Tagle Martin, Barriga Jose A, Gutierrez Sussy, Valdez Luis Manuel, Castle James, Antunez De Mayolo Antonio, Scavino Levy Yolanda, León Barúa Raúl, Mendoza Carlos, Cajas Lucy, Santibáñez Vilma
Gastroenterólogo-Héatólogo, Clínica Anglo Americana, Lima. Peru.
Rev Gastroenterol Peru. 2004 Jan-Mar;24(1):92-6.
We report the case of a 42-year old male with an episode of relapsing hepatitis A of cholestatic pattern, which clinic course was complicated by fever, anemia and renal failure, requiring hemodialysis. The occurrence of cryglobulins and diminished complement levels was detected. A kidney biopsy was performed showing evidence of thrombotic microangiopathy. The patient had a good therapeutic response to corticosteroids, although he developed recurrence of fever and a palpable purpuric rush over his lower extremities when dose was reduced. A skin biopsy found leukocytoclastic vasculitis. Symptoms and physical findings improved when therapy with cycloposphamide was started and the dose of corticosteroids was increased. Hepatitis A virus infection usually has a benign course, although complications may occasionally develop. The relapsing form can be seen in 3-20% of the case; it can appear with a cholestatic pattern and most of the time it has a mild clinic development. Unlike hepatitis B, extra-hepatic manifestations are unusual in hepatitis A, and renal manifestations are even more infrequent. Acute renal failure (ARF) in non-fulminating hepatitis A has been reported only occasionally and its etiology remains unclear. Several hypotheses have been proposed, including renal toxicity due to hyperuricemia or increased bilirrubin, cryoglobulinemia, alterations in the renal blood flow due to endotoxemia or peripheral immune complex-mediated damage when hypocomplementemia is found. Kidney biopsy showed evidence of thrombotic microangiopathy, which raised the hypothesis of a Hemolytic Uremic Syndrome (HUS). An association with HUS has been described in a patient with surface antigen for hepatitis B (HBsAg) and anomalies in the hepatic biochemical tests, but as far as we know this is the first case of relapsing hepatitis A associated with a confirmed microangiopathic renal involvement.
我们报告了一例42岁男性复发性甲型肝炎患者，其表现为胆汁淤积型，临床病程并发发热、贫血和肾衰竭，需要进行血液透析。检测到冷球蛋白的出现和补体水平降低。进行了肾脏活检，显示有血栓性微血管病的证据。患者对皮质类固醇有良好的治疗反应，尽管在剂量减少时出现了发热复发以及下肢可触及的紫癜疹。皮肤活检发现白细胞破碎性血管炎。开始使用环磷酰胺治疗并增加皮质类固醇剂量后，症状和体征有所改善。甲型肝炎病毒感染通常病程良性，尽管偶尔可能会出现并发症。复发型可见于3% - 20%的病例；可表现为胆汁淤积型，且大多数情况下临床进展较轻。与乙型肝炎不同，甲型肝炎的肝外表现不常见，肾脏表现更为罕见。非暴发性甲型肝炎并发急性肾衰竭（ARF）仅偶尔有报道，其病因仍不清楚。已经提出了几种假说，包括高尿酸血症或胆红素升高导致的肾毒性、冷球蛋白血症、内毒素血症引起的肾血流改变或发现低补体血症时外周免疫复合物介导的损伤。肾脏活检显示有血栓性微血管病的证据，这引发了溶血性尿毒症综合征（HUS）的假说。在一名乙型肝炎表面抗原（HBsAg）阳性且肝脏生化检查异常的患者中描述了与HUS的关联，但据我们所知，这是首例复发性甲型肝炎合并确诊的微血管性肾受累病例。
