Donʼt Ask, Donʼt Tell: A Lesson on Evaluating Acute Hepatitis

Abstract

Acute hepatitis A virus (HAV) infection is common in developing countries. It can range from asymptomatic to fulminant hepatitis. The mean peak of total bilirubin in acute HAV infection is usually less than 10 mg/dL with mean jaundice lasting about 4 weeks. Cases of prolonged or relapsing cholestatic HAV were reported at a global incidence of 5-10%. Acute HAV infection with prolonged cholestatic jaundice (PCJ) is rare. We present a severe prolonged cholestatic HAV infection likely complicated by concurrent Chikungunya virus infection and drug induced liver injury. A 39 year old female, born in India, presented to our hospital with subjective fevers, malaise, and myalgias for 3 weeks. She returned from a trip to India 1 month ago. On admission she had a temperature of 100.1°F. Her physical exam was within normal limits with no documented hepatomegaly. Her initial blood work showed elevated transaminases (aspartate aminotransferase (AST u/L) 122, alanine aminotransferase (ALT u/L) 143)with normal alkaline phosphatase (ALP) and total bilirubin (TB). Three days into her admission she showed some clinical improvement but with worsening of AST to 1958 and ALT to 1605 reaching a peak of AST 3804 and ALT 3335; ALP remained normal and TB increased to 4.0 mg/dL. US of abdomen showed hepatic steatosis. Viral markers were positive for HAV IgM but negative for acute EBV, CMV, HBV, HCV and HEV infection. Her autoimmune panel was negative. She was discharged 1 week later with clinical improvement; AST 556 and ALT 1418, ALP 77 and INR 1.58. Her TB remained elevated to 7.6. She was readmitted to the hospital 2 weeks later with pruritus and worsening fatigue. Her AST was 88 and ALT 59, with ALP of 148 and a TB of 23.4. Her INR was 2.09. A repeat US showed no biliary ductal dilation or stones. She tested positive for Chikungunya IgM. She admitted to ingesting multiple herbal products. Her liver tests normalized at 4 months with positive HAV and Chikungunya IgG.FigureFigureFigureWe present a severe prolonged cholestatic HAV infection likely complicated by concurrent Chikungunya infection and drug induced liver injury. Acute HAV infection with prolonged cholestatic jaundice (PCJ) is rare. Acute Chikungunya has been documented as a cause of acute cholestatic hepatitis. A thorough history of drug exposure is essential in the evaluation of cholestatic liver injury. Furthermore, CDC recommendation for HAV vaccination for travelers should be reinforced even on immigrants from endemic countries.