Hepatitis A

Task 1.

Patient, 16 years old, became ill acutely 18.11, when headache, weakness, aching muscles appeared, body temperature increased to 38. The patient took antipyretics, but the fever persisted at 38 – 39, , nausea and heaviness in the right hypochondrium joined. She called the district doctor, who diagnosed "acute respiratory disease", prescribed drinking plenty of fluids, aspirin. Health continued to deteriorate: on the 3rd day of illness appetite disappeared, there was a two-time vomiting consisted of eaten food. On the 4th day of illness the color of the urine has changed (it got the color of the beer). The doctor was called again, who revealed upon examination icteric skin and sclera, enlarged liver (it was palpated at 2-2, 5 cm below the rib cage. No pathology from other organs was revealed. Pulse was 64 per minute wiyhsatisfactory properties, blood pressure 90\60. With the appearance of jaundice patient feltbetter .

From epidemiological anamnesis: in October wasin Sochi, ate in cafeterias, drunkunboiled water.

The patient was hospitalized with the diagnosis influenza with intestinal syndrome

1. Put the preliminary diagnosis.

2. What additional research is needed for clinical diagnosis?

3. Make differential diagnosis

4. Make a treatment plan.

Answers

1. Taking into account the presence of preicteric period, signs of moderate intoxication, lack of appetite, nausea, vomiting, change in urine color, jaundice viral hepatitis , probably HA (considering the acute onset, short preicteric period, data from epidemiological history and young age of the patient) may be suggested.

2. For clinical diagnosis it is necessary to assign biochemical blood analysis (determination of level of bilirubin, ALT and AST), determination anti-HAV Ig M, HBs Ag, anti – H BcoreIgM, anti – HCV.

3. It is necessary to make a differential diagnosis with influenza, food poisoning.

4. Treatment - basictherapy.

Task 2.

The patient, 26 years old, feels bad for 3 weeks: complains on weakness, pain in the joints of the hands and feet, loss of working capacity. In the beginning of the disease she noted the appearance of itchy rash on the trunk and extremities. The patient came to the dermatologist, who diagnosed "allergic reaction". She took Suprastinum and rash disappeared. However, the weakness was growing, periodically there was nausea, appetite decreased. In recent days, urine darkened, the patient slept badly, she had dizziness, surrounding people noticed the icteric color of the skin. She went to the therapist. She was hospitalized to the infectious hospital with the diagnosis "viral hepatitis". It was found out that 2 months ago the patient had got a piercing in the umbilical region at home.

On admission to the hospital: the patient's condition is heavy , she is in consciousness but sluggish, inhibited, has dizziness, flashing "flies" before the eyes, nausea, vomiting, bleeding gums ,nose was bleeding. Jaundice is a bright, hue isochrany. There are hemorrhages on the skin . Body temperature is 36, 6. cardiactones are rhythmical, clear. Pulse - 104 per minute with satisfactory properties, blood pressure 90\60 .In the lungs there is vesicular breath sound. Tongue is coated, moist. The abdomen is soft, painful in the right hypochondrium. The liver is palpated at the edge of the costal arch, soft, upper edge is at the level of 7 ribs. The spleen is not palpable.

Aimed at hospitalization with a diagnosis of " Hepatitis A, severe course".

1. Make the diagnosis.

2. Rate the severity of the patient.

3. Make a plan of the investigation.

4. Assign treatment.

Answer.

1. Acute viral hepatitis b, icteric form, severe course. The basis for diagnosis – gradual onset, long preicteric period of mixed type, rash in preicteric period, deterioration with the appearance of jaundice, the data of anamnesis ( up to 2 months before the onset of clinical symptoms of the disease, the patient pierced the umbilical region at home).

2. The condition of the patient heavy. Talking about this symptoms of intoxication and symptoms of acute hepatic encephalopathy of 1-2 degrees (lethargy, confusion, dizziness, flashing "flies" before the eyes, vomiting), presence of hemorrhage on the skin, bleeding gums, nasal bleeding, increase in size of the liver.

