Complications of Hepatitis A
By Brundage, Stephanie C; Fitzpatrick, A Nicole
A prolonged or relapsing course of illness lasting several months occurs in 10 to 20 percent of symptomatic patients, wit\h persistent fever, severe pruritus, jaundice, diarrhea, weight loss, and malabsorption.4,6-8
Liver enzyme levels return gradually to normal, but the bilirubin level remains elevated.6 Patients with a relapse or a prolonged course should be regarded as potentially infectious.4 A small subset of patients with hepatitis A develop extrahepatic manifestations, which are listed in Table 2.4,6
Less than 1 percent of patients experience a fulminant course of illness characterized by worsening jaundice and development of encephalopathy. Advanced age and comorbid conditions such as chronic liver disease increase the risk of a fulminant course, which often results in death or an emergent liver transplant.4,6 Prognostic indicators used to support the need for a liver transplant are age younger than 10 years or older than 40 years, jaundice lasting more than seven days before the onset of encephalopathy, increased levels of serum bilirubin (more than 17 mg per dL [291 mol per L]), and prolonged prothrombin time (more than 25 seconds).19 The overall fatality rate is relatively low (0.3 percent), but increases to 2 percent in adults older than 40 years.7
Treatment
Treatment is supportive and includes appropriate rest when necessary,4 balanced nutrition, and avoidance of hepatotoxins such as alcohol and acetaminophen.6 No specific antiviral therapy currently is available.8,12 About 30 percent of symptomatic patients require hospitalization for dehydration, severe prostration, coagulopathy, encephalopathy, or other evidence of hepatic decompensation.6,17
Caregivers should observe strict contact precautions during the infectious period with patients who are diapered or incontinent. Otherwise healthy adult patients are noninfectious by two weeks after the onset of illness, but children and immunocompromised persons may remain infectious for up to six months.8-11
REFERENCES
1. Centers for Disease Control and Prevention. Reported cases of acute viral hepatitis, by type and year, United States, 1966-2003. Accessed March 2, 2006, at: http://www.cdc.gov/ncidod/diseases/ hepatitis/resource/pdfs/surv_table.pdf.
2. Wasley A, Samandari T, Bell BP. Incidence of hepatitis A in the United States in the era of vaccination. JAMA 2005;294:194-201.
3. Fiore AE, Wasley A, Bell BP, for the Advisory Committee on Immunization Practices. Prevention of Hepatitis A through active or passive immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2006;55(RR-7):1-23.
4. Cuthbert JA. Hepatitis A: old and new [Published correction appears in Clin Microbiol Rev 2001;14:642]. Clin Microbiol Rev 2001;14:38-58.
5. Centers for Disease Control and Prevention. Hepatitis A outbreak associated with green onions at a restaurant-Monaca, Pennsylvania, 2003. MMWR Morb Mortal Wkly Rep 2003;52:1155-7.
6. Kemmer NM, Miskovsky EP. Hepatitis A. Infect Dis Clin North Am 2000;14:605-15.
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9. Prevention of hepatitis A through active or passive immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 1999;48:1-37.
10. Heymann DL. Viral hepatitis A. In: Heymann DL, ed. Control of Communicable Diseases Manual. 18th ed. Washington, D.C.: American Public Health Association, 2004:247-53.
11. American Academy of Pediatrics, Committee on Infectious Diseases. Hepatitis A. Red Book: 2003 report of the Committee on Infectious Diseases. 26th ed. Elk Grove Village, Ill.: American Academy of Pediatrics, 20\13:309-18.
12. World Health Organization. Hepatitis A vaccine: WHO position paper. Accessed March 2, 2006, at: http://www.who.int/docstore/wer/ pdf/2000/wer7505.pdf.
13. Centers for Disease Control and Prevention. Disease burden from viral hepatitis A, B, and C in the United States. Accessed September 22, 2005, at: http://www.cdc.gov/ncidod/diseases/ hepatitis/resource/pdfs/disease_burden2004.pdf.
14. Acheson DW, Fiore AE. Preventing foodborne disease-what clinicians can do. N Engl J Med 2004;350:437-40.
15. Fiore AE. Hepatitis A transmitted by food. Clinical Inf Dis 2004;38:705-15. Accessed March 2, 2006, at: http://www.cdc.gov/ ncidod/diseases/hepatitis/a/fiore_ha_transmitted_by_food.pdf.
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17. Centers for Disease Control and Prevention. Hepatitis surveillance. 2005;60:8, 11-4, 22-4. Accessed March 2, 2006, at: http://www.cdc.gov/ncidod/diseases/hepatitis/resource/pdfs/ hep_surveillance_60.pdf.
18. Centers for Disease Control and Prevention. Positive test results for acute hepatitis A virus infection among persons with no recent history of acute hepatitis - United States, 2002-2004. MMWR Morb Mortal Wkly Rep 2005;54:453-6.
19. O'Grady JG, Alexander GJ, Hayllar KM, Williams R. Early indicators of prognosis in fulminant hepatic failure. Gastroenterology 1989;97: 439-45.
20. Craig AS, Schaffner W. Prevention of hepatitis A with the hepatitis A vaccine [Published correction appears in N Engl J Med 2004;350:2726]. N Engl J Med 2004;350:476-81.
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STEPHANIE C. BRUNDAGE, M.D., M.P.H., South Carolina Department of Health and Environmental Control, Columbia, South Carolina
A. NICOLE FITZPATRICK, M.P.H., South Carolina Department of Health and Environmental Control, Greenville, South Carolina
The Authors
STEPHANIE C. BRUNDAGE, M.D., M.P.H., is medical liaison for community health for South Carolina Department of Health and Environmental Control (SCDHEC), Columbia. She previously was district health director for Appalachia II Public Health District, SCDHEC, Greenville. Dr. Brundage also served as associate director of the Greenville (S.C.) Hospital System family practice residency program and was associate professor in the Departments of Family Medicine at the Medical University of South Carolina, Charleston, and the University of South Carolina School of Medicine, Columbia. Dr. Brundage received her medical degree from the University of Miami (Fla.) School of Medicine and completed a residency in family practice at affiliated hospitals. She received a master's degree in public health from the University of South Carolina School of Public Health, Columbia.
A. NICOLE FITZPATRICK, M.P.H., is infectious disease epidemiologist for Health Region 2, SCDHEC, Greenville. She received her master's degree in public health from Tulane University School of Public Health and Tropical Medicine, New Orleans, La.
Address correspondence to Stephanie C. Brundage, M.D., M.P.H., Medical Liaison for Community Health, South Carolina Department of Health and Environmental Control, 1777 St. Julian Place, Columbia, SC 29204 (e-mail: brundasc@dhec.sc.gov). Reprints are not available from the authors.
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