2023/11/25 上午9:34 Course Case Studies - Course #94993: Viral Hepatitis - NetCE

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Course Case Studies

HEPATITIS A
Patient A is 19 years of age and a college sophomore who presented to her physician's office with mild
jaundice. The patient reports being in good health until a week before, at which time she began having flu-like
symptoms of headache, low-grade fever, nausea, loss of appetite, and malaise. She self-treated the fever with
acetaminophen. The symptoms persisted. Upon awakening this morning, she noticed that her eyes were
yellow. She therefore contacted her physician's office.

Patient A has presented with classic signs and symptoms of acute hepatitis. Based on her past history, travel,
and exposure history, the most likely diagnosis is acute hepatitis A infection. The hepatic chemistry profile and
serologic studies confirm this diagnosis. Exposure probably resulted from accidental ingestion of contaminated
water while swimming in the lagoon.

Because acute viral hepatitis is usually a self-limited disease and Patient A is alert with no evidence of
coagulopathy, she can be managed as an outpatient with close follow-up. Liver enzymes and PT should be
monitored every 5 to 7 days for the first two weeks, then, if convalescence is satisfactory, at 14-day intervals
until function test results have returned to normal. Bed rest is not indicated, but the patient should avoid
strenuous activity. She should eat a well-balanced diet and abstain from alcohol for the duration of the illness.
Because acetaminophen can be toxic to the liver, ibuprofen would be a better alternative for controlling fever.
No other alterations in the patient's medications are necessary at this point. If nausea precludes the patient
from ingesting food and fluids, IV replacement of fluids and electrolytes may be necessary. In the event the
patient develops bleeding tendencies or signs of encephalopathy, she should immediately be taken to the
hospital or her physician's office.

Hepatitis A virus is a reportable disease. The health department should be informed of the case immediately.
Because the exposure probably occurred outside the geographical area, follow-up will be limited to those with
similar exposure (i.e., persons who were also on the mission trip) and to her intimate and/or household
contacts. A single dose of HAV immunoglobulin is recommended for close contacts. If immunoglobulin is not
available, administration of hepatitis A vaccine may prevent illness or lessen the severity of the contact's
symptoms if infection does occur. Immunoglobulin is not recommended for those who may have been exposed
on the mission trip, as those exposures occurred more than two weeks prior to the diagnosis. Follow-up with
these persons is primarily to determine if they too are experiencing symptoms and are possible sources of
spreading the disease.

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CASE STUDY 2
In response to her physician's questions, she indicated that her urine has been darker than usual and she has
been experiencing joint pain for the last three days. She also acknowledged that her stools have been lighter
than usual.

Her medical history is positive for mild exercise-induced asthma, for which she uses a prophylactic
bronchodilating inhaler. Her only other routine medication is a daily vitamin/mineral supplement. She reports
no surgeries. Family history is positive for cardiovascular disease (father and both sets of grandparents) and
breast cancer (mother).

Other significant history includes that she was immunized against hepatitis B at 12 years of age and she
recently participated in a two-week mission trip to Central America. Although she was very cautious about the
foods she ingested during the mission trip, the patient indicated that a primary recreational activity after the
day's work was to swim in the lagoon near the village. The lagoon was fed both by the stream in which the
natives washed their clothes and the adjacent bay. Rainfall averaged 2–3 inches per day. Patient A returned to
the United States five weeks ago.

Physical examination revealed a well-developed, well-nourished female who was alert and oriented. Her
temperature was 99.7°F; other vital signs were within normal limits. Abnormal physical findings included mild
icterus of sclera and skin, abdominal tenderness, hepatomegaly, and palpable spleen. Results of laboratory
tests are indicated in Table 2.

PATIENT A LABORATORY TEST RESULTS

Test Patient's Results Normal Value or Range

Hematocrit (Hct) 40% 37% to 47%

Hemoglobin (Hgb) 13.3 mg/dL 12.0–16.0 mg/dL

6200
White blood cell count 4300–10,800 cells/microliter
cell/microliter

Aspartate aminotransferase
323 Units/L 5–40 Units/L
(AST)

Alanine aminotransferase
358 Units/L 5–35 Units/L
(ALT)

Total bilirubin 3.7 mg/dL 0.2–1.6 mg/dL

HBsAg Negative Negative

Positive indicates previous disease or immunization;

Anti-HAV IgM Positive Negative

Anti-HCV antibody Negative Negative

Alkaline phosphatase (ALP) 85 Units/mL 30–115 Units/mL

Prothrombin time (PT) 11.6 seconds Control 10.4 seconds (normal is ±2.0 seconds from control)

Albumin 3.8 mg/dL 3.5–5.5 mg/dL

Glucose 84 mg/dL 70–110 mg/dL

Sodium 142 mEq/L 135–150 mEq/L

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Test Patient's Results Normal Value or Range

Chloride 102 mEq/L 100–108 mEq/L

Potassium 3.8 mEq/L 3.6–4.8 mEq/L

Source: Compiled by Author Table 2

Patient B is a paramedic, 48 years of age. Laboratory work obtained during his annual physical examination
reveals hyperlipidemia; CBC, glucose, BUN, and electrolytes were within normal range. With the exception of
his weight (15 lbs heavier than indicated for his height), his exam identifies no abnormalities.