3. It is necessary to conduct blood count, coagulation assessment, including prothrombin index, the definition of markers of viral hepatitis (HBs Ag, anti – H BcoreIgM, anti – HDV IgM, anti - HAV IgM, anti – HCV), determination of level of bilirubin, ALT, AST, alkaline phosphatase, holding thymol and sublimate samples, determination of protein fractions blood acid-base balance, electrolytes, blood sugar and blood amylase, blood group and RH factor.

4. Treatment – an intensive detoxification therapy (intravenous glucose solution, crystalloid solutions up to 2 liters per day), sessions of plasmapheresis , administration of proteolysis inhibitors (Aprotinin (gordox, contrical)). Treatment of hemorrhagic syndrome, gastric irrigation with cold solution aminocaproic acid intravenous aminocaproic acid etamzilata (dicynone), intramuscularly vikasola.Mannitol 10% intravenously in a daily dose of 0, 5 – 1 g / kg, furosemide (lasix) 40 – 80 mg intravenously or intramuscularly 1 time per day.Lactulose 30 to 45 ml through a tube or enemas, with an interval of 4 to 6 hours.

Task 3.

Patient, 18 years after the ski run felt weakness, heaviness in the right hypochondrium, noticed yellowness of the skin and sclera and went to the district doctor.

The condition is satisfactory, body temperature is 36,6. Complains on heaviness in the right hypochondrium. The skin and mucous membranes are slightly icteric. In the lungs there is vesicular breath sound, heart tones are clear. Pulse 72 per minute, BP 110\60, the abdomen is soft, sensitive to palpation in the right hypochondrium. The liver was palpated 1 cm below the edge of the costal arch, spleen not palpated. Urine and feces are coloured normally.

From investigation: conjugated bilirubin 4 µmol / l, unconjugated bilirubin - 42 mkmol\l, ALT – 40 IU / l, AST of 36 IU / l, thymol test – 16 ED.

From anamnesis: the patient a year ago had a viral hepatitis

1. Put the preliminary diagnosis.

2. What additional research is needed for clinical diagnosis?

3. Make a plan of the investigation.

4. Make differential diagnosis

1. The lack of preicteric period, the satisfactory condition, enlarged liver, increased unconjugated bilirubin levels, normal aminotransferases , physical activity before the disease suggest Gilbert's syndrome.

2. You need to find out whether patient and his relatives had early episodes of jaundice , if there was any contact with hemolytic poisons.

3. The plan of examination: General blood analysis, determination of osmotic resistance of erythrocytes, the presence of autoantibodies against red blood cells (Coombs test). The determination of markers of viral hepatitis.

4. It is necessary to make a differential diagnosis with viral hepatitis, hemolytic jaundice. Viral hepatitis are characterized by marked increase of transaminases, that were not seen at this patient. Hemolytic jaundice ischaracterized byhyperbilirubinemia, mainly due to the unconjugated fraction, but the color of the skin is lemon-yellow. Acholic feces are not typical. Signs of anemia are detected clinically and laboratory. Hyperenzymemia is not typical. Hemolytic jaundice in the anamnesis and other anamnestic data typical for patients with hemolytic jaundice are also important.

Task 4.

Patient, 60 years old, during the last 6 months began to notice loss of appetite, increasing weakness, itch of the skin, which lately has become unbearable, especially at night. Appetite is reduced.

The patient came to the clinic, was examined (General analysis of blood, urine, biochemical analysis of blood), but as the patient said the pathology had not been revealed. The patient lost 10 kg. By the End of the 6th month of the disease he have noticed the yellowness of the skin and sclera, changed color of urine and feces (dark urine, discolored feces (acholic). The patient returned to the clinic.

