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]

  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]

  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]

  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]

• 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]

  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]

  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%. [msdmanuals.com]

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

• 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. [patients.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]

  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]

  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]

  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]

  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]

• 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]

  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

  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

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

  […] 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]

• 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]

  • HAV has been known as infectious jaundice since 1912. • Acc. To WHO, HAV had many names in the past: • Epidemic hepatitis • Epidemic jaundice • Infectious hepatitis • Catarrhal jaundice • HA and type A hepatitis 14 15. [slideshare.net]

• 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]

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

  […] 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. [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]

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]

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]

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]

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]

What is the prognosis of viral hepatitis? The prognosis of viral hepatitis for most patients is good; however, this prognosis varies somewhat depending on the infecting virus. [medicinenet.com]

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]

The Viral Hepatitis Action Coalition is a public-private partnership developed by the CDC Foundation to help the Centers for Disease Control and Prevention (CDC) make meaningful advances in the prevention, screening, and treatment of viral hepatitis. [cdcfoundation.org]

Latest Blog Posts 5-9-2019 Trump administration secures historic donation of billions of dollars in HIV prevention drugs. 5-9-2019 HHS wants the public to take an active role in helping to develop an inaugural federal action plan for the prevention, diagnosis [aids.gov]

Training Guide No additional events are scheduled at this time CONTACT INFORMATION Viral Hepatitis Prevention Coordinator – 785-776-4779 ext. 7615 Perinatal Hepatitis B Prevention – 785-368-8208 [kdheks.gov]

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2. Ryder SD, Beckingham IJ. Acute hepatitis. BMJ . 2001; 322(7279):151-153.
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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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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.