Management Of Acute Hepatitis Research Articles

Is Acute Hepatitis E Virus (HEV) Infection a Steroid-Responsive Disease?

Introduction: While HEV infection often is self-limited, prolonged infection can put the patient at significant risk for liver injury, and treatment with Ribavirin can have mixed success. The following case represents an occasion in which lab result delay and clinical decision-making led to the improved outcome of a patient with acute HEV infection. Case Report: A 50 Year old South Asian female presented to her primary care physician (PCP) with complaints of diarrhea and fever after returning from a recent trip to Pakistan. This was treated by her PCP with Rifaximin, but the diarrhea continued. Lab results showed ALT and AST levels at 985 and 679, respectively. The patient was started on a course of ciprofloxacin and azithromycin, but her condition did not significantly improve. She was then referred to the hepatology clinic for workup. Labs were repeated, and tests for Hepatitis E and autoantibody titers were ordered. The patient followed up two days later and lab results showed elevated immunoglobulin G levels and a positive anti-Smith autoantibody titer (1:80). Autoimmune hepatitis was suspected and a liver biopsy was ordered. The liver biopsy results showed signs of nonspecific lobular inflammatory infiltration, and an order for Prednisone 60 mg by mouth once daily was added to the management plan while awaiting results of other serologies. The patient was then hospitalized for exacerbation of her condition and arthralgia in her extremities. However, she quickly responded to the course of steroids with marked improvement of her liver enzymes. Upon her next follow-up, steroids were being tapered, and the previously ordered pending lab results had come back positive for HEV IgG and IgM. HEV viral load was 145,000 IU/mL, and her ALT and AST had dropped to 164 and 25, respectively. She was started on Ribavirin 600mg daily as per HEV protocol. Within 2 weeks, viral HEV RNA was undetectable and her liver enzymes returned to within normal limits. Discussion: This patient had undiagnosed Hepatitis E, most likely contracted on a recent trip abroad. The inadvertent use of and response to prednisone suggests that steroids may be an efficacious adjunct to ribavirin in the management of acute Hepatitis E.

Intervention to improve management of acute hepatitis C infection in a UK sexual health clinic.

A case note review was conducted for all newly-diagnosed acute hepatitis C virus (HCV)-infected patients attending our sexual health clinic pre- and post-implementation of an HCV clinic proforma between January 2010 and September 2016. In total, 87 patient notes were included (40 pre-intervention, 47 post-intervention) of whom 81 were HIV-positive. Data were collected regarding documentation of the following: baseline investigations, four-weekly HCV viral load monitoring, risk assessment, partner notification, advice given and Public Health England (PHE) notification. Appropriate baseline investigations, four-weekly monitoring of HCV viral loads, risk assessment and advice documentation all improved in the post-intervention group when compared to pre-intervention. PHE notification and partner notification remained below the national standard post-intervention, with educational measures among relevant staff implemented accordingly. This audit demonstrates improvement across several key areas post clinic proforma implementation.

Frequency of Acute Hepatitis Following Acute Paraphenylene Diamine Intoxication.

IntroductionParaphenylene diamine (PPD) ingestion is manifesting as one of the more common ways of committing suicide in Southern Punjab, Pakistan, especially Bahawalpur. PPD is an ingredient of a compound commonly known “Kala Pathar” which means “Black Stone” in Urdu. It is readily available in the market at low cost and is used to dye hair and fur. Its intoxication inhibits cellular oxidation and affects the muscles causing rhabdomyolysis. This leads to myoglobinuria followed by renal failure and edema of face and throat resulting in respiratory difficulty. Very little is known about the impact of PPD intoxication on liver tissue.ObjectiveThe purpose of the study was to find out the frequency of acute hepatitis following PPD intoxication.MethodsWe reviewed the medical records of 109 patients with PPD intoxication admitted to Medical Unit-2, Bahawalpur Victoria Hospital from January 1, 2015, to June 30, 2015, in a descriptive, cross-sectional study. We noted the frequency of acute hepatitis and other complications, and we recorded the demographic features, clinical features, and outcomes of these patients.ResultsOur study included 32 men (29%) and 77 women (71%). The mean age was 22 ± 3.4 years, and most patients were young women aged 15 to 24 years. Suicidal ingestion was the leading cause of admission for 101 patients (93%). The most common clinical presentation was cervicofacial edema (95%), throat pain (88%), dysphonia (95%), cola-colored urine (100%), and oliguria (95%). Rhabdomyolysis (86%), acute hepatitis (51%), and acute renal failure (63%) were the most common clinical conditions following poisoning. Overall mortality was noted in 39 patients (36%) while all other patients achieved complete clinical recovery (64%). In patients with mortality, 20 of 39 (51%) developed acute hepatitis. Most patients (95%) in our study underwent tracheostomy.ConclusionThe frequency of acute hepatitis in PPD intoxication is high in this population, especially in young women. Measures need to be instituted regarding the management of acute hepatitis in PPD intoxication to improve patient outcomes. Workups in patients with PPD poisoning should include regular monitoring of aspartate aminotransferase and alanine aminotransferase to observe any damages to the liver so that acute hepatitis can be managed in a timely fashion.