He was hospitalized with diagnosis of "viral hepatitis". On admission: state of moderate severity, the jaundice is intense, with greenish tint, multiple traces of scratching on the skin. Heart tones are muffled, rhythmic. Pulse 76 per minute, BP 140\70 mm Hg.St. . In the lungs there is vesicular breath sound. Tongue is coated with white bloom, wet. Abdomen is slightly distended, soft, painless. The liver is palpated at the 1, 5 – 2 cm below the costal region. While palpation of the abdomen in the region of the projection point of the gall bladder a rounded, elastic, painless, floating on palpation formation is defined . The spleen is not palpable.

General analysis of blood: hemoglobin – 120 g / l, erythrocytes 3, 5 10¹² / l, leukocytes – 8, 2 10⁹ / l, eosinophils - 2%, band – 6%, segmented – 68%, lymphocytes 20%, monocytes – 4%, ESR – 38 mm / h.

1.Put the preliminary diagnosis.

2.What additional research is needed to clarify the diagnosis?

3. Make the differential diagnosis.

Answer

1. The tumor choledocho – pancreatic area ( most likely cancer of the pancreatic head). In favor of this diagnosis - gradual onset, weakness, loss of appetite , weight loss, increasing symptoms of cholestasis, itching of skin, jaundice, change in color of urine and feces; objective data – the enlargement of the liver, gall bladder (Courvoisier symptom).

2. General blood analysis, biochemical blood analysis (bilirubin, cholesterol, ALT, AST, ALP, GGT, amylase, glucose), coagulation. Ultrasound examination of abdominal cavity, a surgeon’s consultation.

3. For tumor choledocho – pancreatic area, in contrast to HA, is typical a gradual onset of the disease, the syndrome of "small" signs (weakness, anorexia, weight loss), positive Courvoisiersymptom, symptoms of cholestasis (jaundice, itching, scratching of the skin).

Task 5.

Patient, 52 years old, was admitted in infectious hospital with complaints on paroxysmal pain in the right hypochondrium and epigastric region, nausea, vomiting, lack of appetite, increased body temperature to 38 C. After finishing painattack she noted the appearance of jaundice of skin and sclera, dark urine.

From anamnesis: similar pain attacks occurred repeatedly after taking spicy and oily food. From epidemiological anamnesis: she had no contact with infectious patients. The patient has not leave the city within six months. Two months ago – intravenous and intramuscular injections of drugs concerning hypertension.

On examination: state of moderate severity, body temperature 37, 0 C. Moderate yellowness of the skin, mucous membranes of the mouth and sclera. Tongue is thickly coated with white bloom, dryish. In the lungs there is vesicular breath sound. Heart sounds are muffled, have regular rhythm, heart rate 80 per minute, BP 150\100 mm Hg. art. The abdomen is increased due to the excess subcutaneous fat layer, soft, painful in the upper half. The lower edge of the liver is at costal arch, smooth, sensitive .Positive symptoms of Ortner, Kehr, soreness at the point of the gallbladder. The spleen is not palpable.

Hemogram: leukocytosis 12 10⁹\l, ESR 30 mm\h. The bilirubin was detected in urine.

The patient was hospitalized with the diagnosis "viral hepatitis a".

1. Make the preliminary diagnosis.

2. Make the differential diagnosis.

The answer

1. Cholelithiasis, chronic calculouscholecystitis, acute stage. In favor of this diagnosis is evidenced by the indication in the history and attacks of biliary colic in the past, acute onset, rapid onset of jaundice after the pain attack with fever, nausea, vomiting, tenderness to palpation at the point of the gallbladder, positive symptoms of Ortner, Kehr, leukocytosis, increased erythrocyte sedimentation rate.

2. Differential diagnosis should be with acute viral hepatitis. It is necessary to make biochemical analysis of blood (in case of cholecystitis, is expected bilirubin – transaminase dissociation, a significant increase of cholesterol and alkaline phosphatase) , review radiography (stones in the gall bladder), ultrasound, cholecystography (expansion of the extrahepatic bile ducts, gallbladder with filling defects). The determination of markers of viral hepatitis.

