The patient presented with symptoms of acute viral hepatitis including fever, nausea, vomiting, loss of appetite, abdominal discomfort, and jaundice. Laboratory tests confirmed the diagnosis of acute hepatitis E virus (HEV) infection based on markedly elevated liver enzymes and a positive IgM anti-HEV test. The patient was treated conservatively with supportive care, hydration, antiemetics, and medications to relieve symptoms while allowing the liver time to recover on its own from the viral infection. Monitoring of liver function tests and symptoms showed gradual improvement over the course of treatment.

1. ACUTE VIRAL HEPATITIS - E
BY,
R SAI CHANDRA
PHARMD IV YEAR
16H61T0016
ANURAG GROUP OF INSTITUTIONS

2. INTRODUCTION
• Viral hepatitis is recognized as a global public health problem.
• Etiological agents : Hepatitis A, B, C, D and E viruses
• Hepatitis A Virus (HAV) and Hepatitis E Virus (HEV) are important causes of acute viral
hepatitis and acute liver failure (ALF).
• Hepatitis B (HBV) and C (HCV) can either clear spontaneously or can lead to chronic
infection and there after sequelae like cirrhosis and hepatocellular carcinoma (HCC).
• Available literatur (india) :
• HAV is responsible for 10-30% of acute hepatitis and 5-15% of acute liver failure.
• HEV is responsible for 10-40% of acute hepatitis and 15-45% of acute liver failure.
Acute
Chronic / Sequel of chronic infection.

3. Hepatitis E
Hepatitis E virus (HEV) is a non-enveloped single stranded RNA virus
belonging to Hepevirus.
Transmission :
• Fecal-oral route ( fecal contamination of drinking water).
• Ingestion of undercooked meat or meat products derived from infected
animals (e.g. pork liver).
• Transfusion of infected blood products and
• Vertical transmission from a pregnant woman to her baby
 It is an outbreak prone disease with an incubation period of around 2-10
weeks.
A vaccine to prevent hepatitis E virus infection has been developed and
is licensed in China, but is not yet available elsewhere.

4. Clinical Presentations
Non-specific symptoms Illness : (Incubation period of 14-70 days )
• Acute viral syndrome with mild fever,
• Marked loss of appetite,
• Aversion to food,
• Upper abdominal discomfort , Nausea and / Vomiting.
• Jaundice usually persists for 1-6 weeks and then gradually resolves.
• Hepatomegaly (slightly)
children No symptom / mild illness without jaundice
Adults prolonged cholestatic phase with significant itching.
Fulminant hepatitis: Pregnant women > 2/3 trimesters Acute liver failure,
Fetal loss and
Mortality (20–25% in 3rdtrimesters)
poor sanitation &
contaminated
drinking water
supply (virus).

5. DIAGNOSIS
• Clinically indistinguishable from other types of acute viral hepatitis.
• Strongly suspected with an appropriate epidemiologic settings
Like - Several cases occurring from disease-endemic areas.
- Risk of water contamination.
- Disease severity in pregnant women etc,.
Definitive diagnosis
Clinical criteria:-
1)acute illness compatible with hepatitis
2)ALT > 10 times the upper limit of the normal range
Serological criteria :-
1) IgM anti-HEV +ve
2) IgM anti- HAV /HBV -ve

6. PREVENTION
At the population level :-
• maintaining quality standards for public
water supplies; and
• establishing proper disposal systems for
human faces.
At individual level:-
• maintaining hygienic practices;
• avoiding consumption of water and ice of
unknown purity.

8. IP NO : 53975
AGE : 39 Years
GENDER : Male
Weight: 54kg
Height : 160cm
BMI : 21.1 kg/m²
DOA : 04-09-19
DEPARTMENT: General medicine
• Generalized Weakness
• Nausea
• Vomiting
• Fever since 1month
• Anorexia,
• Yellowish Urine & sclera
• Constipation
• Body Pains
• PAST MEDICAL HISTORY : Hypothyroidism
• PAST MEDICATION HISTORY : Rx Tab. Thyronorm 100mcg

10. k/c/o hypothyroidism ,
Acut viral hepatitis (IgM
anti-HEV +ve )
Borderline hepatomegaly,
vitals stable .
c/o Fever ,anorexia, yellow urine ,
constipation .
4pm C/o body pains ,general
weakness .
Temp: 99⁰F
BP : 110/70mmHg
PR: 86/min
RR: 20/min
Spo2 :98%
Adv:- USG abdomen, CBP, LFT, ESR,
electrolytes, Viral markers.

