The clinical picture of acute viral hepatitis is variable and is dependent on the type of the virus and the individual circumstances [1]. This is often a self-limiting disease as a majority of patients will exhibit no/mild symptoms [2]. However, a few may develop a rapid onset of fulminant liver failure.

There are 4 phases of viral hepatitis. In the viral replication stage, the infection is not clinically apparent although the serology is positive. This is followed by the prodromal period, which is characterized by acute manifestations such as fatigue, malaise, fever, anorexia, nausea, emesis, abdominal pain, urticaria, and arthralgia. In the icteric phase, the patients develop jaundice, gastrointestinal disturbance, dark urine, gray-colored stools, right upper quadrant pain, and hepatomegaly. Finally, recovery of the symptoms and liver enzymes occurs in the convalescence stage.

Complications

Patients with HBV and HCV can cause chronic infection, cirrhosis, and hepatocellular carcinoma [3].

Physical exam

Assessment of the patient may yield remarkable findings such as jaundice, scleral icterus, and an enlarged and tender liver.

• Splenomegaly

  Mild splenomegaly occurs in 15 to 20% of patients. Jaundice usually peaks within 1 to 2 weeks. Recovery phase: During this 2- to 4-week period, jaundice fades. Appetite usually returns after the first week of symptoms. [msdmanuals.com]

  SIGNS AND SYMPTOMs • Loss of appetite, • Dyspepsia, • Abdominal pain • Gen. aching malaise and weakness • Jaundice • Light-colored stools and dark urine • Hepatomegaly and splenomegaly • Enlarged posterior cervical lymph nodes www.facebook.com/notesdental [slideshare.net]

• Generalized Lymphadenopathy

  GIANOTTI SYNDROME (Infantile papular acrodermatitis):Papular skin eruptions with generalized lymphadenopathy in children under eight years. [meddean.luc.edu]

• Fever

  Abstract A typhoid patient presenting with fever and jaundice is reported. Investigations revealed that the patient had both typhoid fever and acute viral hepatitis A. [ncbi.nlm.nih.gov]

• Fatigue

  Not everyone will have symptoms when they are first infected, but symptoms of acute (newly acquired) hepatitis include: Fever Fatigue Loss of appetite Nausea Vomiting Abdominal pain Headache Diarrhea Clay-colored stools Joint or muscle pain Dark urine [dph.georgia.gov]

  Symptoms Symptoms may include fever, weakness, fatigue, loss of appetite, nausea, vomiting, and jaundice (yellowish eyes and skin, dark urine and pale-coloured faeces). [hepvic.org.au]

  The most frequently reported symptom was fatigue (73.7%), and the most common complications were cholecystitis (0.4%) and fulminant hepatitis (0.4%). The median hospital stay was 9 days (range 1-373). [ncbi.nlm.nih.gov]

  HCV or HBV carriers may exhibit the following symptoms: Fever Fatigue Decreased appetite Nausea Vomiting Abdominal pain Dark urine Grey-coloured faeces Joint pain Jaundice An in vitro laboratory diagnostic test is therefore crucial to confirm a diagnosis [roche.com]

• Weight Loss

  As a result, almost all children are only treated with older pegylated interferon regimens, which often have severe side effects including stunting growth, influenza-like symptoms, anaemia and weight loss, and do not always cure the virus. [thedailystar.net]

  The symptoms are similar to mild flu, and may include: diarrhea fatigue loss of appetite mild fever muscle or joint aches nausea slight abdominal pain vomiting weight loss jaundice The acute phase is not usually dangerous, but in certain people, it can [medicalnewstoday.com]

• Malaise

  She was admitted to the hospital with a history of general malaise and nausea of 5 days duration. Her serum showed high transaminase levels and positive HBs-Ag and increased IgM HBc-Ab titers. [ncbi.nlm.nih.gov]

  Clinically, constitutional symptoms along with malaise, fatigue, and anorexia may be present. [pathwaymedicine.org]

  RECOMMENDED CASE DEFINITION Clinical description Acute illness typically including acute jaundice, dark urine, anorexia, malaise, extreme fatigue, and right upper quadrant tenderness. [helid.digicollection.org]

  Characteristic of viral hepatitis are anorexia, malaise, headache, pain over the liver, fever, jaundice, clay-colored stools, dark urine, nausea and vomiting, and diarrhea. [medical-dictionary.thefreedictionary.com]