After two months of a diet and exercise program, his cholesterol level is 256. Therefore, his physician elects to
begin a lipid-lowering agent. A baseline liver profile is drawn prior to initiation of the medication. Because the
patient is in a profession that is high-risk for bloodborne pathogen exposure, an HCV antibody test with reflex
to qualitative HCV RNA is ordered. The liver profile reveals an AST of 226 Units/L and an ALT of 282 Units/L.
HCV antibody and qualitative HCV RNA are both positive.

The physician reviews Patient B's history and medications. He has been a paramedic for 25 years. He was
immunized against HBV in 1988. During his career, he has experienced several exposures to blood (usually
blood splashes, but also two needlesticks from IV needles), most before the advent of Standard Precautions.
His most recent exposure was two years ago. An HIV test six months post-exposure was negative. He does not
recall hepatitis testing being performed at that time.

Patient B's surgical history includes a hernia repair in childhood and removal of skin lesions three times in the
past eight years. He has had no transfusions. He is the widowed father of two teenage children. His wife died
six years ago from ovarian cancer.

The patient has never smoked. He drinks about six beers per week and rarely drinks hard liquor. He denies
any history of illegal drug use. Although the patient has no current prescription medications, he uses several
herbal preparations including garlic, ginkgo, and an antioxidant preparation. The patient takes ibuprofen for
pain, consuming 6 to 10 tablets (200 mg each) per month.

Although alcohol consumption and herbal antioxidants can both cause liver inflammation, the degree of his
liver inflammation is much higher than would be expected from limited use of these two factors. The patient is
diagnosed with chronic HCV infection.

In order to evaluate the extent of liver damage and determine an appropriate treatment plan, the physician
orders an HCV RNA quantitative PCR and genotype as well as a PT. A gastroenterology specialist is consulted
for further evaluation and possible liver biopsy and to co-manage the patient. The PT is within normal range.
The liver biopsy reveals chronic inflammatory infiltration of the portal areas with minimal fibrosis. Genotype
identifies the virus as type 3. HCV RNA viral load is 350,000 phages/cc.

Treatment options appropriate for HCV genotype 3, and the timing of therapy in relation to biopsy findings and
anticipated progression of disease are discussed with Patient B. He is advised to eat a nutritious, balanced diet
and abstain completely from alcohol. Although he is not currently sexually active, the patient is educated about
the low but present risk of sexual transmission of HCV and how to minimize the risk of transmission. A test for
HAV antibody is found to be negative. Immunization against HAV is also recommended, as acquiring an acute
case of HAV in a patient with pre-existing chronic hepatitis can be much more serious that either condition
alone. Because of uncertainty as to how recently he acquired the infection, the decision is made to defer
treatment for three to four months while monitoring the course of the infection.

Four months after the initial diagnosis, there has been no improvement in Patient B's liver function tests: the
ALT is 356 Units/L and AST is 418 Units/L. The HCV RNA remains detectable in the blood, and the viral load
has increased to 450,000 phages/cc. He is advised to begin antiviral treatment; therapeutic options are
discussed in relation to efficacy, potential drug interactions, and cost reimbursement priorities, bearing in mind

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that he is a treatment-naïve patient with no evidence of cirrhosis. The recommended course of therapy is the
12-week, two-drug oral regimen of sofosbuvir (400 mg) and velpatasvir (100 mg) for a duration of 12 weeks
(reported SVR rate: 95% in clinical trials for genotype 3).

On treatment, the patient experiences transient nausea and persistent mild fatigue, but is compliant with the
recommended duration of therapy. At 12 weeks, the ALT and AST are both within normal range and HCV RNA
is undetectable. Treatment is discontinued and Patient B is asked to return in three months, six months, and
one year after cessation of therapy to repeat HCV viral load and confirm a sustained virologic response.

HIV AND CHRONIC HBV COINFECTION

During his first visit, the patient indicates that he injected drugs off and on beginning at 19 years of age. His first
two experiences with rehabilitation failed, but he has been "clean" for two years, since his best friend died of
an overdose. He reports that he also snorted cocaine occasionally during the years he used injected drugs.

