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ORIGINAL ARTICLE
Year : 2003  |  Volume : 57  |  Issue : 2  |  Page : 71-5
 

Spectrum of acute viral hepatitis and its clinical outcome--a study from Ludhiana, Punjab.


Department of Microbiology, Christian Medical College & Hospital, Ludhiana, Punjab 141 008,

Date of Acceptance03-Dec-2002

Correspondence Address:
H Kaur
Department of Microbiology, Christian Medical College & Hospital, Ludhiana, Punjab 141 008

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PMID: 14514273

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 ¤ Abstract 

This study was carried out to find the etiological spectrum and clinical profile of acute viral hepatitis in Ludhiana. Hepatitis E was encountered most frequently (44.56%) followed by hepatitis B (29.7%), whereas hepatitis D occurred least frequently (0.99%). The age group most commonly affected was 20-30 years(32,67%) followed by 30-40 years (23.76%). Males showed higher incidence as compared to females in the ratio of 62.4:37.6. The most frequent clinical features were anorexia and jaundice. The disease was found to be more common in urban set up(78.2%) than in rural regions (21.8%). Mortality was mainly because of fulminant hepatitic failure. In 1.98% of cases, etiology remained undecided. Total bilirubin and prothrombin time were found to be useful prognostic indicators.


Keywords: Acute Disease, Adolescent, Adult, Aged, Aged, 80 and over, Enzyme-Linked Immunosorbent Assay, Female, Hepatitis, Viral, Human, epidemiology,virology,Human, India, epidemiology,Male, Middle Aged,


How to cite this article:
Kaur H, John M, Pawar G, Ninan J, Verma V. Spectrum of acute viral hepatitis and its clinical outcome--a study from Ludhiana, Punjab. Indian J Med Sci 2003;57:71

How to cite this URL:
Kaur H, John M, Pawar G, Ninan J, Verma V. Spectrum of acute viral hepatitis and its clinical outcome--a study from Ludhiana, Punjab. Indian J Med Sci [serial online] 2003 [cited 2014 Dec 20];57:71. Available from: http://www.indianjmedsci.org/text.asp?2003/57/2/71/11887


Acute viral hepatitis is a diffuse necroinflammatory infection of liver along with various systemic manifestations for a maximum duration of six months. The predominant etiological agents are HAV, HBV, HCV, HDV and HEV. Others like HGV, Cytomegalovirus (CMV), Herpes simplex virus, Epstein Barr virus and Yellow Fever virus account for only 1-2 per cent of all hepatitis causing viruses.[1] Till now six major viruses from Hepatitis A Virus to Hepatitis G Virus have been fully characterized, excluding Hepatitis F virus.

Viral hepatitis is endemic in Ludhiana causing high morbidity and mortality. This study was done to find the etiological profile and clinical outcome of acute viral hepatitis.


 ¤ Materials and methods Top


This study was conducted in Christian Medical College and Hospital, Ludhiana over a period of one year from September Ist, 1999 to August 31st, 2000. A total of 101 cases of sporadic acute viral hepatitis were seen in the inpatient and out-patient departments. The diagnosis of acute viral hepatitis was based on accepted clinical and biochemical criteria.[2] The patients who presented with drug induced hepatitis, cholestatic jaundice of pregnancy, congestive hepatopathy, hepatitis due to severe infection or multisystem failure were not included in this study.

In each case, a detailed history regarding the presenting symptoms and possible risk factors for acquiring viral hepatitis was taken. Liver function tests were done and all the sera were tested by ELISA (Ortho Clinical Diagnostic ELISA Test system 3) for viral hepatitis A to E. The various tests done were - Anti HAV IgM, HBsAg, Anti HCV, Anti HDV IgM, Anti HEV IgM, Anti HBc IgM.

The samples found positive for HBsAg were also screened for HBeAg. The biochemical parameters i.e. bilirubin and aminotransferase were compared in the various groups on admission and were followed up subsequently.


