< Presentation of a Case
>
A 30-year-old man was seen because
of progressive yellowish skin and eyes for 4 days. He had been
in good state of health until 7 days earlier before admission,
when he began to have poor appetite, generalized malaise, and
myalgia. Three days later, he noted that he had progressive
jaundice and eyes became yellow. There was no abdominal pain,
diarrhea, constipation or vomiting. Because of progressive
yellowish skin and eyes and mild fever, he sought medical
attention at our emergency department.
He was an engineer and had
traveled to Mainland China about one month earlier prior to
this admission. He had eaten crabs during his stay in
Shanghai. He denied any systemic disease and
glucose-6-phosphate dehydrogenase deficiency. There was no
consumption of alcohol, tobacco and other medications. He had
no history of animal contact or transfusion.
On physical examination, he had
clear consciousness but was ill-looking. His height was 170 cm
and weight was 70 kg. The temperature was 37.6°C, the pulse
rate was 80 beats per minute and the respiratory rate was 16
breaths per minute. Blood pressure while in supine position
was 100/70 mmHg. The skin was yellowish. There was no
cyanosis, petechiae, purpura or pigmentation. His conjunctivae
were pink, but the sclerae were icteric. The pupils were
isocoric with prompt light reflexes. The neck was supple
without lymphadenopathy, engorged jugular veins, palpable
thyroid gland or carotid bruits. The chest wall expansion was
symmetric and breath sounds were bilaterally clear. The heart
beats were regular without audible murmur. The abdomen was
soft. Bowel sounds were normoactive, and liver and spleen were
impalpable. The liver span was estimated 10 cm at the right
middle clavicle line. His extremities were freely movable
without edema.
< Laboratory data
>
1. CBC
WBC |
RBC |
HB |
HCT |
MCV |
MCHC |
PLT |
K/μL |
M/μL |
g/dL |
% |
fL |
g/dL |
K/μL |
8.33 |
4.6 |
13.4 |
42.8 |
85.1 |
31.3 |
271 | 2.
BCS+e-
ALB |
TP |
T-Bil |
D-Bil |
AST |
ALT |
ALP |
γ-GT |
g/dL |
g/dL |
mg/dL |
mg/dL |
U/L |
U/L |
U/L |
U/L |
3.7 |
6.9 |
12.66 |
10.90 |
1348 |
2068 |
498 |
172 |
UN |
CRE |
Na+ |
K+ |
Ca2+ |
Glucose |
LDH |
mg/dL |
mg/dL |
mmol/L |
mmol/L |
mmol/L |
mg/dL |
U/L |
9.5 |
0.7 |
138 |
4.2 |
2.0 |
99 |
488 |
3. Urine analysis
Appearance |
Sp. Gr |
pH |
Protein |
Glucose |
Ketone |
OB |
|
|
|
g/dL |
mg/dL |
|
|
Y;C |
1.03 |
7.0 |
30 |
- |
- |
- |
Urobilirubin |
Bilirubin |
Nitrate |
WBC |
RBC |
Epi |
Cast |
|
|
|
|
|
HPF |
|
1.0 |
3+ |
- |
0-1 |
0-1 |
3-5 |
- |
4. Coagulation factor
Prothrombin time |
PT cont |
INR |
Sec |
|
|
16.7 |
11.1 |
1.5 |
5.Other tests
IgM anti-HAV |
IgG anti-HAV |
IgM anti-HBc |
Anti-HBs |
HBs Ag |
- |
- |
- |
- |
- |
Anti-HCV |
IgM anti-HEV* (ELISA) |
IgG anti-HEV* (ELISA) |
Hanta* |
Leptospirosis* |
- |
> 3.0 ( > 0.474) |
> 2.18 ( > 0.555) |
- |
- |
EBV EA+EBNA1 IgA |
EBV-EA IgG |
EBV- VCA-IgA |
EBV- VCA-IgM |
ANA |
- |
1 :10(-) |
1 :10(-) |
1 :10(-) |
- |
HAV=hepatitis A virus ; HBc=
hepatitis B core antigen ; HBs Ag =hepatitis B surface antigen
; HBVhepatitis B virus ; HCV= hepatitis C
virus ; HEV =
hepatitis E virus ; IgM = immunoglobulin M ; Ig G =
immunoglobulin G ;
ELISA=enzyme-linked immunosorbent assay; EBV = Epstein-Barr
virus ; EBNA = Epstein-Barr nuclear antigen-1 ; EA = early
antigen ; VCA = viral capsid antigen ; ANA = antinulclear
antibody;
* = available from Center for Disease Control and
Prevention,Taiwan
< Course and treatment
>
Acute viral hepatitis (hepatitis E) was diagnosed.
Supportive management with hydration and glucose supplement
was instituted. Abdominal sonography revealed parenchymal
liver disease and mild splenomegaly. The levels of serum
aminotransferases decreased gradually followed by decreases of
serum bilirubin levels. He was discharged in a stable
condition.
< Discussion
>
急性病毒性E型肝炎(acute hepatitis
E)主要是經由腸道感染而引起肝臟發炎,受污染的食物和飲用水是其主要的傳染途徑,其流行病學特徵及臨床病程與A型肝炎類似,無任何跡象顯示E型肝炎病毒會導致慢性化。除了孕婦死亡率較高之外,其他人口感染E型肝炎則亦與A型肝炎類似。
E型肝炎病毒為一球型、無套膜、單股之RNA病毒。在急性感染期的初期,可在病患糞便中發現32至34
nm大小的病毒顆粒。流行於發展中國家,包括印度、尼泊爾、中國大陸、巴基斯坦及墨西哥等。主要感染年輕及中年人,且男性的感染率較高。目前台灣的E型肝炎病毒屬散發性病例。
急性病毒性E型肝炎主要經由糞口途徑傳染,潛伏期約15-60天,目前尚不清楚可傳染期多長。症狀無特異性,初期可能會有類似感冒症狀,包括食慾不振、噁心、輕微發燒、疲倦,之後出現黃疸(包括鞏膜及皮膚),尿液顏色變深,出現黃疸後病患可能食慾會好轉,體溫也漸正常,病程持續約數天至數週,最後慢慢痊癒。
生化檢查可以發現肝功能指數(AST及ALT)明顯升高,血液膽紅素亦升高,利用聚合酵素鏈鎖反應(PCR)偵測E型肝炎病毒RNA及利用ELISA測定E型肝炎病毒抗體(IgM
anti-HAV)呈陽性可以確定診斷。
急性病毒性E型肝炎的治療為支持性療法,包括:停止服食非必要藥物、充分休息、少量多餐、避免油膩及喝酒。目前並無疫苗可供預防,所以應該注意個人衛生習慣。另外,急性病毒性E型肝炎屬於第三類法定傳染病,發現疑似或確定病例時須於1週內通報當地衛生局(所)。
< References
>
- Hepatitis E virus: epidemiology,
diagnosis, pathology and prevention. Trop Gastroenterol.
2006;27(2):63-8. Review.
- Acute hepatitis E in pregnancy -
study of 16 cases. JNMA J Nepal Med Assoc.
2006;45(161):182-5.
- Prevalence and risk factors for HEV
infection in pregnant women. Med Sci Monit.
2006;12(1):CR36-39.
- Viral hepatitis during pregnancy.
Int J Gynaecol Obstet. 2001;72(2):103-8.
- Detection of HEV antigen as a novel marker for the
diagnosis of hepatitis E. J Med Virol. 2006;78(11):1441-8.
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