CASE PRESENTATION 안산중앙병원 내과 인턴 이효정

박 O 주 ( F / 26 ) Chief complaint Poor oral intake Fever Duration 3 일

Present Illness 상기 26세 여환은 과거력상 특이 병력 없던 자로 본원 내원 약 5일전부터 poor oral intake 있고 fever 있어 시화병원 내원하여 실시한 검사상 AST/ALT , Anti-HAV IgM(1: ) 나와 Acute A-viral hepatitis 진단 받고 2일 정도 치료 받다가 연고지 관계로 본원으로 전원되어 응급실 경유 내과에 입원하였다.

Past History Medical history Family history Social history No known history of Hypertension, Diabetes mellitus, Pulmonary Tuberculosis A viral hepatitis: 금번 진단 Family history N/C Social history Alcohol: 소주 1병/회 x 1-2회/주 Smoking: (-) Travel history

Review of System General weakness / easy fatigue (+/+) Poor oral intake / weight loss (+/-) General ache / generalized edema (+/+) Fever / chill / night sweat(+/+/+) Sore throat / hoarseness (-/-) Headache / dizziness / vertigo (+/+/-) Cough / sputum / hemoptysis (-/-/-) Dyspnea / orthopnea / DOE (-/-/-) Chest pain/palpitation/syncope (-/-/-)

Review of System Anorexia / nausea / vomiting (+/+/-) Indigestion/hunger pain/postprandial pain (+/-/-) Abdominal pain (+) Constipation / diarrhea (+/-) Melena /hematochezia /hematemesis (-/-/-) Frequency/ dysuria/ oliguria/ hematuria (-/-/-/-) Back pain / joint pain (-/-)

Physical Examination Vital sign General appearance Skin BP 150 / 90 mmHg PR 94 회 /min RR 18 회 /min BT 37.8 ℃ General appearance Acute-ill looking appearance Alert mental status Skin Warm and dry No abnormal skin rash

Physical Examination HEENT Neck no deformity not pale conjunctiva icteric sclera dried lip and tongue not injected throat not enlarged tonsil Neck supple no palpable cervical L/N no engorged neck vein

Physical Examination Chest Heart Symmetric expansion without retraction Clear breathing sound without rale No rhonchi No wheezing Heart maximal heart beat at 5th ICS on LMCL Regular heart beat w/o murmur No thrill/ heaving

Physical Examination Abdomen Soft and flat Normoactive bowel sound Direct tenderness(+) No rebound tenderness No organomegaly No palpable ilguinal lymph node No shifting dullness

Physical Examination Back and Extremity Rectal exam Neurologic exam No CVA tenderness No LOM No pretibial pitting edema Rectal exam Not checked Neurologic exam Mental status: alert Mental function: orientation-time/person/place(+/+/+) CNS, motor, and sensory function : intact

Impression Acute viral hepatitis 담석은 증상이 없어 치료를 안하고 있으며 이후 영상소견에서도 보듯이 CBD stone에 의한 pancreatic juice의 reflux 관찰되지 않아 지켜보기로.

Diagnostic plan Complete blood count Serum chemistry Liver function test PT/aPTT Viral marker

Therapeutic plan-I Supportive care Bed rest Maintain normal intravascular volume Maintain caloric intake - Fever control 몰핀 사용 금지

Complete Blood Count (6.27) WBC 4.9X10³/ul RBC 4.27X10*6/ul Hb 13.4 g/dl Hct 38.4 ％ PLT 141X10³/ul Differential count Neutr 34.8 % Lym 51.6 % ↑ Mono 11.5 % Eosin 1.9 % Baso 0.2 %

Serum Chemistry (6.27) Glu 85 mg/dl BUN 8 mg/dl Cre 0.5 mg/dl Na 132 mMol/L K 3.6 mMol/L Cl 97 mMol/L Amy 99 U/L ↑ Ca 8.9 mg/dl P 3.6 mg/dl Bil 8.6 mg/dl ↑ ALP 180 IU/dl ↑ r-GTP 348 IU/dl ↑ Protein 6.6 g/dl Albumin 3.8 g/dl Total chol. 91 mg/dl ALT 5884 mg/dl ↑ AST 4472 mg/dl ↑ PT 11.3 sec INR 1. 01 PTT no coagulation

Viral Marker

APTT

Albumin(serum)

Progression S:nausea(+) Anorexia(+) S: nasea(-) Anorexia(-) POI(+) O: Icteric sclerae Jaundice skin Fever ℃ A: Icteric phase of acute viral hepatitis P: Fever control maintain IV fluid/caloric intake S: nasea(-) Anorexia(-) O: Icteric sclerae Jaundice skin A: Recovery phase of acute viral hepatitis P: maintain IV fluid/caloric intake S: nasea(-) Anorexia(-) O: Icteric sclerae Jaundice skin A: Recovery phase of acute viral hepatitis P: maintain IV fluid/caloric intake

