Acute Viral Hepatitis

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