SAGES Magazine

THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2022 | VOLUME 20 | ISSUE 1 | 12 presents with fluctuating transaminases. 14 Two complications are well described of acute infection. These include a relapsing -remitting course characterized by ALT/AST fluctuations. These should be investigated accordingly for any co-factors or consider autoimmune hepatitis. Liver biopsy may be warranted. Patients 1 and 2 demonstrated this complication. The role SARS- CoV2 played is speculative but may have been a co-factor in patient 1. A second complication, as in patient 3, is prolonged cholestasis demonstrating marked jaundice with complications of cholestasis with modest elevation or normal liver enzymes. Pruritus is usually marked and can be intractable requiring a variety of therapeutic modalities such as cholestyramine, ultraviolet light therapy and conservative measures such as cotton clothing, topical soothing agents such as calamine lotion. It can take months to settle, and morbidity is significant. 16 Prevention is key. If human immunoglobulin is available, it should be administered especially to the very young and very old as soon as index patient is diagnosed with HAV infection. 11 This is effective within hours and protection for severe disease may last for 12 -20 weeks. Active immunization is advised and was offered to the family of our first case. 11,17 There are different formulations, and these as well are protective against severe disease even after a single dose. Immunity via immunization may last for 15-20 years but is lifelong in patients naturally infected with HAV. 18 Universal vaccination of infants is a first step to control infection and is also recommended to at risk populations e.g. those with chronic liver disease, health care workers, transplant recipients. 11,17,18 Hepatitis A is mostly a self-limiting illness however when complications occur their morbidity, and occasionally mortality, is significant. It is vaccine preventable, and we advise universal Hep A vaccination. Although it is in the private EPI schedule in South Africa, it is as yet, not in the national public schedule. This should be considered a priority given its potential mortality in children, morbidity in adults and the global policy to eliminate viral hepatitis in its entirety. References 1. Lemon SM, Jordis J Ott, Van Damme P, et al- Type A viral Hepatitis: A summary update on the molecular virology, epidemiology, pathogenesis and prevention. J Hepatol, 2017-PMID 28887164. 2. Vallbracht A, Fleischer B, Busch F W , et al -Hepatitis A; Hepatotropism and influence on myelopoiesis-Intervirology 1993-PMID 8407240 3. Sukhyun R, Won SA, Jungwoo U-Hepatitis A virus infec- tion from a contaminated tap of ground water facility in neighbourhood park, Republic of Korea-NCBI 2019-PMID 30941940. 4. Tortajada C, de Olalla, P G Diez-Hepatitis A among men who have sex with men in Barcelona, 1989-2010, insuffi- cient control and need for new approaches-BMC infectious diseases 2012-PMID 22264382 5. Nicholay N, Le Bourhis-Zaimi M, Lesourd A et al- A description of hepatitis A outbreak in men who have sex with men and public health measures implemented in Seine-Maritime department, Normandy France 2017-BMC public health 2020-PMID 32962667. 6. Prabdial-Sing N, Molaze V, Manamela J et al- Establish- ment of outbreak thresholds for Hepatitis A in South Africa using laboratory surveillance 2017-2020-NCBI 2021-PMID 34960739. 7. Manka P, Verheyen J, Gerken G, et al- Liver failure due to Acute Viral Hepatitis (A-E)-Visc Med 2016-PMID-27413724. 8. Yotsuvanazi H, Koike K,Yasuda K, et al-Prolonged faecal excretion of Hepatitis A virus in adult patients with Hepati- tis A as determined by polymerase chain reaction-hepatol- ogy 1996-PMID-8707246 9. Enoch A, Hardie DR, Hussey GD, et al-Hepatitis A sero- prevalence in Western Cape Province, South Africa. Are we in epidemiological transition? SAMJ 2019-PMID 31131797. 10. Richardson M, Elluman D, Maguire H, et al-evidence base of incubation periods of infectiousness and exclusion pol- icies for the control of communicable diseases in schools and preschools-Pediatr infect Dis J 2001-PMID 11333667. 11. Parron I, Planas C, Godoy P, et al-Effectiveness of Hepa- titis A vaccine as post exposure prophylaxis-Hum Vaccin Immunother 2017-PMID 27925847. 12. Menon D, Lagtap SA, Nair MD, et al- Guillain -Barre syn- drome following acute viral hepatitis A. J neurosci rural Pract 2014-PMID 24966576. 13. Glikson M, Galun E, Oren R, et al-Relapsing hepatitis A. Review of 14 cases and literature survey-Medicine (Balti- more) 1992-PMID 1312659. 14. Vento S, Garofano T, Perri G Di, et al-Identification of Hepatitis A virus as a trigger for autoimmune chronic hep- atitis type 1 in susceptible individuals-Lancet 1991-PMID 1673738. 15. Aggarwal A, Kumar D, Kumar R, et al-Acute glomerulo- nephritis in Hepatitis A virus infection; a case presenta- tion-Trop Dcot 2009-PMID 19535762. 16. Gordon SC, Reddy K R, Schiff L, et al-Prolonged intra- hepatic cholestasis secondary to acute Hepatitis A- Ann Intern Med 1984 PMID 6486595. 17. Sagliocca L, Amorosso P, Stroffolomi T, et al-Efficacy of hepatitis A vaccine in prevention of secondary hepati- tis A infection; A randomised trail Lancet 1999 – PMID 10209977. 18. Jutaviiittum P, Jivirivawat Y, Jivirivawat W, et al-Present epidemiological pattern of antibody to Hepatitis A virus among Chiang Mai children, Northern Thailand, Southeast Asian J Trop Med Public Health 2002-PMID 12236424. Abbreviations AFP=Alpha feto protein:Alb=Albumin: ALP=Alkaline phosphatase; ALT=Alanine Transaminase; Amm- ammonia: AST=:Aspartate aminotransferase: C Bil =Conjugated Bilirubin; GGT=Gamma- Glutamyl Transferase; HAV =Hepatitis A Virus: INR=International normalized ratio; LD =Lactate Dehydrogenase; SARS-COV = Severe Acute Respiratory Syndrome Coronavirus 2 REVIEW