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Clinical Presentation
ACUTE HEPATITIS
Signs and Symptoms
The majority of acute viral hepatitis infections are asymptomatic, or
they can cause an anicteric illness that may mimic other viral infections. Hepatitis
A generally causes minor illness in childhood, with >80% of infections being
asymptomatic. Adults are more likely to produce clinical symptoms. Symptoms
usually last for <2 months, but some patients may have prolonged infection
or may experience disease relapse. Hepatitis B, C, and D may also be
asymptomatic. Symptomatic hepatitis B will depend on the mode and time of
transmission. Vertical transmission from mother to child is almost always
asymptomatic. Other routes of transmission are more likely to produce
symptomatic disease (30% of cases transmitted by intravenous [IV] drug use are
icteric). Hepatitis E is usually asymptomatic. Patients with symptoms are
usually older adolescents or young adults. Extrahepatic manifestations (eg
Guillain-Barré syndrome, Parsonage-Turner syndrome, neuralgic amyotrophy, bilateral
brachial neuritis, peripheral neuropathy, encephalitis, membranoproliferative
glomerulonephritis with or without cryoglobulinemia, membranous
glomerulonephritis, acute pancreatitis, other autoimmune manifestations [eg
myocarditis, arthritis, thyroiditis], thrombocytopenia) have been observed. Some
patients may experience persistent hepatitis E virus (HEV) replication, and
immunocompromised patients or those with chronic liver disease are at risk for
chronic HEV infection with prolonged viremia (>6 months).
Hepatitis C_Initial AssesmentPre-icteric Phase
Non-specific systemic symptoms (eg myalgia, nausea, vomiting, fatigue, malaise with discomfort in the right upper quadrant of the abdomen), altered sense of smell or taste, coryza, photophobia, headache, cough, diarrhea, dark urine and serum sickness-like syndrome are noted. Hepatomegaly, splenomegaly and lymphadenopathy may be seen on physical examination.
Icteric Phase
Jaundice is usually noted after the onset of fever or upon lysis of fever.
Fulminant Hepatitis
The development of symptoms of hepatic encephalopathy (eg confusion, drowsiness) is seen within 8 weeks of symptoms or within 2 weeks of the onset of jaundice. There may be hypoglycemia and prolonged prothrombin time (PT).
Routes of Transmission of Hepatitis
The routes of transmission of hepatitis are: Hepatitis A, through oral-fecal (eg ingestion of contaminated food or water), person-to-person contact, sexual contact; hepatitis B, through perinatal, percutaneous, sexual, close person-to-person contact, ie by open cuts and sores; hepatitis C, through blood transfusions, organ transplants, percutaneous (especially IV drug use), sexual, and perinatal; hepatitis D, through sexual, percutaneous especially IV drug use, mucous membrane contact with infectious blood or body fluids (found only in patients with hepatitis B since it requires the hepatitis B outer coat for replication); and hepatitis E, through oral-fecal (ingestion of contaminated food or water), blood transfusion in endemic areas, and mother-to-child transmission.
Incubation Period
The incubation periods of hepatitis are: For hepatitis A, 15 to 50 days; for hepatitis B, 30 to 180 days; for hepatitis C, 14 to 180 days; for hepatitis D, 30 to 180 days; and for hepatitis E, 15 to 60 days.
Other Characteristics of Hepatitis Viruses
Hepatitis B virus (HBV) contains a DNA nucleic acid while A, C, and E viruses have an RNA nucleic acid. Hepatitis D has an incomplete RNA and needs the B virus to replicate. Hepatitis A and E viruses cause epidemics. Hepatitis B, C and D viruses may predispose to chronic disease and hepatic malignancy.
History
The important points in the clinical history of patients with suspected viral hepatitis are contacts with jaundiced patients, IV drug use, history of blood transfusion, surgery or hospitalizations, family history of chronic liver disease, occupation, food and water sources, past or current medication use, alcohol use, unexplained chronic liver disease and/or chronic hepatitis, long-term hemodialysis, human immunodeficiency virus (HIV) infection, and a history of multiple sexual partners and/or sexually transmitted infections (STIs).