vaccinating; passive immunization; screening for anti-HAV antibody and then passive immunization. The cost-effective ratio was calculated for each prevention strategy. Threshold analysis, sensitivity analysis, and model extension to include indirect cost from work days lost and secondary attack rates through horizontal transmission were also derived.

RESULTS

The medical costs were lowest and the infection rate highest when no preventive action was taken. Vaccination was most cost effective when the prevalence of immunity was 45% or less, reducing the infection rate by 98% when compared to nonprevention. Screening before vaccination was most cost effective when the prevalence of immunity was greater than 45%. Passive immunization and screening before passive immunization were not comparable to the other strategies in cost effectiveness. Sensitivity analysis showed that the cost-effective ratio for vaccination was dependent on vaccine price, incidence of HAV, and prevalence of immunity in the target group. Extending the model to include indirect costs further increased the cost effectiveness of vaccination.

CONCLUSION

The best cost-effective strategy relates to target group immunity. Where HAV immunity is 45% or less, vaccination is the strategy of choice and when immunity is greater than 45%, then screening followed by vaccination should be used. This study can be used to provide a framework within which choices can be made to achieve better health for less cost.

[Clinical forms of hepatitis A]

INTRODUCTION

Although its incidence has decreased during the last 20 years, hepatitis A is still the most common hepatitis. In most cases, hepatitis A is asymptomatic. When it is symptomatic, the course is benign in most cases. The aim of this review is to summarize current data regarding unusual clinical forms of hepatitis A.

CURRENT KNOWLEDGE AND KEY POINTS

Hepatic insufficiency is the most severe complication of hepatitis A. It is more commonly observed in adult patients. In most cases, the outcome of hepatic insufficiency is rapidly favorable. In rare cases, hepatic insufficiency progresses and encephalopathy subsequently occurs. At this stage, emergency liver transplantation may be necessary. Apart from hepatic insufficiency, the course of hepatitis A may be characterized by a relapse following initial improvement (relapsing hepatitis A) and prolonged cholestasis.

FUTURE PROSPECTS AND PROJECTS

In regard to patients with liver insufficiency, physicians should be educated about the need to prevent all iatrogenic factors which could impair the outcome and to maintain a situation propitious to rapid liver regeneration, a necessary condition for recovery. When this prevention fails and liver transplantation has to be considered, auxiliary transplantation should always be considered because this procedure preserves the possibility of a delayed regeneration. The justification of systematic vaccination of patients with chronic hepatitis B, who could be at higher risk for hepatic insufficiency during hepatitis A, is controversial.

Inflammation-induced cholestasis

Inflammatory cytokines produced in response to various infectious and non-infectious stimuli are potent inducers of intrahepatic cholestasis (inflammation-induced cholestasis). The cholestatic effect of cytokines results mainly from inhibition of expression and function of hepatocellular transport systems which normally mediate hepatic uptake and biliary excretion of bile salts and various non-bile salt organic anions (e.g. bilirubin). These cytokine effects are reversible and bile secretory function is restored upon disappearance of the inflammatory injury. This review summarizes the clinical, pathophysiological and molecular aspects of inflammation-induced cholestasis.

Evaluation of abnormal liver function tests

Although the liver can be affected in a wide range of disorders, the differential diagnosis of abnormal liver function tests can be substantially narrowed by a comprehensive history and physical examination and by the recognition of relatively distinct biochemical patterns of liver injury. Although referral to a specialist may be required for the performance of, for example, percutaneous liver biopsy and long-term management of chronic liver disease, a presumptive diagnosis can usually be made in the vast majority of patients who present to primary care physicians with abnormal liver function tests.

Diagnosis and treatment of the major hepatotropic viruses

The hepatotropic viruses currently include hepatitis A, B, C, D, and E, and are associated with a spectrum of acute and chronic liver disease syndromes. The epidemiology and natural history of each are discussed, with emphasis on uncommon or newly recognized clinical presentations. The serodiagnosis of hepatitis A, B, and D is well established; the serodiagnosis of hepatitis C and E continues to evolve as serologic and virologic assays become refined. Hepatitis A and E only cause acute liver injury; current medical approaches therefore focus on vaccination strategies. Hepatitis B, C, and D can cause both acute and chronic liver injury. Sequelae of chronic liver disease, including portal hypertension and hepatocellular carcinoma, are not uncommon. Medical therapy of resulting chronic liver disease currently consists of interferon, though other anti-viral strategies are being explored. Advanced chronic liver disease due to hepatitis B, C, or D can be treated by orthotopic liver transplantation, but viral recurrence is near uniform and can be problematic. Further study of the hepatotropic viruses at the molecular biologic, epidemiologic, and clinical levels will continue to provide greater insight into the diagnosis and management of their associated clinical syndromes.

