Monday, January 12, 2009

Are You Hep to the Jive?

A patient comes in with abrupt onset fatigue, malaise, nausea, vomiting, anorexia, and abdominal pain several days ago. Today, he noticed dark urine, light stool, and pruritis. Social history is notable for travel to one of the red countries on the map below about 30 days ago. He denies drinking, smoking, drugs, and risky sexual activity. On exam, you find mild jaundice and a RUQ abdominal mass.

Challenge: Knowing the epidemiology of this disease, what's your diagnosis?

Image shown under GNU Free Documentation License


Alex said...

hepatitis b?

Stephanie said...

hepatitis E?

CodeDog said...

Hepatitis A
Most likely contracted by consuming contaminated food during his travel in a country with a high incidence of HAV.
The mass in his upper right quadrant is his swollen liver.
It is the weakened liver function that is causing the jaundice which in turn is causing the dark urine and light stool.
Itchiness is common in all the hepatitis type infections.

shabnam said...

Looks like Hepatitis A to me...isnt it?

Craig Chen said...

Yes! It's certainly one of the hepatitides. When I wrote the case, I was going for A but after reading a bit more, E fits too. UpToDate says "The epidemiology of HEV [...] is similar to that of hepatitis A virus (HAV). However, HAV is more readily transmitted, causes more infections, and has a wider distribution worldwide, although HEV may be more widespread in industrialized countries than generally believed. [...] The clinical signs and symptoms in patients with typical HEV infection are similar to those seen with other forms of acute viral hepatitis, although disease appears to be relatively severe compared with hepatitis A." Interesting!
As for Hep B, that's more likely with sexual exposure and IVDU and its epidemiology is slightly different (high risk in Southeast Asia, China, Pacific Islands, sub-saharan Africa, Alaska).
Good job! I learned a lot in this one.
Are You Hep to the Jive?

Hepatitis A is spread by oral-fecal route. In the U.S., risk factors include international travel, sexual and household contact with other activities, men who have sex with men, food- or waterborne outbreaks, daycare, and IV drug use. Incubation period is 15-49 days (average 30) and is usually a self-limited illness but can proceed to fulminant hepatic failure in patients with underlying disease (esp. chronic hep C). Lab findings indicate ALT>AST, both usually >1000 IU/dL., elevated serum total and direct bilirubin, and alkaline phosphatase. Diagnosis is serum IgM anti-HAV. Treatment is supportive.

Sources: UpToDate; Wikipedia.