Hepatitis, Viral

HEPATITIS, VIRAL 34A

A 27-year-old woman presents to her primary care clinician complaining of nausea and vomiting. She returned 1 week ago from an international trip to South America where she ate at local restaurants and food carts. On physical examination, her skin is jaundiced, her abdomen is tender to palpation in the right upper quadrant (RUQ), and there is mild hepatomegaly. Serum bilirubin and aminotransferases are elevated. Anti–hepatitis A virus (HAV) IgM antibody is positive.

What are the salient features of this patient’s problem? How do you think through her problem?

Salient features: Nausea, vomiting; recent travel with possibly unsanitary food exposure; jaundice; tender abdomen; hepatomegaly; elevated serum bilirubin and aminotransferase tests; positive anti-HAV IgM

How to think through: Acute nausea and vomiting in a returning traveler can be attributable to infectious gastroenteritis, but the overlap of nausea and jaundice places hepatitis high in the differential diagnosis. When considering hepatitis of any cause, what risk factors should be assessed? (Acetaminophen use, alcohol use, possible Amanita mushroom consumption [toxin induced], sexual risk factors—hepatitis B virus [HBV] > HAV > hepatitis C virus [HCV]—injection drug use, tattoos, or blood transfusion [HBV, HCV.]) The duration of travel and of her symptoms should be elicited. The incubation period of the hepatitis viruses varies, and will help narrow the differential diagnosis. All can cause the acute symptoms seen in this patient. What viral hepatitis serologies are detectable during the acute illness and would be most informative here? (Anti-HAV IgM; HBV surface antigen [HBsAg] and anti-HBc IgM; anti-HCV and, if a high suspicion, assay for HCV RNA.) If all of these study results are negative in this patient, what other infectious causes of hepatitis should be considered? (Mononucleosis [Epstein-Barr virus], cytomegalovirus [CMV], leptospirosis, brucellosis, yellow fever.) Would a serum alanine aminotransferase level above 1000 IU/dL or a bilirubin level above 8 mg/dL suggest that the diagnosis of viral hepatitis be reconsidered? (No. this degree of elevation is common.) How should she be managed? (Supportive care, intravenous [IV] hydration and glucose if needed, avoidance of alcohol and hepatotoxic medications.) What is the likelihood of developing fulminant hepatic failure? (Very rare except in patients with underlying HCV or cirrhosis.) Hand washing by the patient and care providers is important.