1- A 5 Yrs old boy presents with low grade fever, malaise,

lethargy, aches & pains preceded by flu-like symptoms for

the last 5 days. He has now developed:
-- Vomiting
-- Jaundice
-- Anorexia
-- Abdominal Pain
-- Dark urine & pale stools

Clinical Scenario
Acute Hepatitis
• Etiology?
• Management?
• Prevention?

Problem?
‘Inflammation of the Liver’

Hepatitis
Infectious
Metabolic
(Viral)

Drug Induced

Cholestatic
Auto
Immune

Causes
• Hepatotropic :
AE
• Non Hepatotropic :
 Herpes Simplex
 Cytomegalovirus
 Epstein Barr
Varicella Zoster

Viral Hepatitis
Nature of HAV

• HAV is a 27 – 30 nm
Picornavirus
• Contain linear single
stranded RNA genome with
size of 7.5 kb.
• Only one serotype

Hepatitis A
 The virus is destroyed by:
• Autoclaving at 1210c for 20 min
• Boiling in water for 5 minutes
• Treatment with chlorine
• Heating food > 850c for 1 minute destroys it.

HAV Characteristics
• 50% of all cases of Acute Hepatitis
• Marked reduction in incidence where routine
immunization practiced
• A major communicable disease in the developing
world.
• Transmitted by close person to person contact
through fecal-oral route

Epidemiology
• Common source foodborne and waterborne
outbreaks have occurred, frozen berries, and
raw vegetables
• Fecal excretion of the virus starts late in the
incubation period and resolves by 2 wk after the
onset of jaundice

Epidemiology (Contd.)
• Well cooked food and sanitary water supply will
protect the individual living
• Community hygiene is important in schools,
hostels and jails, as overcrowding and poor
sanitation favor the spread

Epidemiology (Contd.)
• HAV invades the human body by fecal-oral route
and causes viremia
• After one week, it reaches liver cells & replicates
• Damage of liver cells caused by cytopathic &
immune mediated mechanisms.

Pathogenesis
• Incubation period 2 – 3 weeks
• Usually ANICTERIC with just a flu-like illness, lethargy,
anorexia, nausea, vomiting & diarrhea.
• Severe symptoms in:
 Adolescents or adults
 In patients with underlying liver disorders
 In immunocompromised

Clinical Manifestations
ICTERIC PHASE:
• Jaundice
• Dark urine
• Clay colored stools
• Pruritus
• Hepatomegaly

Duration: 7-14 Days

Contd.
INVOLVEMENT OF OTHER SYSTEMS
(COMPLICATIONS):

• Regional lymphadenopathy & splenomegaly

• Aplastic anemia (pallor, fever, petechiae)
• Gastric Ulcers, Pancreatitis (epigastric pain with persistent
vomiting)
• Myocarditis (chest pain, resp. distress, palpitations)
• Nephritis (flank pain, hypertension, hematuia)
• Arthritis (joint pain, swelling)

Rarely:
SPECIFIC:
• Acute infection is diagnosed by the detection of HAV-IgM
in serum by EIA.
• Past Infection i.e. immunity is determined by the detection
of HAV-IgG by EIA.
• Cell culture – difficult and take up to 4 weeks, not routinely
performed
• Direct Detection – EM, RT-PCR of feces. Can detect illness
earlier than serology but rarely performed.

Laboratory Diagnosis
GENERAL:
• LFTs (S. Bil. ALT, AST, Alk. Phosphatase, Gamma
Glutamyl Transpeptidase)
• Synthetic Func. Tests (S. Albumin, PT, S. Ammonia,
Blood glucose, lactate)
• No specific treatment
• Supportive measures like intravenous hydration

Treatment
1- A 5 Yrs old boy presents with low grade fever, malaise,
lethargy, aches & pains preceded by flu-like symptoms. He
has now developed:
-- Vomiting
-- Jaundice
-- Anorexia
-- Abdominal Pain
-- Dark urine & pale stools
-- Tender Hepatomegaly (on exam.)

Recap.
Returns after 3 days with altered state of consciousness,
deepening of jaundice, bruises over body and an episode of
hematemesis.

The BAD News !

• Acute Liver Failure (ALF):
-- 40% of all cases of ALF caused by HAV in developing
countries
• Cholestatic Syndrome:
-- Waxing & waning symptoms for many months.

Complications
• No specific antiviral drug is available
• Prompt referral to Liver Transplant Center in case of ALF
• Otherwise treatment is symptomatic
• Specific passive prophylaxis by pooled normal human
immunoglobulin given before exposure or in early
incubation period in high risk individuals
• Fat soluble vitamins and anti pruritic agents for
cholestatic syndrome

Treatment
• Hygiene (e.g., hand washing esp. afer changing diapers
and cooking or serving food)
• Sanitation (e.g., clean water sources)
• Hepatitis A vaccine (pre and post exposure)
• Immune globulin (pre and post exposure)

Prevention
• Hepatitis A vaccination is recommended for all children
starting at age 1 year, travellers to certain countries, and
others at risk.
• A safe and effective formalin inactivated alum
conjugated vaccine containing HAV grown in human
diploid cell culture is available
• A full course containing two intramuscular injections of
the vaccine
• Protection starts after 4 weeks after injection and lasts for
10 – 20 years

Vaccination for HAV

• Pre-exposure
-- Travelers to intermediate and high
HAV-endemic regions
• Post-exposure (within 14 days)
-- Household and sexual contacts of HAV cases
-- Newborn infants of HAV-infected mothers

Ig is not routinely recommended for sporadic

nonhousehold exposure (e.g., protection of hospital
personnel or schoolmates).

Immune Globulin
• The prognosis is excellent, with no long-term sequelae.
The only feared complication is ALF.

Prognosis