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ESSENTIALS OF DIAGNOSIS

  • Prodrome of anorexia, nausea, vomiting, malaise, aversion to smoking.

  • Fever, enlarged and tender liver, jaundice.

  • Normal to low white cell count; markedly elevated aminotransferases.

GENERAL CONSIDERATIONS

Hepatitis can be caused by viruses, including the five hepatotropic viruses—A, B, C, D, and E—and many drugs and toxic agents; the clinical manifestations may be similar regardless of cause. Hepatitis A virus (HAV) is a 27-nm RNA hepatovirus (in the picornavirus family) that causes epidemics or sporadic cases of hepatitis. HAV infection is hyperendemic in developing countries. Globally, 15 million people are infected with HAV annually. The virus is transmitted by the fecal-oral route by either person-to-person contact or ingestion of contaminated food or water, and its spread is favored by crowding and poor sanitation. Since introduction of the HAV vaccine in the United States in 1995, the incidence rate of HAV infection has declined from as much as 14 to 0.4 per 100,000 population, with a corresponding decline in the mortality rate from 0.1 to 0.02 death per 100,000 population and an increase in the mean age of infection and death. Common source outbreaks resulting from contaminated food, including inadequately cooked shellfish, or untreated ground water from wells continue to occur, although no drinking water–associated outbreaks have occurred in the United States since 2009. In 2017, an outbreak in California and four other states affected a large number of homeless persons and resulted in many deaths. In addition, HAV infection has reemerged as a food-borne public health threat in Europe. Outbreaks among people who inject drugs or who are unvaccinated residents in institutions and cases among international adoptees and their contacts also occur. In the United States, international travel emerged as an important risk factor, accounting for over 40% of cases in the early 2000s but a lower percentage in the 2010s. Overall, however, reports of HAV infection increased by nearly 300% during 2016–2018 compared to 2013–2015.

The incubation period averages 30 days. HAV is excreted in feces for up to 2 weeks before clinical illness but rarely after the first week of illness. The mortality rate for hepatitis A is low, and acute liver failure due to hepatitis A is uncommon except for rare instances in which it occurs in a patient with concomitant chronic hepatitis C. There is no chronic carrier state. In the United States, about 30% of the population have serologic evidence of previous HAV infection.

CLINICAL FINDINGS

A. Symptoms and Signs

Figure 16–1 shows the typical course of acute hepatitis A. Clinical illness is more severe in adults than in children, in whom it is usually asymptomatic. The onset may be abrupt or insidious, with malaise, myalgia, arthralgia, easy fatigability, upper respiratory symptoms, and anorexia. A distaste for smoking, paralleling anorexia, may occur early. Nausea and vomiting are frequent, and diarrhea or constipation may occur. Fever is generally present but ...

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