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.

Quick Answers for Clinicians

Which testing algorithms are related to this topic?

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

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 Laboratory Tests

Primary Tests

Initial screening for hepatobiliary inflammation

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

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

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

Confirm and quantify presence of HDV

Recommended for determining exposure to HEV

Preferred test for diagnosing acute HEV infection

Confirm and quantify presence of HEV​

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

Related Tests

Diagnose acute hepatitis A virus infection

For panel test that includes HAV IgM, HBV core antibody IgM, HBV surface antigen, and HCV antibody, refer to acute hepatitis panel with reflex to confirmation

Can be ordered as part of acute hepatitis panel which includes HAV IgM, HBV core antibody IgM, HBV surface antigen, and HCV antibody to determine if patient has acute HBV infection

Refer to acute hepatitis panel with reflex to confirmation

Can be ordered as part of acute hepatitis panel which includes HAV IgM, HBV core antibody IgM, HBV surface antigen, and HCV antibody

Refer to acute hepatitis panel with reflex to confirmation

Preferred single screening test for one-time screening of population born between 1945 and 1965 and individuals at risk for HCV

Positive results require confirmation by molecular testing (eg, HCV by quantitative PCR or HCV quantitative PCR with reflex to HCV genotype by sequencing)

Stand-alone antibody testing is recommended

Refer to IgM hepatitis E antibody testing for acute disease or IgG hepatitis E antibody testing for exposure evaluation

Medical Experts

Contributor
Contributor

Slev

Patricia R. Slev, PhD
Associate Professor of Clinical Pathology, University of Utah
Section Chief, Immunology; Medical Director, Immunology Core Laboratory, ARUP Laboratories
Medical Director, Serologic Hepatitis and Retrovirus and Immunology Core Laboratory
Co-Medical Director, Microbial Immunology, at ARUP Laboratories

References

Additional Resources