Relapsing Cholestatic Acute Hepatitis A

A young white female was hospitalized with one week history of malaise, abdominal pain, vomiting and low grade fever. The patient's daughter had developed hepatitis A after a recent trip to Pakistan. On examination, the patient was icteric with mild right upper quadrant tenderness. Laboratory investigations were significant for an elevated Aspartate Aminotransferase (AST) of 570 U/L and Alanine Aminotransferase (ALT) of 525 U/L with an elevated Alkaline phosphatase and normal bilirubin level. The patient soon became icteric with peak AST level of 4837 U/L and ALT of 4461 U/L on day 3 of hospitalization. Acute viral hepatitis A was diagnosed with positive IgM antibody. Serological tests for viral hepatitis B and C and acute cytomegalovirus and Epstein-Barr infections were negative. Autoimmune and metabolic causes were also ruled out. Imaging studies were negative except for a small lesion likely a hemangioma. The patient was followed closely after her discharge from the hospital. She became progressively more icteric with peak bilirubin levels of 14.7 mg/dl and alkaline phosphatase of 917 U/L at 3 weeks of illness. An abdominal ultrasound was repeated at this time with no new findings. The patient had complained of mild pruritus which responded to antihistamines. Renal function was normal and no coagulopathy was evident. During week 4, her ALT level had reached its lowest point and subsequently increased indicating a possible relapse with a continued cholestatic picture. At week 9, bilirubin levels and alkaline phosphatase remained elevated. Even after 24 weeks of acquiring the illness, though she was asymptomatic, her alkaline phosphatase was mildly elevated at 163 U/L with normal bilirubin. Discussion: Acute viral hepatitis A though uncommon in United States poses a significant risk for American travelers. Nearly 30 million Americans travel to Hepatitis A endemic areas every year. This case illustrates a transmission of the disease to an adult who did not travel out of the country. Hepatitis A follows a benign course in majority of the affected individuals but in 3–20% of cases can follow an atypical pattern with relapses and cholestasis. Extra hepatic manifestations are infrequent unlike Hepatitis B. Though healthy adults tolerate this atypical phase, it could be dangerous in patients with chronic liver disease. With the availability of a highly effective vaccine, this presentation could be avoided.