Acute Viral Hepatitis A Topic Review Acute Viral Hepatitis A

History 그리스 히포크라테스 시대: 황달이라 불리움. 카타르성 황달로 진단. 제 1차 세계대전 중 에핑겔에 의해 카타르성 황달이 아닌 유행성간염이라 불리게 됨. 1973년 Feinstone등이 면역 전자 현미경으로 발견 대변에서 발견하여 실험동물에 성공적으로 A형 간염을 발병 1979년 Provost와 Hilleman이 A형 간염 바이러스를 세포 배양을 통해 증식시킴

Virology and Etiology Nonenveloped RNA virus Hepatovirus genus Picornavirus family Incubation period : approximately 4 wks Replication is limited to the liver

Laboratory feature of HAV

Table 285-1

Epidemiology Fecal-oral route Person-to-person spread Enhanced by poor personal hygiene, overcrowding Contaminated food, water, milk, frozen raspberries and strawberries, shellfish

A형간염 발생현황

미국의 심각한 A형 간염 보고건수(1982-2007)

지난 2000년 A형간염을 지정법정전염병으로 등재한 이후, 특히 ‘08년부터 신고 건수가 증가하는 추이로,

환자발생추이 A형 간염 발생건수 및 기관 당 보고건수

연령대별로 보면 주로 20~30대가 전체 신고 건수의 79%를 차지하고 있다. 최근 3년간 A형 간염 연령별 신고현황

Clinical Features Prodromal symptoms(Preicteric phase) Anorexia, nausea, vomiting Fatigue, malaise, arthralgias, myalgias, headache, photophobia Pharyngitis, cough, coryza Low grade fever(38 and 39℃) Dark urine, clay-colored stool

Icteric phase Jaundice Mild weight loss(2.5 to 5kg) Liver becomes enlarged and tender

Recovery phase(posticteric phase) Duration 2~12wks Constitutional symtoms disappear Abnormalities of liver test still evident

Laboratory Features AST/ALT increase during prodromal phase (400~4000IU or more) Does not correlate well with the degree of liver cell damage Jaundice: serum bilirubin exceeds 2.5mg/dL

Transient neutropenia and lymphopenia PT prolongation Severe hepatic synthetic defect Extensive hepatocellular necrosis Worse prognosis

Mild elevation of gamma globulin fraction Serum IgG, IgM Antibodies to smooth muscle and, rheumatoid factor, nuclear antibody, heterophil antibody Diagnosis Detection of IgM anti-HAV

Prognosis Virtually all patients recover completely from their illness with no clinical wequelae Poor prognosis Patients of advanced age Patients with underlying medical disorders Initial presenting feature: ascites, peripheral edema, symptoms of hepatic encephalopathy Prolonged PT / Low serum albumin / Hypoglycemia / High serum bilirubin Fatality rate: approximately 0.1%

일반적인 치료 원칙  ∘ 소아의 경우 A형 간염에 걸리면 대부분 감기처럼 앓고 지나가는 가벼운 증상을 보이지만 20세 이상의 성인에서는 급성 간염이 유발되고 한 달 이상 입원이나 요양을 해야 하는 심각한 증상이 나타날 수 있음.  ∘ 침상 안정, 적절한 영양공급 등의 보존적 치료   ∘ 회복기까지 금주, 성관계 피할 것 (상대가 예방요법 받을 때까지)

입원 치료 ∘ 입원이 필요한 경우 ① 정확한 진단을 위하여 ② 심한 황달이 있거나 자주 토하는 등의 중한 병증 ③ 황달이 심한 수혈 후성 간염 ④ 고령 ∘ 대부분 격리도 필요 없음 ∘ A형 간염의 대부분은 바이러스 분비량이 매우 적기 때문에 장관 안전조치는 권장되지 않음 ∘ 항바이러스제 사용은 일반적으로 회복 속도를 빠르게 하지는 않으므로 필요 없음 ∘ 퇴원 기준 - 증상 호전 - bilirubin ≤ 2mg/dl - normal PT

Preexposure Prophylaxis Formalin-inactivated vaccines made from strains of HAV attenuated tissue culture Frequent travelers Those remaining in endemic areas Military personnel Population with cyclic outbreaks of hepatitis A Employees of day-care centers Primate handlers Laboratory workers exposed to hepatitis A Patients with chronic liver disease

Postexposure Prophylaxis Live with someone who has hepatitis A Have recently had sexual contact with someone who has hepatitis A Have recently shared injection or non-injection illegal drugs with someone who has hepatitis A Have had ongoing, close personal contact with a person with hepatitis A, such as a regular babysitter or caregiver Have been exposed to food or water known to be contaminated with hepatitis A virus IG 0.02mL/kg is recommended

References Harrison’s Principles of Internal Medicine 16th edition, McGraw Hill Publishers, New York, Chicago, Tokyo Young Bong Song, The Age-specific seroprevalence of Hepatitis A virus antibody, Korean J of Hepatol 2007;13:27-33 질병관리본부http://www.cdc.go.kr/kcdchome/ http://www.cdc.gov/