Sofosbuvir and ledipasvir versus sofosbuvir and simeprevir combination therapy in the management of acute hepatitis c: A Randomized open label prospective study. SLAM C study

Sofosbuvir and ledipasvir versus sofosbuvir and simeprevir combination therapy in the management of acute hepatitis c: A Randomized open label prospective study. SLAM C study

SAT-234 - Sofosbuvir and Ledipasvir versus Sofosbuvir and Simeprevir Combination Therapy in the Management of Acute Hepatitis C: A Randomized Open Label Prospective Clinical Pilot Study. Slam C Study

SAT-234 - Sofosbuvir and Ledipasvir versus Sofosbuvir and Simeprevir Combination Therapy in the Management of Acute Hepatitis C: A Randomized Open Label Prospective Clinical Pilot Study. Slam C Study

Sofosbuvir and Ledipasvir Versus Sofosbuvir and Simeprevir Combination Therapy in the Management of Acute Hepatitis C: A Randomized Open Label Prospective Clinical Pilot Study. SLAM C Study, Interim Data

Sofosbuvir and Ledipasvir Versus Sofosbuvir and Simeprevir Combination Therapy in the Management of Acute Hepatitis C: A Randomized Open Label Prospective Clinical Pilot Study. SLAM C Study, Interim Data

Enhancing the detection and management of acute hepatitis C virus infection

Acute HCV infection refers to the 6-month period following infection acquisition, although this definition is somewhat arbitrary. While spontaneous clearance occurs in approximately 25%, the majority will develop chronic HCV infection with the potential for development of cirrhosis, end stage liver disease and hepatocellular carcinoma.Detection of acute HCV infection has been hampered by its asymptomatic or non-specific presentation, lack of specific diagnostic tests and the inherent difficulties in identifying and following individuals at highest risk of transmitting and acquiring HCV infection, such as people who inject drugs (PWID). However, recognition of those with acute infection may have individual and population level benefits and could represent an ideal opportunity for intervention. Despite demonstration that HCV treatment is feasible and successful in PWID, treatment uptake remains low with multiple barriers to care at an individual and systems level. Given the burden of HCV-related disease among PWID, strategies to enhance HCV assessment, treatment and prevention in this group are urgently needed. As the therapeutic landscape of chronic HCV management is revolutionised by the advent of simple, highly effective directly-acting antiviral (DAA) therapy, similar opportunities may exist in acute infection.This review will discuss issues surrounding improving the detection and management of acute HCV infection, particularly in PWID.

Recommendations for the management of acute hepatitis B: position paper of the Italian Society for the Study of Infectious and Tropical Diseases (SIMIT).

To develop recommendations for the management of acute hepatitis B by the Italian Society for the Study of Infectious and Tropical Diseases. Development of the recommendations divided into three levels of evidence according to the GRADE system: A (high), B (medium) and C (low experts opinion), together with three recommendation levels: 1 (strong), 2 (medium), 3 (weak). The treatment with antivirals is in selected cases the mainstay of management of severe acute hepatitis, and should be started as a matter of urgency in order to prevent death. These recommendations are meant to provide the rationale and practical indications for the management of acute hepatitis B (AHB).

