1. REGISTRAR: DR GS HURTER CONSULTANT: DR JCJ VAN VUUREN FIRM: 3 MILITARY HOSPITAL ATYPICAL MANIFESTATION OF HEPATITIS A

2. Patient L: Case Discussion  35 year old female from Bloemfontein referred by local sickbay on 15/02/10:  History: Nausea and vomiting last 2 weeks, Abdominal tenderness, Yellow discoloration of eyes, fatigue, Anorexia  Medical History:No chronic diseases, No chronic medication  Examination: General: Severe Jaundice Abdominal: Right upper quadrant tenderness, Hepatomegaly  Laboratory Investigations: Hepatitis A IgM antibodies present

3. Patient L: Special Investigations  Abdominal Ultrasound:Hepatomegaly No biliary obstruction noted

4. Patient L: Follow Up Consultation 1 MONTH AFTER DISCHARGE  History:Severe Back pain, Unable to sit Abdominal pain, less severe than previously Denies any history of alcohol use Minimal use of paracetamol  Examination:No Jaundice, Severe tenderness over lumbar spine Right Upper Quadrant Tenderness Hepatomegaly still present

5. Patient L: Follow Up Consultation Differential Diagnosis: 1) Infection - Septic diskitis 2) Inflammatory arthritis 3) Mechanical back pain Further investigations:- Lumbar/Thoracic spine X-ray - Skeletal scintigram - Follow up LFT

6. Patient L: Results  Lumbar/Thoracic X-rays: Normal, No signs no diskitis  Skeletal Scintigram:Increased uptake in SI joints

7. Patient L: Results

8. Patient L: Diagnosis  Patient presenting with new onset sacro-iliitis Cholestatic hepatitis A infection 6 weeks previously Newly elevated hepatic cellular enzymes ALT > AST Diagnosis: Relapsing Hepatitis A with extra hepatic manifestation of arthritis

9. Hepatitis A in Adults  Acute hepatitis A incidence has declined by 92 % between 1995 and 2007 due to vaccination  Vaccination has cause a proportion increase of cases among adults  HAV infection is usually silent or subclinical in children. In contrast, infection in adults can vary in severity from a mild flu-like illness to fulminant hepatitis  Atypical manifestations of hepatitis A include: - Cholestatic hepatitis - Autoimmune hepatitis - Extrahepatic manifestations - Relapsing Hepatitis

10. Course of Hepatitis A

11. Overview Relapsing Hepatitis A  Relapsing form of hepatitis is observed in 3-20% of patients with a Hepatitis A infection  Patients initially shows a full recovery from a Hepatitis A infection with near normalization of AST levels  Within 4 to 15 weeks patients can present with a biochemical and/or a clinical relapse of symptoms  Relapse is usually milder than the initial episode  Hepatitis A virus is usually present in stool samples thus patients remain infectious !!  IgM HAV antibodies persists during the course of disease

12. Overview Relapsing Hepatitis A  A cholestatic from can also be seen  Multiple relapses can occur  50% of patients are asymptomatic during relapses  Symptomatic patients can develop extra hepatic disease during relapses such as arthritis, vasculitis, nephritis and cryoglobulinemia  Cause of relapsing Hepatitis A is unknown  No predisposing factors have been identified  Treatment is supportive, use of oral cortico-steroids has been suggested in some articles to improve arthritis symptoms

13. Overview Relapsing Hepatitis A  Recognition of this entity is important to prevent unnecessary, expensive and potentially invasive tests  Abdominal ultrasound should be done to exclude extra hepatic obstruction in patients with severe jaundice  Prognosis is good, complete recovery is expected  Relapses can occur up to 12 months since initial infection  Only one fatality has been reported in association with relapsing hepatitis A in a pregnant patient

14. Patient L: Further Management  Patient started on NSAID’s and Prednisone 20mg daily po  Patients follow up IgM for Hepatitis A was still positive at readmission, confirmed diagnosis of Relapsing Hepatitis A  Patient slowly responded to steroid therapy

15. Patient L: Final Results LAB TESTS 02/02/10 (OUT PATIENT ) 15/02/10 (IN PATIENT ) 22/02/10 (ON DISCHARGE) 16/03/10 (READMISSION) 30/03/10 (ON DISCHARGE) Total Bilirubin 158192672512 Conjugate d Bilirubin 9610929118 AST15136259398114 ALT25185640533243 ALP290526286205169 GGT521280179189315

16. References:  Schiraldi, O, Modugno, A, Miglietta, A, et al. Prolonged viral hepatitis type A with cholestasis: Case report. Ital J Gastroenterol 1991; 23:364  Glikson, M, Galun, E, Oren, R, et al. Relapsing hepatitis A: Review of 14 cases and literature survey. Medicine (Baltimore) 1992; 71:14  Rachima, CM, Cohen, E, Garty, M. Acute hepatitis A: Combination of the relapsing and the cholestatic forms, two rare variants. Am J Med Sci 2000; 319:417  Schiff, ER. Atypical clinical manifestations of hepatitis A. Vaccine 1992; 10 (Suppl 1):S18.