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Abstract: Acute hepatitis E is a relatively common hepatophilic viral infection that occurs mainly in adults, through the gastrointestinal tract or water sources, and is more likely to occur in people who have a habit of eating raw seafood. The patient in this case presented with fever, malaise, poor appetite, and jaundice. After consultation and clinical examination such as physical examination and liver function, the diagnosis of acute hepatitis E was made. After administering symptomatic treatment with drugs, the patient’s condition was stabilized and his symptoms improved, and he was successfully discharged from the hospital.
Basic information】Male, 58 years old
Disease Type】Acute hepatitis E
Hospital】Liaoning Provincial People’s Hospital
Consultation time】March 2019
Treatment plan】Medication (magnesium isoglycyrrhizate injection + polyenophosphatidylcholine injection + compound dichloroacetate diisopropylamine injection + gardenia yellow granules + pantoprazole sodium injection + conversion sugar injection + lactulose oral solution)
Treatment period】16 days of hospitalization
Treatment effect】The patient’s condition was stable and he was discharged successfully
I. Initial consultation
A 58-year-old male came to the hospital with complaints of fever for 7 days, malaise, nausea, loss of appetite for 6 days, and yellow urine for 2 days. The patient complained of fever starting 7 days ago with a maximum temperature of 38.2°C. The following day, he developed malaise, loss of appetite, nausea, vomiting and aversion to greasy food, but he thought it was probably a cold and did not pay attention to it. 2 days ago, he developed yellow urine like strong tea water and came to the hospital for diagnosis and treatment. Laboratory tests showed abnormal liver function and positive IgM antibody to hepatitis E. He was admitted to the department for further isolation treatment as viral hepatitis, acute jaundice type. On examination, the patient’s skin and sclera were found to be mildly yellowish, the liver and spleen were not detected under the ribs, and there was no percussion pain in the liver and kidney area. Auxiliary examination: liver function ALT: 1034.5 U/L; ALP: 268 U/L; GGT: 484 U/L; AST: 292.6 U/L; TBIL: 50.3 umol/L. Urine bilirubin (++).
II. Treatment history
The patient was admitted to the hospital with his explanation of his condition, the need for bed rest, and maintaining a light diet to ensure the intake of nutrients and vitamins. The patient had the habit of eating raw seafood, with acute onset of fever, fever remission, jaundice as the main features, obvious abnormal liver function, positive IgM of hepatitis E antibody, consistent with the characteristics of acute hepatitis virus infection, can exclude drug hepatitis, alcoholic hepatitis, autoimmune liver disease, acute cholecystitis and other diseases. Therefore, the diagnosis of acute hepatitis E was clear. Subsequently, magnesium isoglycyrrhizate injection, polyenyl phosphatidylcholine injection and compound dichloroacetate diisopropylamine injection were given as sedative doses for liver preservation and enzyme lowering treatment; and gardenia yellow granules were given orally to dispel yellowing. As the patient was admitted to the hospital with obvious digestive symptoms and little food intake, pantoprazole sodium injection was given as a sedative to suppress gastric acid and protect gastric mucosa, and converted sugar injection was given as a sedative to supplement calories and ions.
III. Treatment effect
After 2 days of hospitalization, the patient returned a critical value of blood ammonia: 95.6 umol/L, but there was no change in mental status and flutter-like tremor was negative. The elevated blood ammonia was consistent with the characteristics of acute viral hepatitis, and lactulose was given orally to acidify the intestinal environment and reduce blood ammonia to prevent the occurrence of hepatic encephalopathy. After symptomatic treatment of liver protection, enzyme lowering and blood ammonia lowering, the patient’s jaundice was not elevated, symptoms improved and entered the recovery period, the blood ammonia was normal on recheck (25.7 umol/L), liver function improved, glutamate transaminase was normal, to prevent ALT rebound after stopping the drug, magnesium isoglycyrrhizate was reduced, after 16 days of treatment, the patient’s condition was stable and discharge was granted.
(Blood ammonia check)
IV. Notes
I am glad that the patient’s condition improved and recovered after the combination of drugs. We informed the patient that the incubation period of acute hepatitis E is generally 40 days, and the isolation period is from the day of onset to the 3rd week. The patient is now more than 3 weeks old and basically non-infectious, and was released from isolation. Although the liver function is basically normal, but still in the recovery period, which can last 1-2 months, so the patient still needs to pay attention to rest and light diet within 2 months after discharge. Since the peak of acute hepatitis E usually occurs in spring and winter, and most of the disseminated cases are caused by unclean diet, the patient is advised to change the bad habit of eating raw seafood and uncooked food. After returning home, the patient still needs to take oral liver-protective drugs, such as silymarin capsules, otherwise there is still a risk of liver function abnormalities again.
V. Personal insight
Hepatophilic viruses are various viruses that mainly cause inflammatory damage to the liver, including hepatitis A, B, C, D, E and G viruses in a narrow sense, and cytomegalovirus, EBV, herpes simplex virus, rubella virus and yellow fever virus in a broad sense. While hepatitis A and E are mainly manifested as acute infections, hepatitis A is mostly seen in children and hepatitis E is mostly seen in adults, and pregnant women have a higher rate of death after infection. When liver function is impaired, the ability of the liver to remove ammonia decreases, which can lead to elevated blood ammonia, mostly occurring in heavy hepatitis and suggesting the presence of hepatic encephalopathy. Although this patient had elevated blood ammonia, indicators such as jaundice and coagulation function did not support the diagnosis of heavy hepatitis, and after giving symptomatic treatment to lower blood ammonia, the blood ammonia returned to normal.