A 39-year-old previously healthy man comes to the office due to 4 days of nausea, loss of appetite, malaise, and mild upper abdominal discomfort. He has had no vomiting or diarrhea. The patient returned from a trip to the Philippines with his wife 2 weeks ago, but she has had no symptoms. He did not receive any vaccinations or chemoprophylaxis prior to travel and reports that he did not consume bottled water consistently during the trip. The patient does not use tobacco, alcohol, or illicit drugs. Temperature is 37.9 C (100.2 F), blood pressure is 118/72 mm Hg, and pulse is 96/min. Physical examination reveals scleral icterus and tender hepatomegaly. Laboratory results are as follows: Which of the following is the most likely sequela of this patient's condition?

Question

A 39-year-old previously healthy man comes to the office due to 4 days of nausea, loss of appetite, malaise, and mild upper abdominal discomfort.  He has had no vomiting or diarrhea.  The patient returned from a trip to the Philippines with his wife 2 weeks ago, but she has had no symptoms.  He did not receive any vaccinations or chemoprophylaxis prior to travel and reports that he did not consume bottled water consistently during the trip.  The patient does not use tobacco, alcohol, or illicit drugs.  Temperature is 37.9 C (100.2 F), blood pressure is 118/72 mm Hg, and pulse is 96/min.  Physical examination reveals scleral icterus and tender hepatomegaly.  Laboratory results are as follows:  Which of the following is the most likely sequela of this patient's condition?

Quizplus · Accepted Answer

This patient's presentation is consistent with acute hepatitis A virus (HAV) infection. HAV infection commonly presents with fever, nausea, vomiting, and abdominal pain followed by jaundice and pruritus. Patients may also report dark urine (bilirubinuria) and pale stools. Physical examination and laboratory analysis reveal tender hepatomegaly and significant elevations in transaminases (>1,000 U/L), bilirubin, and alkaline phosphatase. Diagnosis involves identifying anti-HAV IgM antibodies in the serum. Transmission occurs via the fecal-oral route and is common in areas with overcrowding and poor sanitation. A number of groups are at increased risk for HAV infection, including international travelers, men who have sex with men, illicit drug users, and those with household or sexual contact with infected persons. Treatment is largely supportive, and most patients completely recover in 3-6 weeks. A small subset of patients will have a more prolonged course complicated by cholestatic or relapsing hepatitis. Fulminant hepatic failure is rare; it can occur in patients age >50 or with preexisting chronic liver disease (Choice B). Post-exposure prophylaxis with either HAV vaccine or HAV immune globulin should be considered for close contacts of patients. HAV vaccination has now been incorporated into routine childhood vaccination schedules in the United States. (Choices C and E) There are few significant long-term consequences of HAV infection; however, both hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are associated with an increased risk for hepatocellular carcinoma and cirrhosis. This patient's travel history without prior HAV vaccination makes acute HAV more likely than acute HBV or HCV, which are more commonly transmitted through intravenous drug use. In addition, acute HAV is symptomatic in >70% of patients, whereas acute HBV and HCV are most often asymptomatic. (Choice D) Patients with portal hypertension from chronic liver disease (eg, cirrhosis) are at increased risk for hepatorenal syndrome (acute kidney injury in setting of liver disease). Hepatorenal syndrome can also rarely occur in patients with fulminant hepatic failure from other causes (eg, hepatitis E). However, development of chronic liver disease or fulminant hepatic failure is extremely rare in a young patient with HAV. (Choice F) Portal vein occlusion can occur due to chronic hepatosplenic schistosomiasis, which can be found in large parts of Africa and Asia. However, acute schistosomiasis (Katayama fever) presents with fever, urticaria, angioedema, dry cough, and eosinophilia, and would not explain the patient's abnormal liver studies. Educational objective: Hepatitis A virus infection commonly presents with fever, nausea, vomiting, and abdominal pain followed by jaundice and pruritus. Physical examination and laboratory analysis reveal tender hepatomegaly and significant elevations in transaminases, bilirubin, and alkaline phosphatase. Most patients completely recover in 3-6 weeks. References: Hepatitis A. (http://www.ncbi.nlm.nih.gov/pubmed/23198670)

A 39-Year-Old Previously Healthy Man Comes to the Office Due