Pediatric emergency medicine trisk 2092 2092

patients may also present with extrahepatic signs and symptoms such as
arthralgia, arthritis, or papular acrodermatitis (on face, buttocks, and extensor
surfaces of arms and legs). The rash may be associated with lymphadenopathy
and fever (Gianotti–Crosti syndrome), and has been reported with several
viruses although HBV is the most common. Onset of the icteric phase of acute
hepatitis most commonly is temporarily associated with improvement in the
constitutional symptoms. In up to 15% of cases, severe fatigue, anorexia,
nausea, and vomiting persist. The icteric period usually lasts 1 to 4 weeks.
Occasionally, the jaundice is prolonged for 4 to 6 weeks, with increasing
pruritus at 2 to 3 weeks. A number of infectious agents may mimic a viral
hepatitis-like illness. The most common are EBV (infectious mononucleosis)
and CMV. Both agents rarely produce clinical jaundice, and high fever and
diffuse adenopathy are more characteristic. Less common agents include
herpes, adenovirus, coxsackievirus, rheovirus, echovirus, rubella, arbovirus,
leptospirosis, toxoplasmosis, and tuberculosis.
Management/Diagnostic Testing
Most causes of hepatocellular injury are associated with an AST elevation that
is lower than that of ALT. An AST to ALT ratio of 2:1 or greater is suggestive
of alcoholic liver disease, particularly in the setting of an elevated GGT,
although much more common in the adult population. The following
laboratory tests should be performed in all cases of suspected viral hepatitis:
serum transaminases (AST and ALT), alkaline phosphatase, serum GGT, total
and direct bilirubin, CBC, PT, electrolytes, BUN, glucose, total protein,
albumin, and globulin. AST and ALT are the best indicators of ongoing
hepatocellular injury, although it is important to note that in those with chronic
and advanced disease, ALT and AST may be normal or only mildly elevated
despite significant damage and fibrosis. Alkaline phosphatase levels are
usually less than two times the upper limit of normal for age. Levels greater
than three times normal should raise suspicions of EBV or CMV hepatitis or
biliary tract disease. Hepatitis classically produces direct fractions of serum
bilirubin in excess of 30% of total, indicating definite liver disease.

Hyperbilirubinemia may be present in the absence of scleral icterus or
jaundice because these signs usually cannot be appreciated until levels of total
bilirubin exceed 3 to 4 mg/dL. Serum bilirubin levels peak 5 to 7 days after
the onset of jaundice.