Use of steroids for prolonged cholestasis secondary to acute Hepatitis A infection

Abstract

Hepatit A is usually a self-limited, asymptomatic infection. However, severe manifestations of hepatitis may occur rarely in adult patients. Here, we present a case of prolonged, relapsed cholestasis secondary to acute hepatitis infection in an adult patient. A 25-year old male patient had been given symptomatic treatment for weakness, abdominal pain, loss of appetite, pruritis, nausea and generalized jaundice. A week later, he had been diagnosed with acute hepatitis A infection. He admitted to our clinic two months after the first episode with complaints of pruritis and jaundice. His laboratory results included a serum alanine aminotransferase (ALT) level of 86 U/L, aspartate transferase (AST) of 91 U/L, total bilirubin of 46.5 mg/dl and direct bilirubin of 33.9 mg/dl. ursodeoxycholic acid (UDCA) therapy was started due to protracted jaundice, severe itching and a marked elevation in bilirubin levels, which was replaced with prednisolone therapy at a dose of 1 mg/kg/day at 12 days. Most of his clinical symptoms resolved with much lower serum bilirubin levels. No clinical or biochemical deterioration was observed after discontinuation of therapy. One year later his general condition was good with no relapse. There are few case reports in literature about the use of corticosteroids for treat­ment of prolonged cholestatic jaundice in patients with hepatitis A infection. Based on our findings, we suggest that this type of therapy may be beneficial for relief of symptoms and improvement of serum biochemistry.

Keywords

• Hepatitis A, prolonged cholestatic hepatitis, hyperbilirubinemia, corticosteroids.

Use of steroids for prolonged cholestasis secondary to acute Hepatitis A infection

Öz

Hepatit A kendi kendini sınırlayan, genellikle asemptomatik seyreden bir enfeksiyondur. Nadiren bazı erişkin olgularda ağır hepatit tablosu görülebilir. Burada tekrarlayan ve uzun sure kolestatik formla seyreden bir olgu sunuldu. Yirmi beş yaşında erkek hasta halsizlik, karın ağrısı, bulantı ve tüm vücutta sararma yakınmaları ile başvurdu. Başvurmadan önce semptomatik tedaviler almış ve bir hafta sonra akut hepatit A tanısı konulmuştu. İlk ataktan iki ay sonra hastanın tekrar kaşıntı ve sarılık şikayeti olduğu için bize başvurmuştu. Başvuruda serum alanin aminoasit transferaz (ALT):86 U/L, aspartat transferaz (AST):91 U/L, T. Bil:46,5 mg/dl, D. Bil:33.86 mg/dl’ idi. Uzun süren sarılık, yoğun kaşıntı ve bilirübin seviyelerinde artma nedeniyle ursodeoxycholic acid (UDCA) tedavisi verildi. Daha sonra tedavi 1 mg/kg/gün prednisolon tedavisiyle değiştirildi. Klinik semptomların çoğu kayboldu ve bilirübin düzeyleri düştü. Bir yıllık takibinde relaps görülmedi. Literatürde kortikosteroit kullanılan uzamış kolestatik tipte sarılıkla seyreden az miktarda hepatit A olguları bulunmaktadır. Bunun, bizim olgumuzda olduğu gibi semptomları giderici ve serum biyokimya değerlerini iyileştirici etkisi olduğu düşünülmektedir

Anahtar Kelimeler

• Hepatit A, uzamış kolestatik hepatit, hiperbilirübini, kortikosteroitler

Kaynakça

1. Michael P. Curry, Sanjiv Chopra. Chapter 115 Acute viral hepa- titis. Mandell Douglas and Bennett Principles and Practice of Infectious Diseases 7th Edition. ogy and prevention in developing countries. World J Hepatol. 2012; 4(3): 68–73.
2. Dökmetaş İ. HAV İnfeksiyonunun Epidemiyoloji ve Patogene- zi. In: Tabak F, Balık İ, Tekeli E, eds. Viral Hepatit 2007. 1. Baskı. İstanbul: Viral Hepatitle Savaşım Derneği, 2007:51- 60. PMid: 16418523 PMCid:1360271.
3. E. R. Schiff. Atypical clinical manifestations of hepatitis A. Vac- cine, vol. 10, supplement 1, pp. S18–S20, 1992.
4. Cuthbert JA: Hepatitis A: old and new. Clin Microbiol Rev 2001;14:38–58.
5. Tosun S. Hepatit A virüs enfeksiyonu. Viral hepatit 2013:217- 246.
6. Robert T. Lapp and Fedja Rochling, “Acute Cholestatic Hepatitis A Virus Infection Presenting with Hemolytic Ane- mia and Renal Failure: A Case Report,” Case Reports in Hepatology, vol. 2013, Article ID 438375, 4 pages, 2013. doi:10.1155/2013/438375
7. N. M. Kemmer and E. P. Miskovsky, “Infection of the liver, hepatitis A,”Infectious Disease Clinics of North America, Vol. 14, pp. 1–11, 2000.
8. S.M.Lemon, “Type A viral hepatitis, ”in Hepatobiliary Dis- eases, J.Prieto, J.Rodes, and D.A.Shafritz, Eds., pp.495– 510,Springer, Berlin, Germany, 1992.

9. Gordon S. C, K. R. Reddy L. Schiff and E. R. Schiff.1984. Prolonged intrahepatic cholestasis secondary to acute hepa- titis A. Ann. Intern. Med. 101:635–637.
10. Yoon EL, Yim HJ, Kim SY, et al. Clinical courses after ad- ministration of oral corticosteroids in patients with severely cholestatic acute hepatitis A; three cases. Korean J Hepatol. 2010 Sep;16(3):329-33. doi: 10.3350/kjhep.2010.16.3.333.
11. Roelofsen H, Schoemaker B, Bakker C, et al. Impaired he- patocanalicular organic anion transport in endotoxemic rats. Am J Physiol 1995;269:G427-434.
12. Ware AJ, Cuthbert JA, Shorey J, et al. A prospective trial of steroid therapy in severe viral hepatitis. The prognostic significance of bridging necrosis. Gastroenterology 1981; 80:219-224.