11. Report USG abdomen: –
splenomegaly edematous gall bladder
wall
Temp: 98.6 ⁰F
BP : 110/70mmHg
PR: 86/min
RR: 20/min
Urine In : 2400ml
Urine Out : 1000ml
No abdominal & Body pains
Icterus +ve
Flapping tremors/Asterixis +ve
Pt is conscious , coherent , afebrile
PR: 87 /min
RR: 20 /min
Bp : 120/80
PT : 21.7 sec
Advised :- Vit K

12. PARAMETER RESULT NORMAL RANGE
Bilirubin Total 12.59 mg/dl 0.3 – 1.3 mg/dl
Bilirubin Direct 7.85mg/dl 0.1 – 0.4mg/dl
Bilirubin Indirect 1.37mg/dl 0.2 - 0.9mg/dl
ALP 95 units/L 33 – 96 units/L
SGOT 2856 units/L 12 – 38 units/L
SGPT 2581 units/L 7 – 41 units/L
Total proteins 6.90 g/dl 6.7 – 8.6 g/dl
Albumin 3.10 g/dl 3.5 – 5.5 g/dl
Globulin 3.90 g/dl 2.0 – 3.5 g/dl
A/G 0.80 1.5 – 2.5 : 1
GGT 116 9 – 58 units/L
LIVER FUNCTION TEST

13. Other Parameters
ESR 17mm 1 – 15mm/hr
Sodium 135 135 – 145 mmol/L
Potassium 4.5 3.8 – 5.0 mmol/L
Chlorides 102 95 – 103 mmol/L
Sr.creatinine 1mg/dl 0.6 – 1.2 mg/dl
PT 21.7 sec 11 – 13.5 sec
Urine Examination
• Bile salts – present
• Bile pigments – present
• Pus cells – 8-10/hpf (4 cells/hpf)
• RBC – 2-4 / hpf (0-2 to 2-3 cells/hpf )
• Epithelial cells – 4-6 hpf (1 – 5 cells/hpf)
• Albumin - present

14. MEDICATION CHART
S.No BRAND NAME GENERIC NAME DOSE ROA FREQ D1 D2 D3 D4
1. Tab.Thyronorm Levothyroxine 100mcg PO OD    
2. Inj. NAC N-Acetylcysteine 1200mg IV TID    
3. Tab. Nusam s-adenosylmethionine 400 mg PO BD    
4. Inj. PAN pantoprazole 40mg IV OD    
5. Inj. Zofer ondansetron 4mg IV OD    
6. Inj.OPTINEURON Vitamin supplement 1amp IV OD    
7. Tab.FOLVITE Folic acid 5mg PO OD    
8. Syp. Duphalac lactulose 10ML PO BD    
9. Inj. Buscopan Hyoscine butylbromide 1amp IV SOS    
10. Inj. Magnex Forte Cefoperazone + sulbctum 1.5g IV BD    
11. Tab. Udiliv Ursodeoxycholic acid 300mg PO BD    
12. Inj. Vit K Menaquinone 1amp IV PO    

16. • Acute viral syndrome with mild fever,
• Marked loss of appetite, Aversion to
food
• Upper abdominal discomfort
• Nausea and / Vomiting.
• Jaundice usually persists for 1-6 weeks
and then gradually resolves.
• Hepatomegaly (slightly)
• Generalized Weakness
• Nausea
• Vomiting
• Fever since 1month
• Anorexia
• Yellowish Urine & sclera
• Constipation
• Body Pains
• Icterus +ve
• Flapping tremors +ve
• splenomegaly edematous gall bladder wall