 ¤ Results Top


Acute viral hepatitis was found to be the most common in the age group of 20-40 years. The youngest patient was 13 years old and the oldest was 81 years old. Males were more commonly affected than the females with a ratio of 1.65:1. Out of 38 female patients, 9 were pregnant and all these 9 were found to have acute viral hepatitis E. On the basis of residential background, the disease was found to be more prevalent in urban setup as compared to that in rural areas in the proportion of 3.6:1.[Table - 1] represents the frequency of various clinical signs and symptoms. Icterus was the most frequent sign whereas anorexia was the major presenting complaint followed by Jaundice.

[Table - 2] marks the distribution of various types of hepatitis. Hepatitis E was the most common type followed by Hepatitis B. Hepatitis D refers to hepatitis D being positive in the absence of HBsAg. NBC IgM refers to cases where anti - HBc igM was positive in the absence of detectable HBsAg.

The maximum incidence of acute viral hepatitis was seen from September to December with a peak (16.8%) in December.

The mean serum bilirubin values in various types of acute hepatitis were compared on presentation, first and second follow ups. The highest mean bilirubin on presentation was seen in hepatitis B(18.66) accompanied by a second rise (12.90) during the second follow up. It was lowest in the case of hepatitis C. Mean aminotransferase on presentation was highest in hepatitis B & E combined (2375.00 IU/dl) followed by that in hepatitis A(2240.20 lUdl).

A history of blood -transfusion in the preceding one year was obtained in 5(4.95%) of the cases. Two of these patients developed hepatitis B and hepatitis C each. One patient developed hepatitis E. History of intravenous drug abuse was obtained in two patients, both of whom developed hepatitis B. History of intravenous/intramuscular injections in the last two months was obtained in 55(54.45%) cases.

The outcome in various kinds of hepatitis was studied. Out of a total of 101 cases, 66 patients recovered completely, 13 patients died whereas 22 patients were lost to follow up. The values of mean prothrombin time of the patients who died and those who recovered were 36.40 seconds and 17.87 seconds respectively.


 ¤ Discussion Top


In this study, acute viral hepatitis E has been found out to be the most frequent cause for acute viral hepatitis. The age group most commonly affected by all types of acute viral hepatitis was between 20 to 30 years (32.67% of all cases). Incidence was higher in males as compared to females and peak incidence was seen during December followed by November. Another study by Melnick contributed this to the fact that the infection was probably acquired during late summer months.[3]

The commonest clinical finding was icterus which was present in 93.06% cases, followed by hepatomegaly in 38.61%. Splenomegaly was seen in 12.87% whereas Lednar et al (1985) found splenomegaly in 15% of the cases.[4] The urban population appeared to be more affected by hepatitis especially with respect to hepatitis E where 93.3% of the cases came from an urban background as compared to hepatitis B where only 60% of the cases come from urban background, emphasizing the fact that poor sanitation, overcrowding and sewage contamination are etiological factors in the spread of HEV infection.[5]

Such a high proportion of acute viral hepatitis E has been consistent with other studies done in North India.Tandon et al[6] reported non-A non- B hepatitis viruses to be the cause for 44% of sporadic acute viral hepatitis in adults. More recently, in a five year study on sporadic acute viral hepatitis by Rana et al,[7] hepatitis E was found to be the cause of 40% of the cases followed by hepatitis B in 19.7% of the cases. In our study, the frequency of hepatitis A has been found to be 4.95% because hepatitis A is predominantly an infection of childhood. Nearly 96% of school age children of poor socio-economic background and 85% of children with well-to-do background develop anti - HAV antibodies.[8] All the patients with acute viral hepatitis A recovered completely. Out of 49 patients of hepatitis E,45 had hepatitis E alone, whereas 3 patients had hepatitis E in combination with hepatitis B and one patient had hepatitis E & D together. The mortality in hepatitis E was 10.204% (5/49). But Mast and Krawczynski[9] reported it to be 4.0% only. Out of those 5 patients who died only one was pregnant. In this study, four cases were found to be anti HBc IgM positive, however negative for HBsAg. A similar finding was noticed by Kryger et al.[10]