A pregnant woman with acute hepatitis B in whom vertical transmission was prevented by tenofovir disoproxil fumarate.

The optimal management of acute hepatitis B in pregnant women remains to be fully evaluated. A case of hepatitis B virus (HBV) infection in a 20-year-old pregnant woman who initially presented with jaundice is reported. Serum samples were positive for anti-HBc IgM and HBe antigen. Her husband was infected with HBV genotype A and received entecavir because of prolonged hepatitis and a high viral load. The HBV DNA sequence of the wife completely matched that of her husband, indicating that he was the source of HBV infection. In accordance with guidelines for the treatment of chronic HBV carriers, the wife started to receive tenofovir disoproxil fumarate (TDF) in her third trimester. After 4months of treatment, the HBV DNA load decreased from 7.6 to 3.5log copies/ml. At delivery, the serum was found negative for the HBe antigen. Seven months after treatment began, the HBs antigens also disappeared. The baby, totally healthy, received passive-active immunoprophylaxis. At 3months, the baby remained free of HBV infection. TDF thus prevented exacerbation and prolongation of acute HBV infection in a pregnant woman. Subsequent treatment also prevented mother-to-infant transmission of HBV. The clinical course of her husband, who had HBV infection and received entecavir, is also reported.

Management of acute hepatitis B and reactivation of hepatitis B

The natural course of hepatitis B virus infection and the resulting hepatic injury is determined by the degree of virus replication and the intensity of host immune response. Upon exposure to hepatitis B virus (HBV), individuals with a vigorous and broad immune response develop acute self-limited infection, which may result in acute hepatitis. However, with stringent testing for HBV and universal precautions, acute HBV is rather rare. Reactivation of HBV most often presents as acute hepatitis B (AVH-B) and clinically, it is difficult to differentiate AVH-B from reactivation of chronic hepatitis B (CHB) and it requires a high index of suspicion. In the presence of high HBV DNA (>2 × 10(4) IU/ml) underlying liver disease should be investigated by liver biopsy, endoscopy and/or imaging. The degree of liver failure often depends on the severity of acute insult and the stage of underlying chronic liver disease. Mutations in the HBV genome, immunosuppressive therapy and viral or drug induced injury are common causes of reactivation. As most patients with AVH-B resolve the infection spontaneously, antiviral therapy is not indicated in them. However, the use of a potent oral nucleoside(tide) analogue is necessary as soon as possible in patients with CHB reactivation. Liver transplantation should be considered in patients who develop liver failure secondary to severe acute exacerbation. If this is not feasible, supportive therapy with the addition of granulocyte colony stimulating factor (GCSF) therapy could be beneficial.

Clinical course and management of acute hepatitis A infection in adults

Background. Hepatitis A is the most common type of viral hepatitis in Mexico. The change of hepatitis A epidemiology in Mexico from high to intermediate endemicity leads to increasing susceptible adults for severe illness. Objective. To describe the clinical characteristics and hospital outcome of adult patients with acute hepatitis A infection, and determine risk factor for mortality.Material and methods. This is a retrospective observational, multicentre study in Mexico City and in Guatemala City. All inhospital patients were followed until discharge or death. Risk factors for death/acute liver failure were identified.Results. Forty seven patients were analyzed, sixty percent were male, the prodrome phase was from 3 to 30 days. The three most common symptoms were fever, malaise and jaundice, with 87%, 74% and 62% respectively. The incidence of patients who were treated with antibiotics before hospital admission was up to 34%. Unnecessary imaging studies and out of guidelines drugs were used. Presence of encephalopathy, leukocytes > 19,000/mL, blood urea nitrogen > 36 mg/dL, creatinine > 2 mg/dL, albumin < 2.5 mg/dL andtotal bilirubin > 9.6 mg/dL, are predictors of mortality. Serum creatinine > 2 mg/dL has the best sensibility and specificity for predicting fulminant hepatitis/death.Conclusion. Acute hepatitis A infection in adults is associated some unnecessary diagnostic and therapeutic approach. Could be associated with fulminant hepatitis, and a creatinine value > 2 mg/dL is the best predictor for fulminant hepatitis and death.

