Acute Viral Hepatitis

Hepatitis viruses A, B, and C cause 95% of viral hepatitis cases in the U.S. Less common hepatitis viruses include D, E, and G (HGV or GBV-C). Generally, patients meeting the indications for testing should be screened for hepatitis A, B, and C concurrently, unless a specific exposure is known.

Tabs Content

Clinical Overview

Diagnosis

Indications for Testing

New onset of jaundice, anorexia, or dark urine
Known or suspected exposure to hepatitis virus

Laboratory Testing

Viral hepatitis information for health professionals (CDC)
Screen for hepatitis A (HAV), hepatitis B (HBV), and hepatitis C (HCV) infections concurrently unless specific exposure is known
Panel testing includes HAV IgM, HBV core antibody IgM, HBV surface antigen, and HCV antibody
- Positive HAV antibodies indicate acute HAV
- Positive HBV antibodies and surface antigen indicate acute HBV or chronic hepatitis
  - Repeat surface antigen testing and consider HBV DNA testing if nonacute presentation
- Positive HCV antibodies indicate acute HCV or chronic HCV
  - High and low positives should be followed by RNA quantitative testing
Hepatitis E virus (HEV) testing – if patient is from a high-risk area and hepatitis screening tests are negative
Hepatitis delta virus (HDV) testing – if patient with known chronic hepatitis manifests acute hepatitis
For further evaluation of hepatitis, refer to specific hepatitis algorithms in ARUP Consult

Differential Diagnosis

Virus
- Cytomegalovirus
- Epstein-Barr virus
- Herpes simplex virus
- Varicella-zoster virus
- Hepatitis A, B, C, D, E, or G
Toxin exposure
- Alcohol
- Tetrachloride
Nonalcoholic steatohepatitis
Drug-induced hepatitis
- Acetaminophen
- Antiseizure medications
- Isoniazid (Nydrazid)
- Oral contraceptives
- Rifampin (Rifadin)
- Sulfonamides
Autoimmune disease
- Systemic lupus erythematosus
- Primary biliary cirrhosis
- Sclerosing cholangitis
- Autoimmune hepatitis
Bacterial infection
- Sepsis
- Leptospira spp
- Coxiella burnetii (Q-fever)
- Rickettsia rickettsii (Rocky Mountain spotted fever)
- Treponema pallidum (secondary syphilis)
- Rickettsia typhi (typhus fever)
Granulomatous disease
- Mycobacterium tuberculosis
- Sarcoidosis
Hereditary disease/disorder
- Wilson disease
- Hemochromatosis
- Alpha-1-antitrypsin deficiency
Ischemia
Parasitic infection
- Liver trematodes
- Toxocara spp

Background

Epidemiology

Transmission – variable according to virus
- HAV, HEV – fecal-oral
- HBV, HCV, HDV, HGV – intravenous (IV) drug abuse, sexual transmission, blood transfusions

Organism

Diverse group of viruses that share a common ability to cause inflammation and necrosis of the liver
Virus may persist in a chronic state (HBV, HCV, HDV)
- May cause the development of cirrhosis
- Patients may remain chronic carriers

Risk Factors

HAV – child daycare settings
HBV and HCV
- Sexual transmission via infected partner
- HIV
- IV drug abusers
- Infection from blood products (patients with hemophilia)
HDV
- IV drug abuse
- Travel to endemic area (Amazon basin, Mediterranean basin, Middle East, South Pacific, Asia, Sub-Saharan Africa)
HEV – travel to endemic area (Central Asia, Middle East, parts of South America, Africa)

Clinical Presentation

May be difficult to diagnose clinically
Frequently asymptomatic – may have only mild increase in aminotransferases
Mild symptoms – malaise, fever, chills, decreased appetite
Similar symptoms among viral hepatitis types
Jaundice not a predominant symptom in most patients
Complication – acute liver failure

Prevention

Chronic hepatitis is a public health concern in terms of transmission and because it can lead to the development of cirrhosis and hepatocellular carcinoma
Vaccines are available to immunize against HAV and HBV

ARUP Lab Tests

Tests generally appear in the order most useful for common clinical situations. Click on number for test-specific information in the ARUP Laboratory Test Directory.