17.  acute illness compatible with
hepatitis
ALT > 10 times the upper limit of
the normal range
IgM anti-HEV +veIgM anti-HEV +ve
 Almost all the clinical features are compatible
 SGPT – 2581 units/L – [7-41 units/L]


18. Based on the above subjective and objective data, the patient
was diagnosed with / Found to be suffering from
Acute viral hepatitis E (Final)

19. TREATMENT (Theory)
 Acute hepatitis E in immunocompetent pts usually requires
symptomatic treatment , as they able to clear the virus
spontaneously.
Study report :- Ribavirin for 21 days showed significant improvement
in LIVER enzymes and functions of a Acute Hepatitis E patient .
GOALS OF TREATMENT :
 sequential Relieving of the symptoms by providing supportive measures.
 Recovering all possible test parameters to fall within the range .
 Boost the immune response in regards to variable infections / HEV.

20. TREATMENT OPTIONS (Subject)
1) TAB.THYRONORM : -
 MOA : T4 and T3 bind to thyroid receptor proteins in the cell nucleus and cause metabolic effects through the control
of DNA transcription and protein synthesis
 Uses: Treat Hypothyroidism , It replaces or provides more thyroid hormone.
 Side Effects:- increased appetite ,weight loss, heat sensitivity, excessive sweating, headache , hyperactivity
 Monitotior Parameters : TSH and total or free T4 at 2 and 4 weeks after starting treatment.
2) TAB.NUSAM :-
 MOA :- Formation, breakdown, and activation of other chemicals in the body such as proteins, phospholipids, hormones,
etc.
 Uses:- Treatment of liver disease associated with reduced bile formation (intrahepatic cholestasis). It protects the liver
cells from toxins.
 Side Effects:- Feeling anxious or nervous ,Vomiting , Abdominal pain ,Diarrhea ,Insomnia.
 Monitotior Parameters : Bioelectric brain activity ,HRS,EEG as it shows altered psychological activity .
3) INJ. NAC :-
 MOA :- It exerts by mucolytic action through its free sulfhydryl group, which reduces the disulfide bonds in the mucus
matrix and lowers mucus viscosity.
 Uses: Treat paracetamol (acetaminophen) overdose, and to loosen thick mucus in individuals with cystic fibrosis or
chronic obstructive pulmonary disease.
 Side Effects:- Runny nose, drowsiness, clamminess, chest tightness,
 Monitotior Parameters : APAP levels 4 – 6 hrs , LFTs ,Sr. Cr, PT , INR.

21. 4) INJ. PAN :-
 MOA : -It is a proton pump inhibitor that decreases the amount of acid produced in the stomach by
covalently binding to the H+/K+ ATP pump.
 Uses : As an antacid.
 Side Effects : Altered sense of taste, runny nose, diarrhea, nausea or vomiting, unusual tiredness and
weakness, skin rash, anorexia
 Monitoring Parameters : Serum gastrin levels
5) INJ. ZOFER :-
 MOA:-It works by blocking the action of a chemical messenger (serotonin) in the brain that may cause
nausea and vomiting.
 Uses : To treat nausea and vomiting.
 Side Effects : Headache, Constipation, Injection site pain.
 Monitoring Parameters :-ECG , potassium, magnesium. Monitor for signs of serotonin syndrome and also
monitor for decreased bowel activity.
6) INJ.OPTINEURON:-
 MOA : Optineuron Injection is a combination of six various forms of vitamin supplements:
Thiamine(Vitamin B1), Vitamin B6 (Pyridoxine), Cyanocobalamin, Vitamin B2, Nicotinamide, and D-
Panthenol. Altogether they provide essential nutrients for the proper functioning of organs and
adequate growth of the body.
 Uses : to treat nutritional deficiencies and anemia.
 Side Effects : Diarrhea, Nausea, Sleepiness, Upset stomach
 Monitoring Parameters : Hematocrit, reticulocyte count, vitamin B12, folate, and iron levels must be
monitored

