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

  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]

  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]

• 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]

  Other viruses can also cause liver inflammation, including cytomegalovirus, Epstein-Barr virus, and yellow fever. [en.wikipedia.org]

• 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]

  Definitsioon: an acute usually benign hepatitis that is caused by a picornavirus (species Hepatitis A virus of the genus Hepatovirus), is marked by fatigue, fever, nausea, vomiting, abdominal pain, darkened urine, and jaundice but may be asymptomatic, [termin.eki.ee]

  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]

  : an acute usually benign hepatitis that is caused by a picornavirus (species Hepatitis A virus of the genus Hepatovirus), is marked by fatigue, fever, nausea, vomiting, abdominal pain, darkened urine, and jaundice but may be asymptomatic, especially [merriam-webster.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]

• 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]

  […] was noted in all patients, hypokalemia in 89%, achlorhydria in 43%, and weight loss in 36%.4 Our patient reported no weight loss and did not have achlorhydria while in the hospital. [mdmag.com]

  […] intestine.[1] Excessive secretion can increase bowel motility and lead to signs and symptoms such as abdominal pain and cramping, severe watery diarrhea, dehydration, flushing of the face, muscle cramps due to low potassium levels (hypokalemia), and weight [rarediseases.info.nih.gov]

• 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]

  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]

  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]

  As the illness develops, the symptoms are: fever jaundice (yellow discolouration of the eyes and/or skin) anorexia (loss of appetite) nausea abdominal discomfort malaise (fatigue, feeling tired) dark urine. [health.govt.nz]

• Anemia

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

  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. [gi.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]

  Certain genetic diseases, such as sickle cell anemia, spherocytosis, thalassemia, pyruvate kinase deficiency, and glucose-6-phosphate dehydrogenase deficiency can lead to increased red cell lysis and therefore hemolytic jaundice. [en.wikipedia.org]

• 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

  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]

  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]

  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]

  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]

• 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]

  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]

  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]

  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]

  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 most people, interferon-ribavirin causes flu-like symptoms with muscular aches, irritability, loss of appetite and depression. Rashes and hair loss also may occur. [ucsfhealth.org]

• Abdominal Pain

  Besides features of viral hepatitis, the presence of typical abdominal pain, high serum amylase, and ultrasound or CT scan features suggested the diagnosis of acute pancreatitis. [ncbi.nlm.nih.gov]

  […] known as "brain fog”), mood swings, depression, anxiety, indigestion, abdominal pain, bloating and itchy skin. [perspectum-diagnostics.com]

• Diarrhea

  […] 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]

  In half of patients, diarrhea is constant; in the rest, diarrhea severity varies over time. About 33% of patients have diarrhea < 1 year before diagnosis, but 25% have diarrhea ≥ 5 years before diagnosis. [msdmanuals.com]

  Case report A 51-year-old Japanese woman presented with the abrupt onset of diarrhea and vomiting. She was in her usual state of health until 5 days prior to admission, when she developed acute diarrhea. [mdmag.com]

  Fluids are often given through a vein (intravenous fluids) to replace fluids lost through diarrhea. The next goal is to slow the diarrhea. Medicines can help control diarrhea. One such medicine is octreotide. [pennstatehershey.adam.com]

  Over-activity of these functions explain the classic symptoms of secretory diarrhea and electrolyte deficiencies 1. [radiopaedia.org]

• 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]

  Hepatitis A is synonymous with "infectious hepatitis," an ancient disease described by Hippocrates and formerly known as epidemic jaundice, acute catarrhal jaundice, and other designations. [pedsinreview.aappublications.org]

• 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]

  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]

  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

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

  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]

  The presence of scleral icterus indicates a serum bilirubin of at least 3 mg/dL. The conjunctiva of the eye are one of the first tissues to change color as bilirubin levels rise in jaundice. This is sometimes referred to as scleral icterus. [en.wikipedia.org]

• 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

  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]

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

  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]

• 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. [gi.org]