Cholestatic viral hepatitis are characterized by a gradual onset of the disease, long-icteric period, the bright jaundice of skin and sclera, itching, scratching on the body, increasing the level of unconjugated bilirubin, alkaline phosphatase, cholesterol, bilirubinuria, and a decrease ofurobilin in the urine.

Task 6

To the patient, 27 years a district doctor was called. The disease started acutely 4 days ago – there appeared chills, headache, weakness, body temperature rose up to 39, 5; back and calf muscles were aching. On the 2nd day of illness nausea and vomiting appeared. She treated independently – took antipyretics, but the condition did not improve, noted dark urine, itchy skin. She had a nose bleeding , and called the doctor.

Objectively: the condition is quite severe, body temperature 38, 8 C. Moderate yellowness of the skin and mucous membranes, significant injection of the vessels of the sclera, petechiae on the skin of the breast. Palpation of the calf muscles is painful. Pulse is 98 per minute, rhythmic, with satisfactory filling, blood pressure 140\90. The abdomen is soft, painless, liver extends out at 2 cm under the edge of costal arc. There are no meningeal signs.

Epidemiological anamnesis: works as a cleaning woman in the place with a lot of rodents.

The doctor sent the patient to the infectious department with a diagnosis of "viral hepatitis".

1. Make the preliminary diagnosis.

2. Make the differential diagnosis.

3. What laboratory studies should be made to verify the diagnosis?

The answer

1. Acute onset of illness, intoxication, high fever, muscle pain, jaundice, hemorrhagic rash, hepatolienal syndrome, data from epidemiological anamnesis suggests leptospirosis. Hemorrhagic manifestations, and jaundice indicate severe disease.

2. Nausea, vomiting, fever, jaundice, hemorrhagic manifestations, enlargement of the liver and spleen can be observed in leptospirosis and viral hepatitis. But the rapid development of the disease, early appearance of jaundice on the background of high fever, severe scleritis, myalgia, and epidemiological anamnesisare not typical for viral hepatitis.

3. For verification of the diagnosis it is necessary to take a blood test (viral hepatitis is characterized by leukopenia and lymphocytosis, normal or slow ESR, and leptospirosis is characterized by neutrophilic leukocytosis and increased ESR), blood chemistry (in both cases revealed an elevation of transaminases, but with leptospirosis, it is much less pronounced than in viral hepatitis). The investigation of blood for markers of viral hepatitis, the reaction of microagglutination and lysis of Leptospira( from the 2nd week of the disease) should be made. In the analysis of urine leptospirosis is characterized by reduced relative density, revealed proteinuria, microhematuria, cylindruria, cells of renal epithelium.

Task 7.

The patient, 19 years old, student, came to the otolaryngologistof the polyclinic with complaints of weakness, malaise, loss of appetite, pain in the throat when swallowing, discomfort in the neck when turning the head, increased body temperature up to 37, 4 with a small itching of the skin, which appeared in the last 3 days. During the investigation:subicteric mucous membranes was noted, follicular tonsillitis was revealed, posterior cervical and submandibular lymph nodes are increased to 1 – 1, 5 cm and sensitive. The liver extends out at 1sm from a rib edge, pole of the spleen is palpated. The patient was hospitalized to the infectious hospital with the diagnosis "viral hepatitis".

In the emergency department uponthe investigation and study of anamnesis was revealed that the patient noted weakness, chilling, sweating, increased body temperature for 10 days. 3 days ago there was pain in the throat when swallowing, body temperature increased to 38 C. In the last a darkening of the urine and itching of the skin appeared. Within this time the patient twice appealed to the doctor, on whose advice he took aspirin, continued to attend classes at the institute.

On examination subicteric skin and mucous membranes, a small pasty face, increased to 1 – 1, 5 cm and sensitivity posterior cervical and submandibular lymph nodes, follicular tonsillitis, enlargement of the liver (1, -1, 5 cm from under the rib cage), pallerols pole of the spleen were revealed. The doctor of emergency department questioned the diagnosis of viral hepatitis.