Hepatic Function Panel 0020416
Method: Quantitative Enzymatic/Quantitative Spectrophotometry

Recommended Use

Initial screening for hepatobiliary inflammation

Panel includes albumin; alkaline phosphatase (ALP); aspartate aminotransferase (AST); alanine aminotransferase (ALT); bilirubin, direct; protein, total; and bilirubin, total

Hepatitis Panel, Acute with Reflex to HBsAg Confirmation 0020457
Method: Qualitative Chemiluminescent Immunoassay

Recommended Use

Order to evaluate viral etiology in patients with acute hepatitis

Not recommended for screening asymptomatic patients

Panel includes HAV IgM, HBV core antibody IgM, HBV surface antigen, and HCV antibody

Hepatitis C Virus (HCV) by Quantitative NAAT 3000572
Method: Quantitative Transcription Mediated Amplification

Recommended Use

Preferred single test to confirm hepatitis C virus (HCV) infection following positive HCV antibody screen

Hepatitis Delta Virus by Quantitative PCR 2013881
Method: Quantitative Polymerase Chain Reaction

Recommended Use

Confirm and quantify presence of HDV

Hepatitis E Virus (HEV) Antibody, IgG 2010151
Method: Qualitative Enzyme-Linked Immunosorbent Assay

Recommended Use

Recommended for determining exposure to HEV

Hepatitis E Virus (HEV) Antibody, IgM 2010156
Method: Qualitative Enzyme-Linked Immunosorbent Assay

Recommended Use

Preferred test for diagnosing acute HEV infection

Hepatitis E Virus by Quantitative PCR 2011654
Method: Quantitative Polymerase Chain Reaction

Recommended Use

Confirm and quantify presence of HEV

Limitations

Negative result (less than 3.3 log IU/mL or less than 1,800 IU/mL) does not rule out presence of PCR inhibitors in patient specimen or HEV RNA concentrations below level of detection of the test

Inhibition may also lead to underestimation of viral quantitation

Medical Reviewers

Hillyard, David R., MD, Medical Director, Molecular Infectious Diseases at ARUP Laboratories; Professor of Clinical Pathology, Adjunct Professor of Biology, University of Utah

Slev, Patricia R., PhD, Laboratory Section Chief, Immunology, at ARUP Laboratories; Associate Professor of Clinical Pathology, University of Utah

References

General References

Aggarwal R, Jameel S. Hepatitis E. Hepatology. 2011; 54(6): 2218-26. PubMed

Clemente MG, Schwarz K. Hepatitis: general principles. Pediatr Rev. 2011; 32(8): 333-40. PubMed

Degertekin B, Lok AS. Update on viral hepatitis: 2007. Curr Opin Gastroenterol. 2008; 24(3): 306-11. PubMed

Denk H. What is expected from the pathologist in the diagnosis of viral hepatitis? Virchows Arch. 2011; 458(4): 377-92. PubMed

Sharapov UM, Hu DJ. Viral hepatitis A, B, and C: grown-up issues. Adolesc Med State Art Rev. 2010; 21(2): 265-86, ix. PubMed

Suriawinata AA, Thung SN. Acute and chronic hepatitis. Semin Diagn Pathol. 2006; 23(3-4): 132-48. PubMed

Testing Algorithms

Hepatitis Virus Screening Algorithm

Read more about Hepatitis Virus Screening Algorithm

Educational Videos

Last Update: October 2018


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	Acute Viral Hepatitis. ARUP Consult^©. Retrieved October 15, 2018, from: https://arupconsult.com/content/hepatitis-acute