  […] disease".[11] Signs and symptoms[edit] The main sign of jaundice is a yellowish discoloration of the white area of the eye (sclera) and the skin. [en.wikipedia.org]

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

• Arthralgia

  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]

  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]

  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]

  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]

  Symptoms of hepatitis A may include fatigue, fever, nausea and vomiting, loss of appetite, abdominal pain, dark urine, pale stools and jaundice (yellowing of the skin and eyes). Some people, especially young children, may not have any symptoms. [immunizebc.ca]

• 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. [gi.org]

  Dehydration Dehydration can cause: thirst dry skin a dry mouth tiredness headaches and dizziness More than 8 out of every 10 people (more than 80%) have dehydration. [cancerresearchuk.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.

• Liver Enzymes Abnormal

  Mild and transient liver enzyme abnormalities can occur in up to 25% of children with varicella 50. [doi.org]

• 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]

Epidemiological features, screening strategies and indications for treatment and monitoring have been explored and commented. [ncbi.nlm.nih.gov]

Therapeutic monitoring recommended during, at the end of treatment, and at a period after end of treatment Hepatitis C No specific treatment for acute HCV. [biomerieux-diagnostics.com]

Prognosis Prognosis is highly variable and is dependent on many factors. In those with benign, surgically resectable tumors, the reported 5-year survival rate is almost 95%. [orpha.net]

These differences impact eligibility for potentially-curative therapy and prognosis. [bmcgastroenterol.biomedcentral.com]

The three major viruses that affect the liver, hepatitis A, B, and C (HAV, HBV, HCV) differ according to mode of transmission, pathology, and prognosis. [healthcommunities.com]

The prognosis for hepatitis A patients is excellent with self-limiting course, and recovery is complete. About 85 percent of people with hepatitis A recover within three months, and almost all recover within six months. [hopkinsmedicine.org]

Roberts, Prognosis of 18 H7N9 Avian Influenza Patients in Shanghai, PLoS ONE, 9, 4, (e88728), (2014). [doi.org]

CONCLUSION: Adie's tonic pupil is benign neuro-ophthalmological disorder of unknown etiology. Most patients commonly present no symptoms and anisocoria is noticed accidentally. [ncbi.nlm.nih.gov]

Further work is needed to confirm this association and to investigate pathophysiologic pathways, potentially advancing etiologic understanding of PD more broadly. © 2017 American Academy of Neurology. [ncbi.nlm.nih.gov]

Most importantly thanks to an enhanced understanding of the pathophysiology of the disease. And also because of developments in diagnostic procedures and improvements in therapy and prevention. [easl.eu]

Further work is needed to confirm this association and to investigate pathophysiologic pathways, potentially advancing etiologic understanding of PD more broadly. [n.neurology.org]

Verner–Morrison syndrome and WDHA syndrome (watery diarrhea, hypokalemia, achlorhydria) (Rom J Morphol Embryol 2017;58:371) ICD coding ICD-10: C7A.8 - other malignant neuroendocrine tumors ICD-10: E16.8 - other specified disorders of pancreatic internal secretion Pathophysiology [pathologyoutlines.com]

"Jaundice associated pruritis: A review of pathophysiology and treatment". World J. Gastroenterol. 21 (5): 1404–13. doi:10.3748/wjg.v21.i5.1404. PMC 4316083. [en.wikipedia.org]

risk assessment for blood product and organ transplants recipients, prevention strategies for severe and chronic VHE, and laboratory test algorithms. [ncbi.nlm.nih.gov]

Hepatitis Updated to 2020 HHS: Action Plan for the Prevention, Care & Treatment of Viral Hepatitis Hepatitis Foundation International Institute of Medicine (IOM): Hepatitis and Liver Cancer National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention [dhss.alaska.gov]

Hepatitis A Prevention Hepatitis A is a vaccine-preventable disease. The hepatitis A vaccine is safe and effective and is usually given in 2 shots with a booster dose six months following the first. [hhs.gov]

Guidance for the Prevention and Control of Hepatitis A Infection. 2009. [biomerieux-diagnostics.com]

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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.
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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.