Blood test: ALT – 400 IU, AST – 600 IU. Hemogram: leucocytes - 12, 3 109г\l, stab – 10%, segmented – 20%, lymphocytes 62%, monocytes – 8%, ESR – 17 mm / h; among the lymphocytes – 37 cells with light basophilic cytoplasm (atypical mononuclear cells).

1.Do you agree with the doctor of the emergency department? Justify the diagnosis.

2. Suggest a further examination of the patient.

The answer

1. The doctor of the emergency department is right. The presence of jaundice and enlargement of the liver always make think about viral hepatitis and dictate the need for differential diagnosis with other clinical data and laboratory results. In this caseit is the most likely to suggestinfectious mononucleosis. Young age of the patient, the gradual onset of the disease with low-grade fever, increased cervical lymph nodes, joining in the later stages symptoms of angina, the combination of these symptoms with hepatolienal syndrome, dull jaundice, itching of the skin, typicalhemogram (leukocytosis, lymphocytosis, the presence of atypical mononuclear cells), moderate elevation of transaminases are in favor of this diagnosis.

2. The examination plan is primarily dictated by the high probability that the patient has infectious mononucleosis (the General analysis of blood and urine, biochemical blood analysis, the reaction Hoff - Bauer, detection by ELISA of antibodies of class IgM to capsid antigen EBV). Blood testing for serological markers of viral hepatitis and HIV should be taken.

Hepatitis E

Task 1

Patient, 20 years old, resident of the rural areas of Tajikistan, a housewife, 2nd pregnancy, a period of 36 weeks. On 01.10 she was ill, when noted weakness and loss of appetite. During 4 days, the intensity of the symptoms was growing. On the 4th day of illness she got nausea, on the 5th - vomiting after eating, with no relief, dark urine, and jaundice of the skin and sclera. For the first time I went to the doctor and was admitted to hospital on the 6th day of illness (the 1st day of jaundice) of the guide with a diagnosis of "hepatitis B". According to the epidemiological history, once handed over a blood from a finger and veins in the antenatal clinic for 5 mo. till the onset. Over the past two months. there have been cases of hepatitis in the village.

On admission: complaints of weakness, loss of appetite, nausea. Status of moderate severity. Jaundice of skin and the sclera. In the lungs - vesicular respiration. No Shortness of breath. Pulse satisfactory filling, 100 min. Cardiac clear, regular rhythm. BP 115 \ 70 mm Hg Liver 1, 5 - 2 cm below the costal margin. The spleen is not palpable.

Biochemical analysis of blood: hyperbilirubinemia due to direct fraction, elevated liver transaminases in 25 times, reducing prothrombin index up to 35%, normal levels of total protein and albumin. BLOOD ANALYSIS: leukopenia. Urine : norm.

Over the next 3 days after the onset of jaundice symptoms of intoxication continued to grow, vomiting was observed 2-3 times a day, the patient began to complain of pain in the right upper quadrant and epigastric pain. On the 9th day of the onset of the disease appeared, "Liver" breath, melena, hemoglobinuria. On the 10th day of illness marked drowsiness, lethargy, weakness, flapping tremor. Two-time,the patient vomited stomach contents in the form of coffee grounds. On the 11th day of illness occurred premature birth stillbirth, after which the patient's condition deteriorated dramatically - within a few hours gradually lost contact with the patientand was diagnosed as coma, areflexia, decreased liver size (limit of hepatic dullness at 3 cm above the right costal arch) , developed anuria. After 8 hours of delivery, patient died.

1. Express the assumption about the diagnosis and justify it.

2. Conduct a differential diagnosis based on the described clinical and laboratory signs and symptoms of the sequence.

3. What are the complications of the disease leading to death, were with the patient?

4. What therapeutic measures needed to carry out with the patient from the moment of hospitalization?

Answer

1. Taking into account the region of residence of the patient, cases of hepatitis in the village, autumn season, the presence of the syndrome of acute hepatitis (jaundice, liver enlargement, asthenovegetative and dyspeptic syndromes, characteristic changes of biochemical parameters), the development of severe course of the disease in pregnant women (expressed intoxication, signs PEI, cerebral edema, signs of gastrointestinal bleeding), the termination of pregnancy on the background of the disease, deterioration after the termination of pregnancy, the development of renal failure with hemoglobinuria.