22. 7) TAB.FOLVITE:-
 MOA :- Folic acid stimulates specifically the production of red blood cells, white blood cells, and platelets in
persons suffering from certain megaloblastic anemias .
 Uses : To treat megaloblastic and folic acid deficiency anemia.
 Side Effects :Allergic reaction, bronchospasm, erythema, fever, skin rash or itching.
 Monitoring Parameters : VitB12 and VitB9 levels.
8)INJ. MAGNEX FORTE:-
 MOA :- Cefoperazone exerts its bactericidal effect by inhibiting the bacterial cell wall synthesis, and sulbactam acts as a
beta-lactamase inhibitor, to increase the antibacterial activity of cefoperazone against beta-lactamase-producing organisms.
 Uses : Urinary tract infections, Respiratory Tract Infection, Intra-abdominal Infections , Bacterial Septicemia
 Side Effects:- Itching, Blood in urine, Decrease in blood cell count ,Gastrointestinal side effects.
 Monitoring Parameters:- Hypersensitivity rxns , Renal & Liver function tests.
9)TAB. UDILIV :-
 MOA:- Ursodeoxycholic acid reduces elevated liver enzyme levels by facilitating bile flow through the liver and protecting
liver cells.
 Uses :- Dissolution of cholesterol rich gallstones, Primary biliary cirrhosis , Cystic fibrosis.
 Side Effects:- Back pain, Bloody and cloudy urine , Frequent and/or painful urination.
 Monitoring Parameters:- Hypersensitivity rxns , Renal & Liver function tests.
10)INJ. VIT K:-
 MOA:-Its essential cofactor for the gamma-carboxylase enzymes which catalyze the posttranslational gamma-carboxylation
of glutamic acid . converts inactive precursors into active coagulation factors.
 Uses :- Treat low levels of Blood clotting factors.
 Side Effects:- flushing , injection site pain or discomfort , taste disturbances.
 Monitoring Parameters:- aPTT,PT,INR .

23. GOALS ACHIEVED
 Generalized weakness & fever got Reduced
 No abdominal & Body pains
 patient is symptomatically statble.
MONITORING PARAMETERS :
 Lfts,
 Blood Cloting Factors ,
 Cbc ,
 Electrolytes.
 Look for viral markers.

24. PROBLEMS IDENTIFIED
Ondansetron + lactulose :-
• Bowel cleansing as well as overuse of laxatives (lactulose) may cause
electrolyte loss.
• Irregular heart rhythm .
Therapeutic duplication:-
Maximum number of medicines in the 'GI drugs' category to be taken
concurrently is usually three.
• pantoprazole
• ondansetron
• Lactulose
• Ursodeoxycholic acid

25. ABOUT THE DISEASE:-
 Explain about the severity of the disease
 Mode of transmissions .
 Precautions for avoidance of infection
 Importance of Hygienic conditions to prevent water and food contaminations .
ABOUT THE MEDICATION :
 Parameters specific for each drug must be monitored.
 Follow the medication as per prescription.
 Don’t double the dose.
 If any dose is missed,do not double the dose and use.
 If any ADR’s are seen , report to the physician immediately.

26. LIFESTYLE MODIFICATIONS :
• Do not use anything that will worsen liver damage such as:
• Alcohol
• Medicine—Acetaminophen and other medicines can affect your liver.
Talk to your doctor about medicines, herbs, and supplements you
take.
• Avoid stress as much as possible, and get as much rest as you can.

27. FOODS TO BE TAKEN:-
• Plenty of fruits and vegetables.
• Whole grains such as oats, brown rice, barley, and quinoa.
• Lean protein such as fish, skinless chicken, egg whites, and beans.
• Low-fat or non-fat dairy products.
• Healthy fats like those in nuts, avocados, and olive oil.
• Hiitake and Reisha mushrooms contain a natural form of interferon
FOODS TO BE AVOIDED:-
• Avoid drinking tap water (drink bottled water where possible)
• Avoid having impure ice cubes in your drinks.
• Avoid cleaning your teeth with tap water (contaminated).
• Avoid drinking unpasteurised milk.
• Avoid eating uncooked meat and shellfish