Hepatitis A and E: Clinical sciences

Hepatitis A and E viruses are RNA viruses typically transmitted by the fecal-oral route that infect hepatocytes, causing inflammation of the liver. Acute infection with both viruses usually causes a mild, self-limiting illness, although manifestations can range from asymptomatic infection to severe, life-threatening disease. Hepatitis E can also persist in the body and progress into a chronic infection.

Now, if your patient presents with a chief concern suggesting Hepatitis A or E infection, perform an ABCDE assessment to determine if they are unstable or stable. If the patient is unstable, first stabilize their airway, breathing, and circulation. Next, obtain IV access and put your patient on continuous vital sign monitoring, including blood pressure, heart rate, and pulse oximetry. Finally, if needed, don’t forget to provide supplemental oxygen!

Now here’s a clinical pearl to keep in mind! In rare cases, acute Hepatitis A or E infection can lead to fulminant hepatic failure, causing an unstable presentation that requires acute management. Patients may present with manifestations of hepatic encephalopathy, like impaired mental status and asterixis; coagulopathy, with INR greater than or equal to 1.5; and elevated AST, ALT, and bilirubin. In addition to stabilization efforts, you should consult the surgical team, since these patients need rapid transfer to a liver transplant center!

Okay, now let’s go back to the ABCDE assessment and focus on stable patients. If your patient is stable, first obtain a focused history and physical examination, and order labs, including CMP, CBC, and INR. History typically reveals symptoms, such as malaise, loss of appetite, nausea, vomiting, and right upper quadrant pain. Your patient will also likely report a risk factor for fecal-oral transmission, such as exposure to contaminated food or water; travel to areas with poor hygiene and sanitation; and direct contact with an infected person.

Next, the physical exam will typically reveal elevated temperature, jaundice, and hepatomegaly, sometimes with tenderness to palpation of the liver. Finally, labs will usually show elevated ALT, AST, and bilirubin. In some individuals, you might even notice elevated INR and thrombocytopenia. With these findings, you should suspect acute Hepatitis A or E infection!

Now, once you suspect hepatitis A or E infection, your next step is to order additional labs to detect the infection. First, you could check whether or not your patient has IgM antibodies against hepatitis A and E viruses, which is the first type of antibody to appear during an acute infection. Alternatively, you could order a reverse-transcriptase polymerase chain reaction, or RT-PCR, to detect viral RNA of hepatitis A and E viruses in the blood.

Okay, now, if both IgM antibody tests and both RT-PCR tests are negative, consider an alternative diagnosis! Remember that several other viruses can present similarly, including hepatitis B, C, and D, as well as cytomegalovirus and Epstein-Barr virus!

On the flip side, if your patient has positive anti-Hepatitis A Virus IgM and positive Hepatitis A Virus RT-PCR, diagnose acute hepatitis A Infection! Hepatitis A infection is generally a self-limited condition, with full clinical recovery and clearance of lab markers within 3 to 6 months. So, in this case, management primarily relies on supportive care with oral or IV fluids, as well as nutritional support. If needed, offer symptomatic treatment with medications for nausea and vomiting.

Next, counsel your patient on lifestyle modifications, such as avoidance of hepatotoxins, including acetaminophen and alcohol. Your patient should also receive the Hepatitis B vaccine series once recovered from acute Hepatitis A infection.