Acute hepatitis C in Spain: a retrospective study of 131 cases

The management of acute hepatitis C (AHC) is controversial. We have conducted a retrospective study to determine the epidemiological and biochemical aspects, the genotypes, the spontaneous clearance of HCV (SVC), and the treatment responses in patients with AHC. We have retrospectively collected data from 131 patients with AHC from 18 Spanish hospitals. The mean age was 43 ± 16 years (17-83), 69% were symptomatic. The causes of infection were nosocomial in 40% and intravenous drug users in 20%. Eighty two percent had genotype 1. The delay from symptoms-onset to HCV-RNA confirmation was 50 ± 68 days (range, 11-350 days) and to treatment (in 59%) 14±1 3 weeks (range, 2-58 days). In the treated group, 80% achieved sustained virological response (SVR) versus 57% SVC in untreated patients (p = 0.004). Up to 96% of those treated within the first 12 weeks had SVR versus 86% of those treated later (p = 0.04). Patients with HCV-RNA(-) at week 4 resolved with or without treatment more frequently than those HCV-RNA(+) (98% versus 69%, p = 0.005). The treatment was not beneficial if HCV-RNA was undetectable at week 12. No differences in SVR were found in genotype 1 patients treated for 24 or 48 weeks. Patients with low baseline viral load achieved higher SVC and SVR. The SVC in patients with bilirubin > 5 mg/dL was 78 versus 40% in those with lower values (p = 0.004). The most common transmission route was nosocomial. SVR was higher in patients treated than SVC in non-treated.Early treatment (before week 12) achieved the highest response rate. SVC and SVR were more common in patients with a low baseline viral load. Undetectable HCV-RNA at week 4 was associated with high SVR and SVC rates. Jaundice was related with SVC.

Effectiveness of entecavir in the management of acute hepatitis B developing in a patient with Hodgkin's lymphoma: A case report

We describe a case of severe acute hepatitis B developing in a patient with Hodgkin's lymphoma after chemotherapy and before radiotherapy. Entecavir was administered leading to virological and biochemical response, which allowed the scheduled treatment to be completed. The patient had complete haematological remission and made a complete recovery from hepatitis B.

A case of hepatitis attributable to repeated exposure to methoxyflurane during its use for procedural analgesia

A 33-year-old woman was admitted to our service for investigation and management of acute hepatitis. She reported symptoms of nausea, fatigue, pruritus and right upper abdominal discomfort. The symptoms had first occurred 3 weeks earlier, resolving over 5 days, then recurred 2-3 days before presentation. The symptoms were temporally related to varicose vein sclerosing procedures, of which she had had three in total. The first procedure occurred 4 weeks before admission, with no subsequent side effects. It was after the second procedure, 1 week later, that symptoms first developed. The final procedure occurred a week before admission. During each procedure, the patient was given methoxyflurane as an inhaled analgesic administered from a 3 mL disposable cartridge. Other medications administered during the procedures were the sclerosing agent sodium tetradecyl sulfate and fexofenadine. There was no history of exposure to alcohol or to other prescription or over-the-counter medications. The patient had no risk factors for viral hepatitis, and there was no history of hepatitis or liver disease in her family. Clinical examination revealed jaundice and mild tender hepatomegaly only. Initial investigations showed hepatic enzymosis, with an elevated alanine transaminase level (2710 U/L [reference range, < 34 U/L]) and hyperbilirubinaemia (bilirubin 921 μmol/L [reference range, < 20 μmol/L]). Markers of liver synthetic function (albumin and prothrombin time) were within normal limits, as were full blood counts, electrolyte levels and renal function. Abdominal ultrasound demonstrated a normal-sized spleen and mild hepatomegaly, with an increased liver echotexture. Doppler sonography of the portal vein was normal. Serological tests for hepatitis A, B and C, Epstein-Barr virus, cytomegalovirus and HIV were negative. Iron and copper studies and levels of α-1-antitrypsin, antinuclear antibodies, antimitochondrial antibodies, anti-liver/kidney microsomal antibodies, anti-smooth-muscle antibodies and antinuclear cytoplasmic antibodies were all normal. Paracetamol was undetectable. Bilirubin levels continued to rise over the following 8 days (peaking at 202 μmol/L), although liver synthetic function remained normal throughout this time. A liver biopsy revealed evidence of resolving acute hepatitis with confluent perivenular hepatocyte dropout and bridging necrosis. There was no evidence of cholestasis or underlying fibrosis. The pathological diagnosis was of an idiosyncratic drug reaction, with the implicated drug being methoxyflurane. The patient's condition continued to improve, with resolution of symptoms over 4 weeks and associated normalisation of liver enzyme and bilirubin levels. She has since remained well, and has been advised to avoid future exposure to methoxyflurane. ♦