  In contrast, most older children and adults have typical manifestations of viral hepatitis, including anorexia, malaise, fever, nausea, and vomiting; jaundice occurs in over 70%. [merckmanuals.com]

• Anemia

  The interferons have side effects, which include anemia, depression, and other problems and while they are a recommended therapy, are much less commonly used in the United States than the oral medications. [patients.gi.org]

  At Mayo Clinic, we reported two cases of a less severe form of hepatitis-associated aplastic anemia 79. [doi.org]

  Laboratory examinations of blood revealed anemia (hemoglobin 11.1 g/dL), hypokalemia (K 2.4) and acidosis (pH 7.32). Fecal culture and intestinal parasites study were negative. [scielo.isciii.es]

  HEMOPOIETIC SYSTEM: aplastic anemia (rare).Cryoglobulinemia of mixed type can be seen in hepatitis B infection. [meddean.luc.edu]

• Common Cold

  This virus family also includes enteroviruses, such as poliovirus and rhinoviruses, which are frequent causes of the common cold. [academic.oup.com]

• Nausea

  She was admitted to the hospital with a history of general malaise and nausea of 5 days duration. Her serum showed high transaminase levels and positive HBs-Ag and increased IgM HBc-Ab titers. [ncbi.nlm.nih.gov]

  Symptoms Symptoms may include fever, weakness, fatigue, loss of appetite, nausea, vomiting, and jaundice (yellowish eyes and skin, dark urine and pale-coloured faeces). [hepvic.org.au]

  Early in the disease, called the prodromal phase, symptoms may include: Fever Joint pain or arthritis Rash Edema (swelling) Symptoms of the next phase, the preicteric phase, include: Fatigue Myalgia (muscle pain) Anorexia Nausea and/or vomiting Fever [hopkinsmedicine.org]

  Common symptoms include: Feeling tired Discomfort or an ache over the liver Nausea Viral Hepatitis Diagnosis The diagnosis of viral hepatitis begins with blood tests for liver enzymes, such as an aspartate aminotransferase (AST) test and/or an alanine [uofmhealth.org]

  Soda, juices, and hard candy may help reduce nausea. Follow your doctor’s instructions for medicines to take to relieve your symptoms. As your symptoms improve, you may gradually increase your level of activity. [hepatitiscentral.com]

• Vomiting

  Symptoms Symptoms may include fever, weakness, fatigue, loss of appetite, nausea, vomiting, and jaundice (yellowish eyes and skin, dark urine and pale-coloured faeces). [hepvic.org.au]

  […] and feet, reduction in sexual desire and potency in men, malodorous smell, oily diarrhea, emergence of dead blood cells under skin, irritation and bloody vomit [17]. [intechopen.com]

  Early in the disease, called the prodromal phase, symptoms may include: Fever Joint pain or arthritis Rash Edema (swelling) Symptoms of the next phase, the preicteric phase, include: Fatigue Myalgia (muscle pain) Anorexia Nausea and/or vomiting Fever [hopkinsmedicine.org]

  Affected people may have a poor appetite, nausea, vomiting, fever, pain in the upper right part of the abdomen, and jaundice. Doctors do a physical examination and take blood samples to analyze. Vaccines can prevent hepatitis A, B, and E. [merckmanuals.com]

  Not everyone will have symptoms when they are first infected, but symptoms of acute (newly acquired) hepatitis include: Fever Fatigue Loss of appetite Nausea Vomiting Abdominal pain Headache Diarrhea Clay-colored stools Joint or muscle pain Dark urine [dph.georgia.gov]

• Loss of Appetite

  Symptoms Symptoms may include fever, weakness, fatigue, loss of appetite, nausea, vomiting, and jaundice (yellowish eyes and skin, dark urine and pale-coloured faeces). [hepvic.org.au]

  Not everyone will have symptoms when they are first infected, but symptoms of acute (newly acquired) hepatitis include: Fever Fatigue Loss of appetite Nausea Vomiting Abdominal pain Headache Diarrhea Clay-colored stools Joint or muscle pain Dark urine [dph.georgia.gov]

  In healthy individuals, it causes an acute illness with fever, loss of appetite and jaundice lasting two to three weeks. Complete recovery is the rule, followed by life-long immunity to the virus. [ucsfhealth.org]