Simultaneous active and passive immunization against hepatitis A studied in a population of travellers

Three hundred travellers, seronegative for hepatitis A, were enrolled into this study to evaluate a new inactivated hepatitis A vaccine. Three injections, each containing at least 720 ELISA units, were administered intramuscularly at months 0, 1 and 6. The subjects were distributed into three groups: 100 received vaccine only; 100 received a single injection of immunoglobulin enriched in HAV antibody; and the 100 remaining travellers received the vaccine and immunoglobulin administered simultaneously with the first vaccine dose. In both vaccinated groups, the rate of seroconversion was found to be higher than 90% at month 1, reaching 100% and 97.8% at month 2 in groups 1 and 3, respectively, and 100% at month 7. In the group receiving both vaccine and immunoglobulin, antibody production was somewhat slower and the final titres were, on average, slightly lower than those obtained in the group with the vaccine alone (GMT 2488 and 3614 mIU ml-1 respectively; p = 0.02). The vaccine appeared to be highly immunogenic in all subjects and was also well tolerated. The slight inhibition of antibody production, induced by the concurrent administration of immunoglobulin, does not affect the overall protection afforded by the vaccine. We conclude that simultaneous active and passive hepatitis A immunizations can be recommended.

Relapsing hepatitis A in Saimiri monkeys experimentally reinfected with a wild type hepatitis A virus (HAV)

Saimiri monkeys were inoculated three times with hepatitis A virus and observed in a follow-up study for sixteen months. The monkeys developed recurrent hepatitis involving liver damage and cycles of HAV antigen shedding in stools. The relapses were presumably due to immune response effects.

Atypical clinical manifestations of hepatitis A

Viral A hepatitis is a self-limited infection occurring predominantly among children usually as an anicteric often subclinical illness. Adults afflicted with this virus are more likely to develop icteric hepatitis. This is exemplified in developed countries when a common source outbreak occurs among non-immune adults. Fulminant hepatitis is uncommon in the USA and hepatitis A has never been documented to evolve into chronic hepatitis. However, prolonged cholestasis and relapsing hepatitis are well described. The usual features of cholestatic viral hepatitis A are pruritus, fever, diarrhoea, and weight loss. Serum bilirubin levels are > 10 mg/dl and the clinical course lasts at least 12 weeks. Cholestasis will spontaneously resolve, although corticosteroids will hasten the resolution but may predispose the patient to develop a relapse of the hepatitis. A biphasic or relapsing form of viral hepatitis A occurs in 6 to 10% of cases. The initial episode lasts 3 to 5 weeks and is followed by a period of remission characterized by normal liver chemistries lasting 4 to 5 weeks. Relapse may mimic the initial episode of the acute hepatitis. The full duration of the illness ranges from 16 to 40 weeks from the onset and immunoglobulin M antibody to hepatitis A virus persists throughout the clinical course. Hepatitis A virus has been recovered from stools during the relapse. Extrahepatic manifestations of hepatitis A include evanescent skin rash and transient arthralgias. Documented cases of arthritis and cutaneous vasculitis have been associated with cryoglobulinaemia and are rare.

Jaundice and cholestasis. Some common and uncommon causes

Jaundiced patients may not always be as sick as they look, and cholestatic patients may be quite ill but not yet jaundiced. There is variability in presentation of cholestasis, and jaundice may be intrahepatic or extrahepatic and acute or chronic. Even though the diagnosis of jaundice can be elusive, an unnecessarily exhaustive search for a cause should be avoided, because some tests are not without dangers. Dr Gordon describes many possible causes, some of which are rare but are still worth consideration.

Hepatic fibrin-ring granulomas in a patient with hepatitis A

Hepatic fibrin-ring granulomas were found in a 30-year-old patient with serologically confirmed hepatitis A. Other causes associated with the presence of fibrin-ring granulomas in the liver, such as Hodgkin's and non-Hodgkin's lymphoma, cytomegalovirus infection, visceral leishmaniasis, and consumption of allopurinol, were ruled out. It is suggested that hepatitis A must be included in the differential diagnosis of a patient with hepatic fibrin-ring granulomas.