The patient's medical history includes a hospitalization for a motorcycle accident at age 24, with surgery on his
right leg both on that admission and again about a year later. He received 2 units of blood during the first
admission. The patient denies a history of heart disease, neurologic disorders, or endocrine disorders. He has
had pneumonia both in adolescence and again last year.

The patient's parents are living and in good health. Grandparents all have hypertension, and maternal
grandmother has type 2 diabetes. The patient smokes 1/2 to 1 pack of cigarettes per day and consumes two or
three drinks per day. The patient's current medications include acetaminophen or ibuprofen as needed for leg
pain and paroxetine for anxiety and depression.

Physical examination reveals no acute distress. Vital signs are within normal limits, and sclerae are non-icteric.
Oral cavity is free from thrush and leukoplakia. Cervical lymph nodes are palpable but moveable and
nontender. Heart sounds are normal; lungs are clear. Abdomen is soft; both liver and spleen are palpable.
Neurologic exam is normal. The patient has full function in upper extremities and left leg; right leg has a slight
decrease in strength and a moderate decrease in range of motion.

Initial laboratory tests ordered by the nurse practitioner (NP) include an HIV PCR viral load, a CD4 count, a CBC,
a chemistry panel, and a liver profile. Because of the high incidence of HCV and/or HBV coinfection in persons
whose HIV was acquired percutaneously, the NP also orders a hepatitis profile. Baseline tuberculosis testing is
also recommended for persons with HIV who are entering care. Therefore, a T-SPOT interferon gamma release
assay is also ordered. The patient is instructed to return in 72 hours to review lab results and formulate a
treatment plan.

Upon his return, all results except the HIV PCR are available. His CD4 count is 246. Hematocrit is 44%,
hemoglobin 15 gm/dL, and WBC is 3,800. The liver profile reveals an alkaline phosphatase of 143 Units/mL,
AST 358 Units/L, ALT 383 Units/L, total bilirubin 1.2 mg/dL, and albumin 2.8 gm/dL. The remainder of the
chemistry panel is unremarkable. Hepatitis profile is positive for HBsAg, HBeAg, and total anti-HBc. The anti-
HAV, anti-HCV and anti-HBc IgM are negative. The PPD is negative.

The NP informs Patient C that he is coinfected with HIV and HBV and instructs him about the problems
associated with HIV/HBV coinfection. He is given HAV and pneumococcal immunizations and options for
antiretroviral therapy are discussed. Because of its effectiveness against both HIV and HBV, a medication
regimen including tenofovir with lamivudine or tenofovir with emtricitabine should be utilized. A third
medication for HIV viral suppression should be added, with consideration of the hepatotoxicity profile of the

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medication. After discussing available options with limited hepatotoxicity, an integrase inhibitor is selected as
the third active agent in the combination. A single tablet medication containing bictegravir, emtricitabine, and
tenofovir alafenamide in a once daily formulation was therefore selected to treat both HIV and HBV.

Information is provided to Patient C regarding safe sex practices. He is also instructed to abstain from alcohol
and to use ibuprofen (or no more than 2 g acetaminophen in 24 hours) for pain control. The NP also orders a
PT to be drawn; in addition, the patient is referred to hepatology for a liver biopsy to be performed in order to
evaluate the progression of the liver disease. The patient is scheduled for a follow-up visit in four weeks, with a
repeat HIV PCR performed at that time. In the interim, his baseline HIV PCR is found to be 123,000.

Upon his return to the office, Patient C is advised that the liver biopsy revealed periportal inflammation with
focal necrosis and bridging fibrosis. PT is 15.6 seconds (control: 12 seconds). These findings indicate severe,
advanced liver disease and the guarded prognosis. Because of the severity of his liver disease, he is not a
good candidate for PegIFN therapy. The patient's current HIV status precludes his being a transplant candidate
at the time. The recommended treatment plan for Patient C is to maximize his HIV suppression while
minimizing his continued liver damage. If he is compliant with his therapy, he should be able to maintain a fairly
good quality of life for three years or more. Prolonging the time until liver failure also provides the opportunity
to improve immunocompetency. Some liver transplant centers now accept HIV-positive patients, provided that
HIV viral loads are undetectable and CD4 counts are sufficiently high (usually >500). Patient C's future,
therefore, depends upon his tolerance of the regimen, his compliance with the treatment plan, and his body's
response to therapy.

The patient will initially be followed on a monthly basis. The viral load will be checked one month after the
initiation of therapy, then every three months thereafter. Liver profile, CBC, and amylase will be assessed after
one month, then bimonthly. After three months, HIV and HBV quantitative PCRs will be measured. If both are
well suppressed, follow-up will be extended to every two to three months. If the patient's liver function
significantly deteriorates, supportive therapy for end-stage liver disease will be instituted.

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