  Possible symptoms may include, tiredness, abdominal pain, loss of appetite, feeling and being sick and jaundice (yellowing of the whites of the eyes and skin). [perspectum-diagnostics.com]

• Abdominal Pain

  This case report, along with the review presented, describes a patient diagnosed with acute viral hepatitis, who developed a framework of intense abdominal pain and laboratorial alterations compatible with acute pancreatitis. [ncbi.nlm.nih.gov]

• Diarrhea

  In older cattle bovine virus diarrhea (mucosal disease) is the major cause. [medical-dictionary.thefreedictionary.com]

  Not everyone will have symptoms when they are first infected, but symptoms of acute (newly acquired) hepatitis include: Fever Fatigue Loss of appetite Nausea Vomiting Abdominal pain Headache Diarrhea Clay-colored stools Joint or muscle pain Dark urine [dph.georgia.gov]

  […] the prodromal phase, symptoms may include: Fever Joint pain or arthritis Rash Edema (swelling) Symptoms of the next phase, the preicteric phase, include: Fatigue Myalgia (muscle pain) Anorexia Nausea and/or vomiting Fever Cough Abdominal pain and/or diarrhea [hopkinsmedicine.org]

  Others may have Loss of appetite Nausea and vomiting Diarrhea Dark-colored urine and pale bowel movements Stomach pain Jaundice, yellowing of skin and eyes Some forms of hepatitis are mild, and others can be serious. [medlineplus.gov]

  […] along with metabolic acidosis and hypokalemia may prompt investigation for VIPoma • Severe secretory diarrhea, elevated serum VIP level and pancreatic mass suggests diagnosis • Patients who complain of severe diarrhea must be evaluated carefully for [accesssurgery.mhmedical.com]

• Jaundice

  Jaundice is a rare clinical presentation in typhoid fever, therefore hepatitis A should be considered in typhoid fever and jaundice because both enterically transmitted disease may simultaneously occur. [ncbi.nlm.nih.gov]

  Icteric phase: After 3 to 10 days, the urine darkens, followed by jaundice. Systemic symptoms often regress, and patients feel better despite worsening jaundice. [msdmanuals.com]

• Hepatomegaly

  Three patients presented only jaundice and hepatomegaly; one also had liver failure. All the four patients underwent bone marrow aspiration which showed bone marrow aplasia. [ncbi.nlm.nih.gov]

  In the icteric phase, the patients develop jaundice, gastrointestinal disturbance, dark urine, gray-colored stools, right upper quadrant pain, and hepatomegaly. Finally, recovery of the symptoms and liver enzymes occurs in the convalescence stage. [symptoma.com]

  •Affects liver functions- hyperbilirubinaemia-jaundice •Inflammation of liver-hepatomegaly-pressure effects on other organs. 37 37. [slideshare.net]

  Rare manifestations of CMV hepatitis include tender hepatomegaly, granulomatous hepatitis, anicteric or icteric cholestatic hepatitis, and acute hepatitis with massive necrosis. Figure 2. Massive hepatic necrosis due to Hsv-1. [doi.org]

• Scleral Icterus

  Icteric Phase During this phase clinical signs of jaundice and scleral icterus will appear and some right upper quadrant tenderness may develop due to enlargement of the liver. [pathwaymedicine.org]

  Physical exam Assessment of the patient may yield remarkable findings such as jaundice, scleral icterus, and an enlarged and tender liver. [symptoma.com]

• Hepatosplenomegaly

  Hepatosplenomegaly and laboratory evidence of mild to moderate hepatic dysfunction are the predominant features, with increased aminotransferases and alkaline phosphatase in 88% and 64% of cases, respectively, but lower than commonly encountered in active [doi.org]

• Urticaria

  Skin signs of acute viral hepatitis Acute urticaria is commonly observed in patients with viral infections, including HAV, HBV and HCV. [dermnetnz.org]

  Occasionally, especially with hepatitis B, infected people develop joint pains and itchy red hives on the skin (wheals or urticaria). [merckmanuals.com]

  This is followed by the prodromal period, which is characterized by acute manifestations such as fatigue, malaise, fever, anorexia, nausea, emesis, abdominal pain, urticaria, and arthralgia. [symptoma.com]

