Title : HAV-ing a Moment
Abstract:
Clinical case: We present a case of a 32-year-old Indian gentleman admitted to a tertiary hospital in the West of Ireland Hospital with a weeklong history of fevers and right upper quadrant pain complicated by the development of clinical jaundice. His past medical history was significant for previously treated Malaria. 3 weeks prior to presentation to our hospital, he travelled from Southern India, spending time in Mumbai before relocating to Ireland. In Mumbai he noted being bitten by numerous mosquitos as well as consuming street food including fresh watermelon.
Initial work up demonstrated thrombocytopenia of 124 x109L (150-400x109L), haemoglobin of 15g/dL (13.0-17.0g/dL) and Bilirubin of 95g/dL (1-21g/dL). Liver function tests were grossly deranged with ALT of 2000 u/L (0-40u/L) and INR of 1.3.
Patient was investigated extensively for Fever in Returning traveller work up. Multiple malaria blood films returned negative and blood cultures remained sterile. HIV, Hepatitis B, C and E were not detected. Leptospirosis, Chikungunya and Dengue serology returned negative. Hepatitis A IgM subsequently returned positive with HAV IgG negative.
Ultrasonography of his abdomen showed a thickened oedematous appearing gallbladder wall consistent with acute acalculous cholecystitis.
The patient clinically and biochemically improved with supportive therapy.
Background: Hepatitis A is the leading cause of hepatitis worldwide. It is an RNA virus which is spread by direct contact with persons who have been infected or by ingesting contaminated water or food, with an incubation period of 14 to 28 days. It occurs sporadically and in epidemics worldwide with a tendency for cyclic recurrence. The virus is endemic in low-income countries where sanitary conditions are poor. Interestingly improved living conditions in certain countries has reduced the incidence of Hepatitis A infection, however, this can lead to more severe disease in susceptible adults who have not acquired immunity in childhood. The changing epidemiology of Hepatitis A sees a higher proportion of symptomatic cases as the average age of infection increases. Mandatory vaccination for high-risk groups is being called for in certain parts of India following outbreaks of Hepatitis A earlier this year.
Acute acalculous cholecystitis is inflammation of the gallbladder without evidence of gallstones. This is a very rare complication of Hepatitis A. The pathophysiology of acalculous cholecystitis during acute viral hepatitis remains unclear.