2. Diff. diagnosis should be made with the UGA and OGD (including parenteral intervention for 6 months before the illness) heavy currents, sharp FH pregnant women (including 3 trimester of pregnancy). For the presence of viral hepatitis in a patient by the data of epidemiological history, the presence of prodromal period, laboratory signs, deteriorating after abortion. However, there are signs, not specific to hepatitis B and delta heavy currents in pregnancy: abortion until the development of PEI 2 and 3 degrees, hemoglobinuria, renal failure. Unlikely diagnosis of hepatitis B and C, since these nosological forms rarely recorded heavy for a termination of pregnancy. For the hepatitis A is not characterized by a gradual onset of the disease and the deterioration of the appearance of jaundice. For fat pregnant liver steatosis not characterized by the development of PEI after a spontaneous abortion, it is rarely disturbed consciousness. Not characterized by increasing transaminases. The cause of mortality in fat liver steatosis usually a hemorrhagic syndrome (uterine bleeding), the development of DIC - syndrome.

3. Hemorrhagic syndrome, PEI, kidney failure. Lethal outcome was a brain edema.

4. Without waiting for a comprehensive picture of the liver dystrophy (PEI, hemorrhagic syndrome), carry out preventive and curative measures aimed at the preservation of pregnancy (see table "especially obstetric tactics in pregnant women with HE."), The prevention of acute liver disease (use of proteolysis inhibitors - gordoksa, kontrikala ), sessions of plasmapheresis. Required detoxification therapy (intravenous saline and concentrated solutions of glucose), the usage of antiplatelet agents, anticoagulation when starting replacement therapy of fresh frozen plasma donation, complete pain relief in labor, the prevention of postpartum haemorrhage (use of aminocaproic acid, protamine sulfate, etamzilata (datsinona)).

Task 2

The patient, 17 years old, student of 11th grade, a resident of Moscow. Acutely ill 29.09, when there was a slight fever and muscle aches, sore throat, mild headache, decreased appetite, fever up to 38C. On 30.09, morning body temperature was 38, 5 ° C, nausea, dry mouth, appetite was out single night vomiting after eating. On 01. 10 fever continued to 38.8, with the increased fluid intake there was still dry mouth, decreased appetite absent, nausea appeared periodically throughout the day, no vomiting but there was a weakness. On 03.10 (5th day of illness),at morning patient noticed dark urine and jaundice of the sclera. Body temperature was 37, 8 C, the weakness is not growing, with little nausea, there was no vomiting, in the evening appeared jaundiced skin. Relatives were worried and called an ambulance, the patient was hospitalized in the infectious diseases hospital.

When viewed in the office on the 6th day of illness, we mark a significant improvement in health over the past day, he slept quietly at night, at morning was discolored stool, body temperature was normal, there was still a moderate weakness. No Nausea with presence of appetite. On examinationyellowness of the sclera and skin, no rash. No wheezing, respiratory rate 16 per minute. Heart sounds clear, pulse 72 per minute. The mucosa of the oropharynx is not hyperemic, tonsils are not enlarged. The liver is enlarged, peaks at 2 cm from under the costal arch, the spleen is not palpable. Effleurage on the lumbar region waspainlessl. Urinating enough, dark urine.

Epidemiological history: no parenteral interventions over the past 6 months, not sexually active , drug use denied. Chronic diseases are not present,he doesn’t know about the transferred child infections ,3 years ago vaccinated against hepatitis B. The patient is engaged in mountain tourism, 2 months before the disease he went hiking in the Tien Shan, drankunboiled water from rivers and streams after going live in the dormitory in Alma-Ata, I ate in canteens. 3 more people also from a tourist group were hospitalized in the infectious hospital with a variety of diagnoses.