• Yellow Discoloration of the Skin

  The most notable symptom of acute viral hepatitis is jaundice, which is a yellow discoloration of the skin and the whites of the eyes. Patients also usually complain of vague upper abdominal pain. [patients.gi.org]

  discoloration of the skin and the whites of the eyes ( jaundice ). [labtestsonline.org]

• Arthralgia

  Shed HBsAg can form immune complexes that can then deposit in multiple tissues causing certain glomerular pathologies, skin rash, and arthralgia. Gross Appearance The liver may be enlarged and slightly reddened. [pathwaymedicine.org]

  This is followed by the prodromal period, which is characterized by acute manifestations such as fatigue, malaise, fever, anorexia, nausea, emesis, abdominal pain, urticaria, and arthralgia. [symptoma.com]

  Urticaria and arthralgias occasionally occur, especially in HBV infection. Icteric phase: After 3 to 10 days, the urine darkens, followed by jaundice. Systemic symptoms often regress, and patients feel better despite worsening jaundice. [msdmanuals.com]

  Non-specific or absent symptoms (90% of cases): pain in right hypochondrium - fever nausea and vomiting - arthralgia urticaria Specific symptom ( 10% of cases) 4 : icterus (jaundice) Severe form: fulminant hepatitis clinical signs: hepatic encephalopathy [biomerieux-diagnostics.com]

• Myalgia

  Early in the disease, called the prodromal phase, symptoms may include: Fever Joint pain or arthritis Rash Edema (swelling) Symptoms of the next phase, the preicteric phase, include: Fatigue Myalgia (muscle pain) Anorexia Nausea and/or vomiting Fever [hopkinsmedicine.org]

  Myalgia. Sleep disturbance. Depression. Weight loss. Alopecia. Skin rash. Fatigue. Headache. Arthralgia. Lamivudine Lamivudine is a nucleoside analogue that inhibits viral DNA replication. [pmj.bmj.com]

  The most common reported side effects are pain and erythema at the injection site, transient low-grade fever, headache, malaise and myalgia. [clinicaladvisor.com]

• Dark Urine

  Symptoms Symptoms may include fever, weakness, fatigue, loss of appetite, nausea, vomiting, and jaundice (yellowish eyes and skin, dark urine and pale-coloured faeces). [hepvic.org.au]

  Not everyone will have symptoms when they are first infected, but symptoms of acute (newly acquired) hepatitis include: Fever Fatigue Loss of appetite Nausea Vomiting Abdominal pain Headache Diarrhea Clay-colored stools Joint or muscle pain Dark urine [dph.georgia.gov]

  HCV or HBV carriers may exhibit the following symptoms: Fever Fatigue Decreased appetite Nausea Vomiting Abdominal pain Dark urine Grey-coloured faeces Joint pain Jaundice An in vitro laboratory diagnostic test is therefore crucial to confirm a diagnosis [roche.com]

  urine and light stool color During the icteric phase : Jaundice (yellowing of the skin and whites of the eyes) develops Anorexia, nausea and vomiting may worsen Irritated skin lesions may develop Other symptoms may subside Hepatitis A and E Diagnosis [hopkinsmedicine.org]

• Headache

  She complained of blurred vision and headache mainly while reading. She had a 35-year history of hepatitis B and liver cirrhosis. [ncbi.nlm.nih.gov]

  Not everyone will have symptoms when they are first infected, but symptoms of acute (newly acquired) hepatitis include: Fever Fatigue Loss of appetite Nausea Vomiting Abdominal pain Headache Diarrhea Clay-colored stools Joint or muscle pain Dark urine [dph.georgia.gov]

  Characteristic of viral hepatitis are anorexia, malaise, headache, pain over the liver, fever, jaundice, clay-colored stools, dark urine, nausea and vomiting, and diarrhea. [medical-dictionary.thefreedictionary.com]

  The symptoms of acute viral hepatitis can include low-grade fever, headaches, muscle ache, tiredness, loss of appetite, nausea, vomiting, diarrhea, dark-colored urine or light-colored stools. [patients.gi.org]

The workup consists of the assessment of the clinical presentation, history and risk factors, physical examination, and the pertinent tests.

Laboratory tests

Patients suspected to have viral hepatitis should undergo serology studies to determine the presence of antibodies to the virus. Interpretation of serology markers takes into account differentiation between acute and chronic infection as well as what constitutes an immune status. Also, the clinician must consider the window period for the specific viral subtypes.