In one case, HDV was found positive in the absence of detectable levels of HBsAg. Similar observations were seen by Ghuman and Suchitra[11] and DeCock et al.[12] The extrahepatic manifestations of acute hepatitis B like arthralgia and rash were noticeably rare. The biochemical recovery or normalization of the serum transferases was slower in hepatitis B than in hepatitis A or E. A transient rise in serum bilirubin was also noticed in patients with hepatitis B on follow up before normalizing.

It was found that the mean total bilirubin in patients who expired was 20.1 mg/dl as against 10.56 mg/dl in patients who recovered. So total bilirubin on presentation can be a predictive parameter for outcome. The mean prothrombin time was also studied in the two categories of outcome. It was seen that in the patients who recovered, the mean prothrombin time was 17.87 seconds as compared to 36.41 seconds in the patients who expired.

 
 ¤ References Top

1.Dienstag JL, Isselbacher KJ. Acute viral hepatitis. In: Principles of Internal Medicine, 14th Ed. Fauci AS, Braunwald E, Isselbacher KJ, Wilson JO, Martin JB, Kasper DL. et al. Ed. New York: McGraw Hill; 1998. p. 1677-92.  Back to cited text no. 1    
2.Khuroo MS. Epidemiology of acute viral hepatitis in Northen India: Role of hepatitis D virus and hepatitis non-A, non-B superinfection. Indian J Gastroent 1989;9:119-20.  Back to cited text no. 2    
3.Melnick J. Properties and classification of hepatitis A virus. Vaccine 1992;10:S24.  Back to cited text no. 3    
4.Lednar W, Lemon S, Kirkpatrick J. Frequency of illnesses associated with epidemic hepatitis A virus infections in adults. Am J Epidemiol 1985;122:226-33.  Back to cited text no. 4    
5.Jyoti Kumar, Aparna NK, Kamachiammal S, et al. Detection of hepatitis E virus. Detection of hepatitis E virus in raw and treated waste water with the polymerase chain reaction. Appl Env Microbial 1993;59:2558-62.  Back to cited text no. 5    
6.Tandon BN, Gandhi BM, Joshi YK. Etiological spectrum of viral hepatitis and prevalence of markers of hepatitis A and B virus infection in North India. Bull World Health Organization 1984;62:67-73.  Back to cited text no. 6  [PUBMED]  
7.Rana SS, Rajan A, Kar P. The spectrum of sporadic acute viral hepatitis in North India: Experience of a tertiary care centre. Indian J Gastroenterol 2000;19:A 31.  Back to cited text no. 7    
8.Thapa BR, Singh K, Singh V, et al. Patterns of hepatitis A and hepatitis B markers in cases of acute sporadic hepatitis and in healthy schoold children from North-West India J Trop Pediatrics 1995;41:328-9.  Back to cited text no. 8  [PUBMED]  
9.Mast E, Krawczynski K. Hepatitis E: An overview, Annual Rev Med 1996;47:257-66.  Back to cited text no. 9    
10.Kryger P, Aldershvile J, Mathiesen LR, et al. Acute type B hepatitis among HBcIgM. Hepatology 1982;2:50-4.  Back to cited text no. 10    
11.Chuman HK, Suchitra SK. Acute delta hepatitis without circulating HBsAg in blood - A case report. J Infect 1992;25:317-8.  Back to cited text no. 11    
12.DeCock KM, Govindrajan S, Redeker AG. Acute delta hepatitis without circulating HBsAgA case report. Gut 1985;26:212-4.  Back to cited text no. 12    


Tables

[Table - 1], [Table - 2]

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