Case: Prolonged acute hepatitis – is there more to it? Presenter: Abhamoni Baro Moderator: Ashish Bavdekar Panelists: Prakash Vaidya, Harshad Devarbhavi, Seema Alam

1. Prolonged Acute Hepatitis
– Is there more to it?
Dr. Abhamoni Baro
Under Guidance of - Dr. Aabha Nagral
Kasturba Hospital of Infectious Disease,
Mumbai

2. • 9 years old , Female child , BO3CM
• Chief complaints-
1.Fever -15 days
2.Gradually progressive abdominal distension - 5days
3.Altered sensorium-1 day
Past history- no h/o similar illness
Family history- no h/o liver disease
Developmentally- normal

3. Wt- 23 kg(10th centile)
Ht- 130 cms (25th centile)
PR-104 bpm
RR-24/min
BP-110/70 mmHg
Icterus –present
Pedal edema – present
No e/o of any vitamin deficiency
No stigmata of chronic liver disease
P/A-
Hepatomegaly
Firm, Sharp edge
(10 cm span)
Splenomegaly
(just palpable)
Shifting dullness +
CNS- Grade 1
encephalopathy
Chest/CVS- NAD

4. Date 7/6 11/6 17/6 21/6 28/6 5/7 7/6
Hb 9.7 11.2 10.3 9.7 10.3 NH3(v) 260µg/dl
(N -120)
TLC 28710 9660 9500 6500 11700 Na/K 136/3.8
Platelet 1.3L 1L 71000 1L 1.2L BUN/Cr 6/0.2
Bili-T/D 5.8/1.9 5.2/2.4 9/4.6 11.3/4.8 9.1/4.2 10.2/4.6 Ascitic
fluid
800cells/
mm3
L75 / N25
ALT/AST 87/185 240/628 116/293 95/254 141/41 133/319 AF pr 1g/dl
Alk.Pho
s
707 518 279 246 318 346 AF alb 0.4g/dl
T.Pr/Alb 6.2/2 5.9/1.7 7.3/2.3 7.4/2.2 8.1/2.2 8.5/2.2 SAAG 1.6 g/dl
Globulin 4.2 4.2 5 5.2 5.9 6.3 RBS 120mg/dl
INR 1.56 1.68 1.58 1.89 1.74 1.77
Investigations

5. “Acute liver failure”
Infections
Hepatotrophic (A to E)and
Non-hepatotrophic viruses
Drugs
Acetaminophen, Isoniazid,
Antiepileptics, Herbal
Medicine etc.
Metabolic
Autoimmune Indeterminate
HAVIgM- Positive
HBsAg/ HCVantibody/
HEVIgM - Negative

6. Diagnosis : Acute liver failure d/t Hepatitis A
Management- Hepatic drip N-acetyl cysteine IV Cefotaxime
Vitamin K Tab. Furosemide Tab. Aldactone
FFP Susp. Lactulose
Course in the ward-
 Edema and ascites decreased.
 Sensorium normalized
 Icterus –darkened, P/A- firm hepatomegaly
 LFT- no improvement
 CBC-persistent Thrombocytopenia

7. ?Prolonged cholestasis of hepatitis A
USG Abdomen –
Liver-Coarse echotexture (span-10.3cm)
 PV-13mm at porta
 mild splenomegaly (11 cm)
 moderate ascites
IgG- 1650 g/dl
(N <1600)
ANA/ ASMA/ Anti- LKM
negative
? Metabolic
? Autoimmune

8. B/L KF ring
DCT- Negative
Urine –Trace albumin
Ph- 7.29
Hco3-22
Pco2-46
Ceruloplasmin- 7.16 mg/dl
( 30- 65 )
24hr urine copper- 290.6 µg/24 hrs
(N<54)
Esophago-gastro-duodenoscopy - Small oesophageal varices

9. Final Diagnosis
Acute on Chronic liver failure
( hepatitis A superadded on a
Wilson disease cirrhosis)
with portal hypertension
with hypersplenism

10. Treatment-
• Cap. Penicillamine (20mkd)
• Tab. Pyridoxine
• Low copper diet
Follow up-
Duration of
penicillamine
1 month 3month 6month
Bili-T/D 7.5/2.1 4.2/2.4 2.8/1.4
ALT/AST 120/290 75/162 52/105
T.Pr/Alb 8.5/2.5 8.8/2.7 8.8/3.0
INR 1.66 1.5 1.4

11. Review of literature
• Early hepatic form of Wilson Disease go unrecognised
in absence of positive family history
–superadded hepatitis A infection uncovers the disease.
• Hepatitis A infection rarely has a fulminant course.
(0.1-0.4%---Whitington PF et al) with a fatality rate of
0.14 - 2%
- Severity and fatality increases with coexistent Wilson disease.
• Acute hepatitis E with superadded Wilson disease
- A more severe disease.( Kumari et al)
Superadded acute viral insult releases free copper .

12. HAV vaccination
in all children with Chronic liver disease
is advisable.

13. Thank you