Hepatitis A

An acute infection with HAV is associated with immunoglobulin M (IgM) anti-HAV antibodies [4], which persists for a few months whereas immunoglobulin G (IgG) antibodies reflect a history of infection.

Hepatitis B

Diagnosis of hepatitis B is based on numerous markers. An acute infection is represented by the detection of HBsAg, anti-HBc (total- IgM and IgG antibodies), IgM anti-HBc, and negative anti-HBs [5].

Chronic hepatitis B infection is characterized by the presence of HBsAg that has persisted for more than 6 months [4], positive anti-HBc (total), and negative IgM anti-HBc and anti-HBs [5]. Also, HBV DNA levels are increased [6]. Additionally, alanine transaminase (ALT) and aspartate transaminase (AST) levels are consistently or intermittently elevated [6].

Patients who are immune due to past exposure exhibit negative HBsAg but positive anti-HBc and anti-HBs while those who have received vaccination for hepatitis B demonstrate negative HBsAg and anti-HBc with a positive anti-HBs [5].

Also, HBeAg is present when viral replication is taking place while anti-HBe is detectable when HBeAg subsides.

Hepatitis C

In addition to serology, HCV RNA testing and liver biopsy also helpful for diagnosis of hepatitis C. A reactive HCV antibody test does not determine whether the infection is acute or chronic [7] [8], hence further evaluation with HCV RNA testing is warranted. If the latter is detected, then the infection is currently active [9] [10]. Moreover, liver enzymes should be obtained.

Hepatitis D

This disease is diagnosed with the detection of IgM anti-HDV and IgG anti-HDV.

Hepatitis E

HEV infection is diagnosed by IgM anti-HEV and IgG anti-HEV. Moreover, blood and stool samples may be positive for HEV RNA.

• Hepatocellular Carcinoma

  Abstract Chronic infection with hepatitis viruses represents the major causative factor for end-stage liver diseases, including liver cirrhosis and primary liver cancer (hepatocellular carcinoma, HCC). [ncbi.nlm.nih.gov]

  Keywords Hepatocellular carcinoma Hepatitis B Hepatitis C Viral hepatitis Background Hepatocellular Carcinoma (HCC) is the third leading cause of cancer related mortality worldwide [ 1 ]. [bmcgastroenterol.biomedcentral.com]

• Liver Biopsy

  Background/Aims: The invasiveness of a liver biopsy and its inconsistent results have prompted efforts to develop noninvasive tools to evaluate the severity of chronic hepatitis. [ncbi.nlm.nih.gov]

1. McIntyre N. Clinical presentation of acute viral hepatitis. Br Med Bull. 1990; 46(2):533-47.
2. Ryder SD, Beckingham IJ. Acute hepatitis. BMJ . 2001; 322(7279):151-153.
3. Wasley A, Grytdal S, Gallagher K. Surveillance for acute viral hepatitis--United States, 2006. MMWR Surveill Summ. 2008; 57(2):1-24.
4. Krajden M, McNabb G, Petric M. The laboratory diagnosis of hepatitis B virus. Can J Infect Dis Med Microbiol. 2005; 16(2):65-72.
5. Interpretation of Hepatitis B Serologic Test Results. Centers for Disease Control and Prevention. https://www.cdc.gov/hepatitis/hbv/pdfs/serologicchartv8.pdf. Accessed November 4, 2016.
6. Lin KW, Kirchner DO. Am Fam Physician. 2004; 69(1):75-82.
7. Yuki N, Hayashi N, Ohkawa K, et al. The significance of immunoglobulin M antibody response to hepatitis C virus core protein in patients with chronic hepatitis C. Hepatology. 1995; 22(2):402–406.
8. Irshad M, Mankotia DS, Irshad K. An insight into the diagnosis and pathogenesis of hepatitis C virus infection. WJG. 2013; 19(44):7896-7909.
9. Centers for Disease Control and Prevention. Testing for HCV infection: An update of guidance for clinicians and laboratorians. MMWR. 2013; 62(18):362-5.
10. Klimashevskaya S, Obriadina A, Ulanova T, et al. Distinguishing Acute from Chronic and Resolved Hepatitis C Virus (HCV) Infections by Measurement of Anti-HCV Immunoglobulin G Avidity Index . J Clin Microbiol. 2007; 45(10):3400-3403.