Hepatitis C — feedback from the Consensus Conference on the Management of Acute Hepatitis C (AHC) in Paris, May 2010

7‐11 November 2010, Tenth International Congress on Drug Therapy in HIV Infection, Glasgow, UK

Acute hepatitis C infection: Can immunology teach us the right way to treat?

Management of acute hepatitis C has been discussed controversially in recent years. Early administration of interferon alpha prevents chronicity in almost all cases. However, interferon treatment is associated with significant side effects and costs; thus, alternative treatment strategies were also investigated. These data also suggested that a delayed therapy may cure the infection in 80% to 90% of cases. A detailed understanding of the pathophysiologic mechanisms of acute hepatitis C virus infection may help to find the best way to treat our patients. It has been shown that antiviral humoral and cellular immune responses may influence the outcome of the disease. While a weak T-cell immunity is associated with chronicity, a strong and multispecific cellular immune response is observed in self-limited infection. This article summarizes very recent immunologic and clinical studies on acute hepatitis C and illustrates the knowledge transfer from bench to bedside.

Successful treatment of hepatitis C after kidney transplantation with combined interferon alpha-2b and ribavirin

The management of acute hepatitis C virus (HCV) infection after renal transplantation (RT) remains controversial, due to the potential risk of interferon-induced graft dysfunction. There is little experience with combined interferon and ribavirin therapy in this group of patients. We treated four consenting RT recipients who developed acute de novo HCV infection with a combination of interferon-alpha 2b and ribavirin. After 48 weeks’ treatment, sustained virologic and biochemical remission were achieved in three patients infected with HCV genotypes 1a, 2, and 6a, respectively. The median time from treatment onset to ALT normalization was 8 weeks. The fourth patient was a non-responder infected with genotype 1b. Dose-dependent hemolysis was the most frequent side-effect. No patient developed allograft dysfunction. Our experience indicates that the judicious use of combined interferon and ribavirin can be considered in selected RT recipients with severe acute hepatitis C infection.

Acute hepatitis C: high rate of both spontaneous and treatment-induced viral clearance

Background & Aims: Acute hepatitis C virus infection accounts for approximately 20% of cases of acute hepatitis today. The aim of this study was to define the natural course of the disease and to contribute to the development of treatment strategies for acute hepatitis C virus. Methods: The diagnosis of acute hepatitis C virus in 60 patients was based on seroconversion to anti-hepatitis C virus antibodies or clinical and biochemical criteria and on the presence of hepatitis C virus RNA in the first serum sample. Results: Fifty-one of 60 (85%) patients presented with symptomatic acute hepatitis C virus. In the natural (untreated) course of acute symptomatic hepatitis C (n = 46), spontaneous clearance was observed in 24 patients (52%), usually within 12 weeks after the onset of symptoms, whereas all asymptomatic patients (n = 9) developed chronic hepatitis C. The start of antiviral therapy (interferon-α with or without ribavirin) beyond 3 months after the onset of acute hepatitis induced sustained viral clearance in 80% of treated patients. Conclusions: The management of acute hepatitis C has to take into account the high rate of spontaneous viral clearance within 12 weeks after the onset of symptomatic disease. Treatment of only those patients who remain hepatitis C virus RNA positive for more than 3 months after the onset of disease led to an overall viral clearance (self-limited and treatment induced) in 91% of patients, and unnecessary treatment was avoided in those with spontaneous viral clearance. Patients with asymptomatic acute hepatitis C virus infection are unlikely to clear the infection spontaneously and should be treated as early as possible.