Case History: Acute Viral Hepatitis

PATIENT DETAILS

CHIEF COMPLAINTS

1. Fever - 7 days
2. Pain abdomen (right hypochondriac region) - 7 days
3. Nausea and vomiting - 7 days
4. Yellowish discoloration of eyes (jaundice) - 4 days

Why this order? In acute viral hepatitis, the prodromal (preicteric) phase comes first (1-2 weeks), marked by fever, malaise, nausea, vomiting, and right upper quadrant discomfort. The icteric phase (jaundice) develops later, typically 5-7 days into the illness, when serum ALT peaks and bilirubin rises enough to be visible in sclerae. So physiologically: systemic viral prodrome (fever + GI symptoms + RUQ pain) precede jaundice. (Yamada's Textbook of Gastroenterology, 7th Ed)

HISTORY OF PRESENT ILLNESS

• Low-grade fever, continuous, not associated with chills/rigors, partially relieved by paracetamol
• Generalized malaise, fatigue, and weakness - severe enough to restrict activity
• Loss of appetite (anorexia) - marked, with aversion to food especially in the evening
• Nausea - present throughout the day
• Vomiting - 3-4 episodes per day, initially food contents, then bile-stained; non-projectile; no blood in vomitus
• Dull aching pain in the right hypochondriac region (under right ribcage), non-radiating, not related to meals
• Headache - mild, diffuse
• Patient noticed aversion to her usual cigarette/tobacco (if applicable) - a classical early sign

• 4 days back, patient and family members noticed yellowish discoloration of the sclerae (eyes), which progressively increased
• Urine color became dark yellow/tea-colored (choluria) around the same time
• Stools became pale/clay-colored (acholic stools) - due to intrahepatic cholestasis
• Mild itching (pruritus) over skin - not severe
• Fever partially subsided after onset of jaundice (as is typical in hepatitis A/E where fever tends to decrease with icteric phase)
• Vomiting persisted - total 4 episodes per day, hence patient presented to OPD

• Hematemesis or melena
• Altered sensorium or confusion (no encephalopathy)
• Abdominal distension or ascites
• Pedal edema
• Bleeding from any site
• Chest pain or cough

PAST HISTORY

• No similar episode in the past
• No history of jaundice previously
• No history of blood transfusion, IV drug use, tattooing, or body piercing
• No history of unprotected sexual contact
• No history of tuberculosis, diabetes mellitus, hypertension
• No previous surgery or hospitalization

PERSONAL HISTORY

• Diet: Vegetarian / Mixed (specify)
• Appetite: Severely reduced (present illness)
• Bowel habits: Pale stools since 4 days
• Micturition: Dark-colored urine since 4 days
• Sleep: Disturbed due to illness
• Menstrual history: Regular cycles, LMP ______ (document)
• Addictions: No alcohol, no smoking (or specify)
• Significant exposure history: Ate outside food / consumed water from unknown source / ate at a community function approximately 3-4 weeks ago (incubation period of HAV is ~25 days - consistent with this timeline)

FAMILY HISTORY

• No similar illness in family members (or specify if siblings/contacts have similar illness - common in HAV outbreaks)
• No family history of liver disease, malignancy, or hereditary disorders

DRUG HISTORY

• Took paracetamol (500 mg SOS) for fever - symptom relief
• No other medications
• No herbal/ayurvedic medications (important to ask - can cause drug-induced hepatitis)
• No known drug allergies

SOCIOECONOMIC HISTORY

• Lower/middle socioeconomic class (consistent with HAV risk - contaminated food/water)
• Lives in a semi-urban area, shared housing
• Water source: municipal tap water / hand pump (document)
• No history of recent travel to endemic area for HEV

GENERAL PHYSICAL EXAMINATION

SYSTEMIC EXAMINATION

Gastrointestinal / Abdominal Examination

• Abdomen flat, moves with respiration
• No visible distension, no visible peristalsis
• No engorged veins (no caput medusae)
• No surgical scars

• Abdomen soft
• Liver: Palpable 2-3 cm below right costal margin in mid-clavicular line, surface smooth, edge rounded, tender on palpation - consistent with acute hepatic inflammation
• Spleen: Not palpable (splenomegaly can occur in ~10-20% of acute viral hepatitis)
• No other organomegaly
• No palpable mass
• Mild tenderness in the right hypochondriac region

• Liver dullness present, upper border at 5th intercostal space (normal)
• Murphy's sign: Negative (important to differentiate from acute cholecystitis)
• No shifting dullness (no ascites)
• Traube's space: Resonant (spleen not enlarged)

• Bowel sounds: Present, normal
• No bruit over liver

Cardiovascular Examination

• S1 S2 heard, no murmurs
• JVP not raised

Respiratory Examination

• Air entry bilateral, equal
• No added sounds

Central Nervous System

• Higher mental functions intact
• No flap (asterixis) - no hepatic encephalopathy
• No focal neurological deficit

PROVISIONAL DIAGNOSIS

INVESTIGATIONS TO BE ORDERED

• S. Bilirubin (total, direct, indirect) - expected: direct-predominant hyperbilirubinaemia
• SGPT (ALT) / SGOT (AST) - expected: markedly elevated (often >10x normal)
• Alkaline phosphatase (ALP) - mildly elevated
• Serum albumin / total protein
• Prothrombin time / INR - to assess severity

• Anti-HAV IgM - positive in acute HAV (diagnostic)
• HBsAg + Anti-HBc IgM - to rule out acute HBV
• Anti-HCV - to rule out HCV
• Anti-HEV IgM - if epidemiologically relevant (monsoon season, water contamination)

• CBC: may show mild leukopenia with relative lymphocytosis (typical in viral hepatitis)
• Urine: bile salts and bile pigments positive (bilirubinuria), urobilinogen elevated
• Blood glucose (hypoglycemia possible in severe hepatitis)
• Urea, creatinine, electrolytes
• Ultrasound abdomen: hepatomegaly, periportal edema (bright periportal echogenicity), gall bladder wall edema - typical of acute hepatitis

TREATMENT PLAN (Supportive)

• Bed rest, high-calorie diet (take majority of calories in the morning when nausea is least)
• IV fluids if oral intake compromised due to persistent vomiting
• Antiemetics (ondansetron/metoclopramide)
• Avoid hepatotoxic drugs (NSAIDs, alcohol, hepatotoxic antibiotics)
• No specific antiviral needed for HAV - self-limiting
• Isolation precautions (enteric precautions for HAV)
• Monitor INR/PT for signs of acute liver failure
• Advise regarding hygiene and notify contacts