Hepatitis E | Clinical presentation and management

Hepatitis E | Clinical presentation and management

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Hepatitis E virus (HEV) is a non-enveloped single stranded RNA virus belonging to Hepevirus. This agent is transmitted almost exclusively by the fecal oral route. It is an outbreak prone disease with an incubation period of around 2-10 weeks.

Clinical Presentation

The illness usually begins after the incubation period of 14-70 days as an acute viral syndrome with mild fever, marked loss of appetite, aversion to food, upper abdominal discomfort ,nausea and/vomiting. Within a few days of onset of these non-specific symptoms jaundice can appear with the resolution of these non-specific symptoms.

Jaundice usually persists for 1-6 weeks and then gradually resolves. In children, most HEV infections occur without any symptom or as a mild illness without jaundice. In contrast, in adults, acute hepatitis E may have a prolonged cholestatic phase with significant itching. Acute liver failure may be seen in a small proportion (0.4-5%) which is higher in pregnant women normally within a week of onset of symptoms.

Laboratory Diagnosis

Cases of hepatitis E are not clinically distinguishable from other types of acute viral hepatitis. Diagnosis is strongly suspected in appropriate epidemiologic settings e.g. occurrence of several cases in localities in known disease-endemic areas, in settings with risk of water contamination, if the disease is more severe in pregnant women and if hepatitis A has been excluded.

Definitive diagnosis of hepatitis E infection is based on the detection of specific IgM antibodies to the virus in a person’s blood. In acute hepatitis with clinical jaundice, the serum bilirubin levels are above 2.5mg/dL and serum ALT is more than 10 times the upper limit of normal.

Management of Viral Hepatitis E

There is no specific treatment capable of altering the course of acute hepatitis E. As the disease is usually self-limiting, hospitalization is generally not required. Hospitalization is required for people with fulminant hepatitis and symptomatic pregnant women. Immunosuppressed people with chronic hepatitis E benefit from specific treatment using ribavirin, an antiviral drug. In some specific situations, interferon has also been used successfully.


Management of acute viral hepatitis during pregnancy

The patient is preferably managed in a hospital with ICU facilities and blood banking to provide adequate blood product support, in addition to Obstetric services.

• Monitor blood pressure, exclude toxaemia of pregnancy.

• Permit oral intake, maintain adequate hydration.

• Monitor closely for development of signs of acute liver failure.

Premature induction of labor has no proven role in preventing or treating ALF. If spontaneous premature rupture of membranes or premature labor occur, one should: Give vitamin K (10 mg IV, repeat after 24 h), monitor fetal heart rate, arrange blood (may need if postpartum bleeding occurs). If the fetus is above 34-36 weeks, consider induction of labour, otherwise manage conservatively. For premature rupture of membranes, give antibiotic prophylaxis.

In case of intrauterine death, induction of labor (misoprostol or oxytocin) should be considered in a patient not in acute liver failure. However, if the mother has acute liver failure, labour should not be induced. Oxytocin should be used after delivery, to prevent post-partum bleeding. If bleeding occurs, use oxytocin infusion; if needed, ergometrine or misoprostol can be used. Use blood transfusion, if necessary.

For baby, assess for hypothermia and hypoglycaemia, and treat if present. Administer vitamin K, give normal vaccines and initiate breast feeding (if the mother can nurse).

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